`L6621` Flex/ext wrist w/wo friction

Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external powered terminal device

Medicare coverage: Carrier judgment
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 0 units per day (clinical), rationale: CMS Policy
Outpatient hospital: max 2 units per day (policy), rationale: Anatomic Consideration
DME supplier: max 2 units per day (policy), rationale: Anatomic Consideration

Medicare pricing for L6621

DMEPOS fee schedule, July 2026 (DME26-C)

no modifier, prosthetics and orthotics (PO): non-rural $2,748.98 to $2,847.38 in the contiguous states; $2,748.98 to $3,023.86 in AK, HI, PR and VI; ceiling $3,354.73, floor $2,516.05

Payer policies and prior authorization for L6621

62 of 62 payer prior-auth lists that name L6621 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), CarePlus Health Plans, Humana, Molina Complete Care (Virginia), Molina Healthcare of California, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of New Mexico, Molina Healthcare of Texas, Neighborhood Health Partnership, Passport by Molina Healthcare (Kentucky), Rocky Mountain Health Plans, UnitedHealthcare, UnitedHealthcare Community Plan.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Cross Blue Shield of Arizona (AZ Blue)	Federal Employee Program (FEP)	AZ	prior auth under conditions	FEP Blue Focus only	Sep 1, 2026	Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026)
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana D-SNP (FL)	FL	prior auth required		Jan 1, 2027	1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List
Humana	Humana D-SNP (IL)	IL	prior auth required		Jan 1, 2027	Humana Dual Fully Integrated Illinois Prior Authorization and Notification List
Humana	Humana D-SNP (IN)	IN	prior auth required		Jan 1, 2027	*New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List
Humana	Humana D-SNP (MI)	MI	prior auth required		Jan 1, 2027	1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List
Humana	Humana D-SNP (SC)	SC	prior auth required		Jan 1, 2027	Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List
Humana	Humana D-SNP (VA)	VA	prior auth required		Jan 1, 2027	Virginia Prior Authorization and Notification List
Humana	Humana Healthy Horizons	IN	prior auth required		Jan 1, 2027	1 Humana Healthy Horizons® in Indiana Preauthorization and Notification List (PAL) for Indiana PathWays for Aging Please note the term prior authorization when used in this communication, is defined a
Humana	Humana Healthy Horizons	KY	prior auth required		Jan 1, 2027	please visit Humana Healthy Horizons in Kentucky Clinical coverage policies.
Humana	Humana Healthy Horizons	OK	prior auth required		Jan 1, 2027	Humana Healthy Horizons® in Oklahoma Prior Authorization Notification List (PAL) The following preauthorization and notification list
Humana	Humana Healthy Horizons	VA	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL)
Humana	Humana MA and D-SNP	All	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana Puerto Rico MA and Dual Medicare-Medicaid	PR	prior auth required		Nov 3, 2025	Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification
Humana	Oak Street Health	All	prior auth required			Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
Molina Complete Care (Virginia)	Medicaid	VA	prior auth required		Apr 1, 2025	Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
Molina Healthcare of California	Medicaid	CA	prior auth required		Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of Idaho	Medicaid	ID	prior auth required		Jan 1, 2025	Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025
Molina Healthcare of Illinois	Medicaid	IL	prior auth required		Jul 1, 2024	Molina Healthcare of Illinois Codification Grid Q3 2026
Molina Healthcare of Michigan	Medicaid	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Michigan	Medicare Advantage	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Mississippi	Medicaid	MS	prior auth required		Jan 1, 2025	Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
Molina Healthcare of New Mexico	Medicaid	NM	prior auth required		Jul 1, 2026	New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026
Molina Healthcare of Texas	STAR	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19
Molina Healthcare of Texas	STAR+PLUS	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19
Molina Healthcare of Texas	STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix)	TX	prior auth required		Jul 1, 2024	Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3
Passport by Molina Healthcare (Kentucky)	Medicaid	KY	prior auth required		Jul 1, 2026	Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
Neighborhood Health Partnership	Neighborhood Health Partnership	FL	prior auth under conditions	Prior authorization required only for prosthetic codes listed with a retail purchase or cumulative rental cost of more than $1,000.	Sep 1, 2026	Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans CHP+	CO	prior auth required		Oct 1, 2026	Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans Prime / RAE	CO	prior auth required		Oct 1, 2026	Rocky Mountain Health Plans PRIME Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Medicare Advantage D-SNP	CO	prior auth required		Feb 1, 2025	Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025
UnitedHealthcare	UnitedHealthcare Complete (Individual & Family plans)	All	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcare	UnitedHealthcare Individual Exchange plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026
UnitedHealthcare Community Plan	AHCCCS Complete Care (ACC)	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026
UnitedHealthcare Community Plan	ALTCS Developmentally Disabled	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026
