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HCPCS Level II Table of Contents

L6890 - L6915  Prosthetic Procedures - Hand Restoration

L6890
Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment
shortPrefab glove for term device
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.03 Date of Service Edit: ClinicalAnatomic Consideration
DME2.03 Date of Service Edit: ClinicalAnatomic Consideration
L6895
Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated
shortCustom glove for term device
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.03 Date of Service Edit: ClinicalAnatomic Consideration
DME2.03 Date of Service Edit: ClinicalAnatomic Consideration
L6900
Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining
shortHand restorat thumb/1 finger
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.02 Date of Service Edit: PolicyAnatomic Consideration
DME2.02 Date of Service Edit: PolicyAnatomic Consideration
L6905
Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining
shortHand restoration multiple fi
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.02 Date of Service Edit: PolicyAnatomic Consideration
DME2.02 Date of Service Edit: PolicyAnatomic Consideration
L6910
Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining
shortHand restoration no fingers
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.02 Date of Service Edit: PolicyAnatomic Consideration
DME2.02 Date of Service Edit: PolicyAnatomic Consideration
L6915
Hand restoration (shading, and measurements included), replacement glove for above
shortHand restoration replacmnt g
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.02 Date of Service Edit: PolicyAnatomic Consideration
DME2.02 Date of Service Edit: PolicyAnatomic Consideration