Transcription of Prosthetic Devices, Wigs, Specialized, Microprocessor or ...
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Prosthetic Devices, Wigs, Specialized, Microprocessor or ...
Prosthetic devices , wigs , specialized , Microprocessor or Myoelectric Limbs Page 1 of 21 UnitedHealthcare Commercial Coverage Determination Guideline Effective 01/01/2022 Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc. UnitedHealthcare Commercial Cover a ge Deter mina tion Guideline Prosthetic devices , wigs , specialized , Microprocessor or Myoelectric Limbs Guideline Number: Effective Date: January 1, 2022 Instructions for Use Table of Contents Page Coverage Rationale.
Meets all of the criteria below: Has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee K3 functional level only Weight greater than 110 lbs. and less than 275 lbs. Has a documented comorbidity of the spine and/or sound limb …
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