Medicare AdvantageCoverageHigh impact
Prosthetics - Medicare Advantage (Revised)
Humana·Orthopedics, General Surgery, Plastic Surgery +1 more·Medicare Advantage
Effective date
Sep 1, 2026
We identified it
Sep 2, 2026
Summary
Humana has updated its Medicare Advantage prosthetics coverage policy (HUM-1194-009) effective September 1, 2026, which revises coverage criteria and guidelines for artificial limbs, eyes, facial prostheses, and specialized devices including osseointegrated prostheses, myoelectric hands, and neurogenic lower limb prostheses. The policy provides expanded clinical descriptions and references updated CMS Local Coverage Determinations (LCDs) by geographic DME MAC jurisdiction, requiring billing teams to verify regional LCD applicability before processing prosthetics claims.
Action Required
By August 1, 2026: Billing team must update claims processing workflows to reference the revised policy HUM-1194-009 for all Medicare Advantage prosthetics claims. (1) Identify the applicable DME MAC jurisdiction for your practice location (DME A, B, C, or D) and download the corresponding LCD (L33787 for lower limb, L33737 for eye, L33738 for facial prostheses). (2) Update billing software to route osseointegrated prosthesis claims (OI/OPRA) for medical necessity review, as this policy clarifies that OPRA coverage is limited to transfemoral amputation due to trauma or cancer in skeletally mature individuals. (3) Ensure all prosthetics claims include documentation of the specific prosthesis type (passive, body-powered, myoelectric, neurogenic, osseointegrated, etc.) as the policy references device-specific coverage criteria. (4) Providers submitting claims for advanced myoelectric hands (bebionic, iLimb, Michelangelo, Vincent) or neurogenic prostheses (Walkasins) must include clinical justification per the revised LCD requirements. (5) Before September 1, 2026, train billing and prior authorization staff on the new policy distinctions, particularly for osseointegrated and neurogenic devices. Failure to apply regional LCD requirements will result in claim denials and delays in reimbursement.