L6883 Replc sockt below e/w disaReplacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power
54 of 54 payer prior-auth lists that name L6883 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, CarePlus Health Plans, Humana, Rocky Mountain Health Plans, 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) |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community Health Plans (BCCHP), Illinois Medicaid | IL | prior auth required | Oct 1, 2026 | Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026 | |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative) | IL | prior auth required | Jan 1, 2025 | Procedure Code List, Effective 1/1/2025 | |
| Blue Cross and Blue Shield of New Mexico | Turquoise Care (New Mexico Medicaid) | NM | prior auth required | Oct 1, 2026 | New Mexico Medicaid Benefit Preauthorization Procedure Code List 10/1/26 | |
| 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 | LA | prior auth required | Jan 1, 2027 | Humana Healthy Horizons in Louisiana Prior Authorization and Notification List To Except where noted via links on the following pages, prior authorization requests for medical services may be initiate | |
| 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 | SC | prior auth required | Jan 1, 2027 | Humana Healthy Horizons in South Carolina Prior authorization and Notification List The following list describes services and medications that are commonly reviewed and may require additional clinical | |
| 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 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 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 | Louisiana Medicaid (Healthy Louisiana) | LA | 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. | Jan 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Louisiana |
| 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 | Michigan Medicaid, Healthy Michigan Plan, CSHCS | MI | 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 Michigan, Healthy Michigan Plan and Children’s Special Health Care Services Effective October 1, 2026 |
| 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 | North Carolina Medicaid | NC | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of North Carolina Effective October 1, 2026 July 1, 2024 | |
| 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 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 |
L6883 appears in 15 coverage policies from Blue Cross & Blue Shield of Mississippi, Capital Blue Cross, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), 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 |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Myoelectric Prosthetic and Orthotic Components for the Upper Limb (DME104.001) HCPCS Codes A8005, A8006, L6026, L6611, L6621, L6646, L6648, L6700, L6715, L6880, | listed, no stance | Jun 15, 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 (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 |
Prior authorization required or conditional in CO, IL, KY, LA, MA, MD, MS, NY, OH, VA, WA, WV.
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.