`L6890` Prefab glove for term device

Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment

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 (clinical), rationale: Anatomic Consideration
DME supplier: max 2 units per day (clinical), rationale: Anatomic Consideration

Medicare pricing for L6890

DMEPOS fee schedule, July 2026 (DME26-C)

no modifier, prosthetics and orthotics (PO): non-rural $208.23 to $277.64 in the contiguous states; $276.00 to $856.60 in AK, HI, PR and VI; ceiling $277.64, floor $208.23

Payer policies and prior authorization for L6890

3 of 3 payer prior-auth lists that name L6890 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), 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)
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 L6890

L6890 appears in 15 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Capital Blue Cross, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Upper Limb Prostheses (0399)	covered if criteria are met	Jul 16, 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	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

Aug 9, 2024: PA removed, humana:pa:commercial

Medicaid fee-for-service

Prior authorization required or conditional in CO, LA, MA, MS, NY, OH, VA, WV.

AZ: $258.46 (dme), effective Oct 1, 2026
CO: $152.67 (chp_plus, non-facility), effective Jul 1, 2026
FL: $83.79 (dme), effective Jul 1, 2026
IL: $181.73 (dme), effective Jan 1, 2026
IN: $204.94 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
KS: $222.11 (default), effective Jul 1, 2026
KY: $130.10 (dme), effective Jan 1, 2026
LA: $122.51 (dme), effective Jul 1, 2012
MA: $176.19 (orthotics_prosthetics_rates), effective Apr 1, 2024
MD: $177.00 (dme), effective Apr 1, 2026
MS: $166.58 (comprehensive), effective Jul 1, 2026
ND: $0.00 (dme), effective Aug 1, 2026
NE: $238.39 (dme), effective Jul 1, 2026
NY: $187.10 (dme), effective Jul 1, 2026
OH: $162.94 (dme), effective Jan 1, 2024
OK: $158.00 (dme), effective Jan 1, 2026
TX: $116.22 (dmepos_tos_9_e_j_l_and_r, Medical Supplier (Dme), non-facility), effective Apr 1, 1992
VA: $117.00 (medical), effective Jan 1, 1990
VT: $193.02 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $170.86 (prosthetics_orthotics), effective Jul 1, 2026
WY: $142.46 (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.

L6890 Prefab glove for term device