HCPCS Level II › L codes L6677 Ue triple control harnessUpper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow
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 L6677 DMEPOS fee schedule, July 2026 (DME26-C) no modifier, prosthetics and orthotics (PO): non-rural $356.52 to $369.29 in the contiguous states; $356.52 to $392.16 in AK, HI, PR and VI; ceiling $435.09, floor $326.32 Payer policies and prior authorization for L6677 14 of 14 payer prior-auth lists that name L6677 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), CarePlus Health Plans, Humana, Rocky Mountain Health Plans.
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 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 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
Payer coverage policies that name L6677 L6677 appears in 16 coverage policies from Anthem, Blue Cross & Blue Shield of Mississippi, Capital Blue Cross, UnitedHealthcare.
Payer Policy Role in policy Reviewed Document Anthem Myoelectric Upper Extremity Prosthetic Devices (CG-OR-PR-05) covered if criteria are met May 14, 2026 payer 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 (CS360.E)Upper Limb Prosthetics listed, no stance Jun 1, 2026 payer document UnitedHealthcare Upper Extremity Prosthetic Devices (2026T0641I)Upper Limb Prosthetics listed, no stance Apr 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 North Carolina Only) (CSNCT0641.04) 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 Medicaid fee-for-service Prior authorization required or conditional in MA, MS, NY, OH, VA, WA, WV.
AZ: $298.69 (dme), effective Oct 1, 2026 CO: $285.00 (chp_plus, non-facility), effective Jul 1, 2026 IN: $304.38 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026 KS: $290.74 (default), effective Jul 1, 2026 MA: $312.73 (orthotics_prosthetics_rates), effective Apr 1, 2024 MD: $303.04 (dme), effective Apr 1, 2026 MS: $293.84 (comprehensive), effective Jul 1, 2026 NE: $312.07 (dme), effective Jul 1, 2026 NY: $252.66 (dme), effective Jul 1, 2026 OH: $279.62 (dme), effective Jan 1, 2026 OK: $257.08 (dme), effective Jan 1, 2026 TX: $180.03 (dmepos_tos_9_e_j_l_and_r, Medical Supplier (Dme), non-facility), effective Mar 1, 2026 VA: $268.71 (medical), effective Jan 1, 2012 VT: $298.85 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $267.95 (prosthetics_orthotics), effective Jul 1, 2026 WY: $227.37 (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.