UnitedHealthcare Community Plan	ALTCS Long Term Care	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for Arizona Long Term Care Effective October 1, 2026
UnitedHealthcare Community Plan	KanCare	KS	prior auth under conditions	Prior authorization is required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500.	Oct 1, 2026	Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth under conditions	Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500	Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community Plan	Massachusetts OneCare	MA	prior auth under conditions	Prior authorization is required only for prosthetic codes listed with a retail purchase or cumulative rental cost of more than $1,000.	Nov 1, 2025	Prior authorization requirements for Massachusetts OneCare Effective November 1, 2025
UnitedHealthcare Community Plan	Minnesota Metro Medicaid	MN	prior auth under conditions	Prior authorization required only for orthotics and prosthetics with a retail purchase or a cumulative rental cost of more than $500	Oct 1, 2024	Prior authorization requirements for Minnesota Medicaid Effective October 1, 2024
UnitedHealthcare Community Plan	Mississippi CHIP	MS	prior auth under conditions	Prior authorization is required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500.	Apr 1, 2025	Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025
UnitedHealthcare Community Plan	MississippiCAN	MS	prior auth under conditions	Prior authorization required only for orthotics and prosthetic codes listed, with a retail purchase or cumulative rental cost of more than $500	Apr 1, 2025	Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025
UnitedHealthcare Community Plan	Missouri Medicaid	MO	prior auth under conditions	Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500	Jul 1, 2026	Prior authorization requirements for Missouri Medicaid Effective July 1, 2026
UnitedHealthcare Community Plan	New Jersey FamilyCare	NJ	prior auth under conditions	Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Jersey Effective October 1, 2026 General Information This list contains prior authorization requirements for participating U
UnitedHealthcare Community Plan	New Mexico Turquoise Care	NM	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026
UnitedHealthcare Community Plan	Pennsylvania CHIP	PA	prior auth under conditions	Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500	Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026
UnitedHealthcare Community Plan	Pennsylvania Medicaid	PA	prior auth under conditions	Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500	Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026
UnitedHealthcare Community Plan	Rhode Island Medicaid	RI	prior auth under conditions	Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500	May 1, 2026	Prior authorization requirements for Rhode Island Medicaid Effective May 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Rhode Island h
UnitedHealthcare Community Plan	TennCare	TN	prior auth under conditions	Prior authorization is required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500.	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026
UnitedHealthcare Community Plan	Texas CHIP	TX	prior auth required		Jan 1, 2015	Prior authorization requirements for Texas CHIP Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan Texas CHIP health care
UnitedHealthcare Community Plan	Texas STAR	TX	prior auth required		Jan 1, 2015	Prior authorization requirements for Texas STAR Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR h
UnitedHealthcare Community Plan	Texas STAR Kids	TX	prior auth under conditions	Prior authorization is required only for orthotics and prosthetics with a retail purchase or a cumulative rental cost of more than $500.	Nov 1, 2016	Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki
UnitedHealthcare Community Plan	Texas STAR+PLUS	TX	prior auth required		Jan 1, 2015	Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Florida	FL	prior auth under conditions	Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500	Oct 1, 2026	Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Hawaii (QUEST Integration)	HI	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Kentucky	KY	prior auth under conditions	Cost over $500	Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of New York	NY	prior auth under conditions	Prior authorization is required only for the orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500.	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Connected (Texas MMP)	TX	prior auth required		Jan 1, 2015	Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U
UnitedHealthcare Community Plan	Virginia Cardinal Care LTSS	VA	prior auth under conditions	Prior authorization required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500.	Oct 1, 2026	Prior authorization requirements for Virginia Cardinal Care LTSS Effective October 1, 2026
UnitedHealthcare Community Plan	Virginia Cardinal Care Medicaid	VA	prior auth under conditions	Prior authorization required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500.	Oct 1, 2026	Prior authorization requirements for Virginia Cardinal Care Effective October 1, 2026
UnitedHealthcare Community Plan	Washington Apple Health	WA	prior auth under conditions	Prior authorization required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500.	Oct 1, 2026	Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023
UnitedHealthcare Community Plan	Wisconsin BadgerCare Plus and Medicaid SSI	WI	prior auth under conditions	Prior authorization required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500.	Sep 1, 2026	Prior authorization requirements for Wisconsin Medicaid Effective September 1, 2026 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community

