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CurrentAetnaPolicy 0399

Upper Limb Prostheses

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Clinical policy governing medical necessity, coverage, coding, and exclusions for upper limb prosthetic devices and related services for Aetna members.

Policy Summary

PayerAetna

PolicyUpper Limb Prostheses

Policy CodePolicy 0399

Change TypeNo material changes

Effective DateOct 9, 2000

Last ReviewJun 6, 2023

Next Review DateApr 25, 2024

Key ActionEnsure prosthetic devices are prescribed by a qualified prescriber and furnished by a licensed/certified orthotist or prosthetist, and provided within six months of prescription to meet medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2max socket inserts per prosthesis

2replacement liners per 12 months

12/12moprosthetic sheaths/socks frequency

1 yeartypical warranty period

2-3 yrsmotor/drive life

~20+HCPCS/related codes listed

Coverage and Medical Necessity Criteria

inv-01: Medical Necessity - General and Myoelectric Specific

Covered when ALL of the following are met

General prosthesis medical necessity: 1) Care is prescribed by a qualified prescriber (physician, nurse practitioner, podiatrist or other health professional authorized by state law); 2) Device will significantly improve or restore physical functions required for mobility-related activities of daily living (MRADLs); 3) The prescribing clinician has determined the device will allow performance of ADLs based on physical examination; 4) Device is provided within six months of the date of prescription; 5) Orthotic/prosthetic services are performed by a duly licensed and/or certified orthotic and/or prosthetic provider; 6) Services are of sufficient complexity to require provision by a licensed/certified professional orthotist/prosthetist or under their direct supervision; 7) The certified orthotist/prosthetist is in good standing with ABC, BOC, or is state-licensed where required.

Myoelectric prosthesis specific: Covered for members with traumatic amputation or congenital absence of the upper limb at the wrist or above when ALL of the following are met: 1) Adequate cognitive and neurologic ability to utilize a myoelectric prosthetic device; 2) Remaining musculature contains the minimum microvolt threshold to allow operation of the myoelectric device (documented EMG signal and successful control test); 3) A standard body-powered prosthetic device cannot be used or is insufficient to meet functional needs for ADLs; 4) Absence of comorbidity that could interfere with maintaining prosthesis function (e.g., neuromuscular disease).

Policy Summary

PayerAetna

PolicyUpper Limb Prostheses

Policy CodePolicy 0399

Change TypeNo material changes

Effective DateOct 9, 2000

Last ReviewJun 6, 2023

Next Review DateApr 25, 2024

SourceLink

On This Page

minimum microvolt threshold (documented); successful control test

inv-02: Accessory, repair, replacement, and supply coverage

Covered when used with medically necessary prosthetic devices

Included or limited accessories and services: Supplies and accessories necessary for effective functioning of approved prosthetic equipment; repairs or adjustments required due to bone growth, reasonable weight change, or normal wear and tear; replacement of medically necessary prosthetic devices when repairs/adjustments fail or are not possible; no separate payment for batteries or battery chargers when billed concurrently with powered base items (batteries/chargers included with powered base).

Quantity limits: No more than 2 socket inserts per individual prosthesis; no more than two replacement liners per prosthesis in a 12-month period; prosthetic sheaths/socks (including gel cushion) limited to 12 in 12 months.

inv-03: Medical necessity for myoelectric upper-limb prosthesis

Covered when ALL of the following are met

Myoelectric prosthesis candidacy: 1) Patient has traumatic or congenital absence of the forearm/hand or other upper-limb amputation and is an appropriate candidate for a myoelectric prosthesis; 2) Patient demonstrates adequate EMG signals from residual musculature meeting the minimum microvolt threshold and passes a control test (documentation required); 3) Device is appropriate for patient age (myoelectric hand prostheses indicated for persons age ≥ 1 year); 4) A standard body-powered device cannot be used or is insufficient to meet functional ADL needs; 5) Absence of comorbidity that would interfere with prosthesis function (e.g., neuromuscular disease).age >= 1 year; minimum microvolt threshold (documented); successful control test

Document device lifespan/warranty considerations (typical 1‑year warranty; motor/drive life 2–3 years; sockets for growing children may need replacement every 12–18 months; heavy use may require replacement by year 5).

inv-04: Partial-hand myoelectric prosthesis evidence

Coverage/assessment guidance

Partial-hand myoelectric prostheses are intended for patients with amputations through or just proximal to the metacarpophalangeal (MCP) level for one or more digits. Currently there is insufficient peer‑reviewed evidence demonstrating clinical value (improvements in function or health‑related quality of life) for partial‑hand myoelectric prostheses.

