HCPCS Level II › L codes L7403 Add ue prost b/e acrylicAddition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material
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 L7403 DMEPOS fee schedule, July 2026 (DME26-C) no modifier, prosthetics and orthotics (PO): non-rural $442.58 to $458.43 in the contiguous states; $442.58 to $486.81 in AK, HI, PR and VI; ceiling $540.12, floor $405.09 Payer policies and prior authorization for L7403 15 of 15 payer prior-auth lists that name L7403 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), 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) 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 UnitedHealthcare Community Plan Ohio Medicaid OH prior auth required Nov 1, 2025 Prior authorization requirements for Ohio Medicaid Effective November 1, 2025 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community Plan
Payer coverage policies that name L7403 L7403 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 Jan 1, 2027: PA added, Humana Nov 1, 2025: PA added, uhc:pa:summary-of-changes Nov 1, 2025: PA added, uhc:pa:summary-of-changes Nov 1, 2025: PA added, UnitedHealthcare Community Plan Medicaid fee-for-service Prior authorization required or conditional in IL, LA, MA, MS, NY, OH, VA, WA, WV.
AZ: $412.00 (dme), effective Oct 1, 2026 CO: $349.22 (chp_plus, non-facility), effective Jul 1, 2026 FL: $296.36 (dme), effective Jul 1, 2026 IL: $387.04 (dme), effective Jan 1, 2026 IN: $377.90 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026 KS: $360.99 (default), effective Jul 1, 2026 KY: $268.11 (dme), effective Jan 1, 2026 LA: $247.48 (dme), effective Jul 1, 2012 MA: $388.21 (orthotics_prosthetics_rates), effective Apr 1, 2024 MD: $376.19 (dme), effective Apr 1, 2026 MS: $364.75 (comprehensive), effective Jul 1, 2026 ND: $402.16 (dme), effective Aug 1, 2026 NE: $387.43 (dme), effective Jul 1, 2026 NY: $306.99 (dme), effective Jul 1, 2026 OH: $347.12 (dme), effective Jan 1, 2026 OK: $319.12 (dme), effective Jan 1, 2026 TX: $335.88 (dmepos_tos_9_e_j_l_and_r, Medical Supplier (Dme), non-facility), effective Jul 1, 2010 VA: $333.58 (medical), effective Jan 1, 2012 VT: $370.98 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $332.64 (prosthetics_orthotics), effective Jul 1, 2026 WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026 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.