L7405 Add ue prost s/d acrylicAddition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material
45 of 45 payer prior-auth lists that name L7405 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 | 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 | 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 under conditions | Cost over $500 | 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 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 | 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 |
L7405 appears in 3 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 | Upper Extremity Prosthetic Devices (for North Carolina Only) (CSNCT0641.04) | listed, no stance | Jun 1, 2026 | payer document |
Prior authorization required or conditional in LA, MA, MS, NE, 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.