Further research, including real‑time functional studies, is needed before broad conclusions about effectiveness can be drawn.

inv-05: Evidence and clinical-use considerations

Summary of clinical evidence and considerations for use of partial-hand myoelectric systems and TMR:

Partial-hand myoelectric prostheses evidence: Laboratory and pattern‑recognition studies indicate between‑day deterioration in classifier performance when training and testing are performed on different days; multi‑day training (e.g., over 11 consecutive days) has shown improved between‑day performance approaching within‑day levels. However, many analyses were performed off‑line with limited motion classes (e.g., four classes) and real‑time, multi‑day validation with virtual or physical prostheses is needed to establish functional benefit.

Requests based solely on off‑line pattern‑recognition data may not generalize to real‑world prosthesis performance.

Targeted Muscle Re-innervation (TMR): TMR surgically transfers severed motor nerves to denervated target muscles to create additional EMG control sites, potentially improving intuitive control of myoelectric prostheses. TMR has been shown to improve functional control in high‑level amputations and is under investigation for more distal amputations and for prevention or treatment of neuroma and phantom limb pain. Primary TMR at the time of amputation may reduce subsequent surgeries and may prevent neuroma formation, but long‑term effects continue to be evaluated.

When requesting TMR-related procedures include clinical rationale, prior treatments, and expected functional benefit.

The policy excludes coverage for replacement or upgrade of a prosthesis that is currently functional, devices provided primarily for cosmetic appearance, and prostheses intended primarily for leisure or sporting activities (e.g., skiing, swimming). Repairs or replacements for appearance, comfort, convenience, or due to individual abuse, misuse, or neglect are not covered, nor are repairs/replacements of parts for duplicate prostheses or water-specific prostheses. Additionally, CAD-CAM fabrication, routine fitting/evaluation, and services included in the allowance for a prosthesis are not separately reimbursed; batteries and chargers billed concurrently with a powered base item are included in payment for that base item and are not paid separately.

Certain ICD-10 diagnosis ranges and specific codes are identified as not covered for the indications addressed by this clinical policy bulletin. Claims listing diagnoses in the G00–G99 range (diseases of the nervous system) or the stump neuroma codes T87.31 and T87.32 as the reason for prosthetic coverage may be denied. Implantable myoelectric sensors (IMES) and other novel components without established coverage/coding determinations are considered investigational and are not covered pending further evidence and coding guidance.

Findings based solely on off-line analyses (for example, classifier performance measured within a single experimental session) should not be assumed to generalize to functional prosthesis performance. Studies of partial-hand pattern-recognition control have shown that classification can deteriorate across days, and that most published analyses were performed off-line with a limited set of motion classes; further real-time, multi-day validation is required before these results can be extrapolated to everyday prosthesis use.

Adjustable click retention systems (e.g., Revo and Boa) and implantable myoelectric sensors are listed among technologies considered experimental/investigational. Myoelectric prostheses provided for indications other than those specified in the policy (traumatic amputation or congenital absence at or above the wrist with appropriate candidacy) are not supported. The policy also emphasizes correct coding practices: all grasp patterns are included in L6880 and use of L6881 with L6880 is considered unbundling; L7499 must not be used to bill additional features or components when all-inclusive codes (such as L6025 or L6880) apply.

There is currently insufficient peer-reviewed evidence demonstrating the clinical value (improved function or health-related quality of life) of partial-hand myoelectric prostheses. Implantable myoelectric sensors (IMES) remain investigational; preliminary reports suggest feasibility but published clinical trial evidence is limited and ongoing. Until more robust peer‑reviewed data and established coding/coverage guidance are available, partial-hand myoelectric systems and IMES are considered investigational/not medically necessary for the indications described.

Use of off-line pattern-recognition or classifier systems without evidence of sustained, real-time, multi-day performance and demonstrated functional benefit remains unproven. Published partial‑hand studies commonly used off-line analyses with only four hand motion classes and single-session data; while multi-day training has been shown to improve between-day performance in laboratory settings, the relationship between off-line error and real-time usability is unclear and real-time multi-day validation is needed before such control systems can be assumed to provide functional advantage.