Payer coverage policies that name L6621

L6621 appears in 14 coverage policies from Blue Cross & Blue Shield of Mississippi, Capital Blue Cross, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Blue Cross & Blue Shield of Mississippi	Prosthetics (L.1.04.401)	covered if criteria are met		payer document
Capital Blue Cross	Upper Limb Prostheses (MP 6.052) Procedure codes	covered if criteria are met	Apr 1, 2026	payer document
UnitedHealthcare	Durable Medical Equipment (DME), Prosthetics, Orthotics (Non-Foot Orthotics), Nutritional Therapy, and Medical Supplies Grid (MMP028.23)	listed, no stance	Oct 1, 2025	payer document
UnitedHealthcare	Upper Extremity Prosthetic Devices (2026T0641I) Upper Limb Prosthetics	listed, no stance	Apr 1, 2026	payer document
UnitedHealthcare	Upper Extremity Prosthetic Devices (CS360.E) Upper Limb Prosthetics	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Upper Extremity Prosthetic Devices (for Idaho Only) (CS360ID.D) Upper Limb Prosthetics	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Upper Extremity Prosthetic Devices (for Kansas Only) (CS360KS.03) Upper Limb Prosthetics	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Upper Extremity Prosthetic Devices (for Kentucky Only) (CS360KY.05)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Upper Extremity Prosthetic Devices (for Nebraska Only) (CS360NE.E) Upper Limb Prosthetics	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Upper Extremity Prosthetic Devices (for New Jersey Only) (CS360NJ.E) Upper Limb Prosthetics	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Upper Extremity Prosthetic Devices (for New Mexico Only) (CS360NM.D) Upper Limb Prosthetics	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Upper Extremity Prosthetic Devices (for Ohio Only) (CS360OH.F) Upper Limb Prosthetics	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Upper Extremity Prosthetic Devices (for Pennsylvania Only) (CS360PA.E)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Upper Extremity Prosthetic Devices (for Tennessee Only) (CS360TN.E) Upper Limb Prosthetics	listed, no stance	Jun 1, 2026	payer document

Recent prior-auth changes

Jan 1, 2027: PA added, Humana
Oct 1, 2026: PA removed, UnitedHealthcare
Oct 1, 2026: PA removed, UnitedHealthcare
Oct 1, 2026: PA removed, UnitedHealthcare
Oct 1, 2026: PA removed, UnitedHealthcare
Oct 1, 2026: PA removed, Surest
Oct 1, 2026: PA removed, Oxford Health Plans
May 1, 2026: conditions changed, UnitedHealthcare
Apr 1, 2026: conditions changed, UnitedHealthcare
Apr 1, 2026: conditions changed, Surest

Medicaid fee-for-service

Prior authorization required or conditional in CO, KY, MA, MD, MS, NY, OH, VA, WA, WV.

AZ: $2559.03 (dme), effective Oct 1, 2026
CO: $2169.03 (chp_plus, non-facility), effective Jul 1, 2026
IN: $2347.08 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
KS: $2242.15 (default), effective Jul 1, 2026
KY: $2236.32 (dme), effective Jan 1, 2026
MA: $2411.30 (orthotics_prosthetics_rates), effective Apr 1, 2024
MD: $2336.63 (dme), effective Apr 1, 2026
MS: $2265.37 (comprehensive), effective Jul 1, 2026
NY: $1948.21 (dme), effective Jul 1, 2026
OH: $2156.06 (dme), effective Jan 1, 2026
OK: $1982.04 (dme), effective Jan 1, 2026
TX: $1387.98 (dmepos_tos_9_e_j_l_and_r, Medical Supplier (Dme), non-facility), effective Mar 1, 2026
VA: $2071.90 (medical), effective Jan 1, 2012
VT: $2304.29 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $2066.07 (prosthetics_orthotics), effective Jul 1, 2026
WY: $1753.23 (professional), effective Jan 1, 2021

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.

L6621 Flex/ext wrist w/wo friction