HCPCS and ICD-10 Coding

HCPCS codes referencedHCPCS

L6000	Partial hand, thumb remaining
L6010	Partial hand, little and/or ring finger remaining
L6020	Partial hand, no finger remaining
L6050	Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad
L6100	Below elbow, molded socket, flexible elbow hinge, triceps pad
L6715	Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement
L6880	Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s)
L6026	Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device(s)
L6025	Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power... (complete prosthesis, includes custom fabricated socket)
L6895	Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated

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Covered HCPCS/L-codes (listed in this section)HCPCSCovered

L6965	Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device.
L6975	Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device.
L7007	Electric hand, switch or myoelectric controlled, adult or pediatric.
L7008	Electric hand, switch or myoelectric controlled, adult or pediatric.
L7009	Electric hook, switch or myoelectric controlled, adult or pediatric.
L7045	Electric hook, switch or myoelectric controlled, adult or pediatric.
L7190	Electronic elbow, variety village or equal, myoelectronically controlled, adolescent or child.
L7191	Electronic elbow, variety village or equal, myoelectronically controlled, adolescent or child.
L7259	Electronic wrist rotator, any type.
L7368	Lithium ion battery charger.

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Related HCPCS L-codes (accessories/replacements)HCPCSCovered

L7360	Six volt battery, each.
L7362	Battery charger, six volt, each.
L7364	Twelve volt battery, each.
L7366	Battery charger, twelve volt, each.
L7367	Lithium ion battery, rechargeable, replacement.
L7368	Lithium ion battery charger, replacement only.

ICD-10 diagnosis codesICD-10

Q71.00 - Q71.53	Reduction defects of upper limb
Q71.811 - Q71.93
S48.011+ - S48.929+	Traumatic amputation of shoulder and upper arm
S58.011+ - S58.929+	Traumatic amputation of elbow and forearm
S68.411+ - S68.429+	Traumatic amputation of hand

ICD-10 codes covered if selection criteria are metICD-10Covered

Q71.00 - Q71.53	Reduction defects of upper limb.
Q71.811 - Q71.93
S48.011+ - S48.929+	Traumatic amputation of shoulder and upper arm.
S58.011+ - S58.929+	Traumatic amputation of elbow and forearm.
S68.411+ - S68.429+, S68.711+ - S68.729+	Traumatic amputation of hand.
Z89.011 - Z89.239	Acquired absence of upper limb.

ICD-10 codes not covered for indications listedICD-10Not Covered

G00 - G99	Diseases of nervous system [neuromuscular disease that interferes with prosthesis function]
T87.31	Neuroma of amputation stump, right upper extremity.
T87.32	Neuroma of amputation stump, left upper extremity.

Coding references and correct coding notesHCPCS

L6895	Articulating digit(s) and prosthetic hands (referenced as billing code in coding guidance)
L7499	Unspecified prosthetic code (referenced in correct coding notes)

Minimum EMG signal (inv-19)

Minimum EMG signal requirementPatient must demonstrate residual musculature that meets the policy’s minimum microvolt threshold (documented) to allow operation of a myoelectric prosthetic device.

Successful control testPatient must pass a control test demonstrating functional control of the prosthesis using detected EMG signals.

Documentation requiredMedical record must document measured EMG amplitude meeting the microvolt threshold and results of the control test to support candidacy.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Ensure qualified prescriber, licensed/certified provider, and 6-month furnishing window

Prosthetic devices must be prescribed by a qualified prescriber, provided by a duly licensed/certified orthotic and/or prosthetic provider, and furnished within six months of the date of prescription to meet medical necessity criteria; services must be performed by licensed/certified professionals (ABC, BOC, or state-licensed where required) or under their direct supervision.

Prescriber must be qualified to prescribe orthotics/prosthetics per state law.
Provider must be a duly licensed and/or certified orthotist/prosthetist (ABC, BOC, or state-licensed).
Device must be provided within six months of prescription.
Services must require and be of the complexity appropriate for licensed/certified professionals or provided under their direct supervision.

Prior Authorization

Obtain prior authorization for listed myoelectric/prosthesis HCPCS/L-codes

Prior authorization is implied for provision and replacement of the listed external power myoelectric prosthesis components and specified HCPCS/L-codes when coverage criteria apply; see the policy's HCPCS lists for the affected codes (e.g., L6965, L6975, L7007-L7009, L7190-L7191, L7259, L7368, L7400, L7403, L8465, L6026, L6715, L6880).

Prior authorization applies when coverage criteria are met for the listed myoelectric/prosthesis codes.
Refer to the policy HCPCS lists to identify which items require prior authorization.

Prior Authorization

Document indication and expected benefit when requesting TMR

When requesting surgical procedures for targeted muscle re-innervation (TMR), include justification that TMR is intended to improve prosthetic control or to treat/prevent neuroma or phantom limb pain; if proposing primary TMR at time of amputation, describe expected benefits and follow-up plan.

State the indication (improved myoelectric control and/or neuroma/phantom limb pain treatment or prevention).
If primary TMR is requested, describe expected benefits and plan for follow-up.

Step Therapy

Sequence: consider body-powered device before myoelectric

Consider a standard body-powered prosthetic device first; myoelectric prostheses are covered only when a standard body-powered device cannot be used or is insufficient to meet functional needs for ADLs.

Document why a body-powered device is insufficient for the member's activities of daily living when requesting a myoelectric prosthesis.

Step Therapy

No mandated step-therapy sequencing required by policy

The policy does not mandate a formal step therapy sequence (e.g., mandatory trial of a body-powered hook before myoelectric); no explicit step therapy sequencing is required in this policy.

Providers should not assume the policy requires a specific trial sequence unless documented clinical need dictates.

Step Therapy

Document prior neuroma treatments and justify primary vs. secondary TMR

For neuroma management and TMR, document prior conservative treatments before requesting delayed (secondary) TMR; if proposing primary TMR at the time of amputation, justify use and note that primary TMR is under investigation and should be supported by expected benefits.

Record prior neuroma treatment attempts when requesting secondary TMR.
If primary TMR is planned, document rationale and expected impact on future surgeries and neuroma prevention.

Documentation Required

Record product details and include PDAC CVR where required

Record product information (manufacturer, part number or part name) in the medical record; PDAC coding verification review (CVR) documentation is required for codes L6715 and L6880 where applicable.

Include manufacturer and part number/part name in the patient's record.
Submit PDAC CVR documentation for L6715 and L6880 as required per PDAC guidance.

Documentation Required

Document EMG signal, control test, age, and device lifespan for myoelectric candidacy

Provide documentation that the patient meets myoelectric candidacy: adequate EMG signal meeting the minimum microvolt threshold and a successful control test; document device lifespan/warranty considerations when requesting replacements.

Document measured EMG amplitude and that it meets the minimum microvolt threshold and control test results.
Document patient age (myoelectric hands indicated for age ≥ 1 year) and justification for replacement frequency (warranty, motor life, growth in children).

Documentation Required

Include clinical rationale and prior-treatment history for TMR requests

When requesting procedures related to TMR, document the clinical rationale including the indication (e.g., improved myoelectric control or treatment/prevention of neuroma/phantom limb pain), prior treatments, and expected functional benefit.

Describe prior treatments for neuroma or phantom limb pain.
State the anticipated functional benefit for prosthetic control and pain outcomes.

Denial Risk

Avoid billing unbundled codes (L6715, L7499) with all-inclusive base codes

Do not bill L6715 on initial issue with base prosthesis codes (e.g., L6025, L6026) or bill L7499 for components included in all-inclusive codes; such billing will be denied as unbundling.

Avoid billing L6715 with L6025 or L6026 on initial issue (denied as unbundling).
Do not bill L7499 with all-inclusive codes such as L6025 or L6880 on initial issue.

Denial Risk

Avoid non-covered ICD-10 diagnoses (G00–G99, T87.31–T87.32) as justification

Claims submitted with ICD-10 diagnoses in the G00-G99 range (diseases of the nervous system) or with stump neuroma codes T87.31/T87.32 for indications listed in this policy are identified as not covered and may trigger denial.

Verify diagnosis codes; avoid using G00–G99 or T87.31/T87.32 as the primary justification for prosthetic coverage under the CPB indications.

Denial Risk

Do not base coverage requests solely on off-line pattern-recognition data

Do not rely solely on off-line pattern-recognition performance data when supporting claims or requests; the policy notes that off-line analyses without demonstration of real-time or multi-day training benefits may not generalize to functional prosthesis performance and can be challenged.

Provide real-time, multi-day training or performance data when claiming functional benefit from pattern-recognition control systems.
Include evidence of improved between-day performance or functional usability rather than only off-line classification results.

Background and Epidemiology

Upper limb prostheses replace absent or nonfunctioning parts of the upper extremity and include terminal devices, partial-hand systems, and whole-arm prostheses. Myoelectric prostheses use electromyographic (EMG) signals from residual limb muscles detected by surface electrodes, amplified and processed to drive motors that move terminal devices, wrist, or elbow. Myoelectric devices are appropriate for traumatic amputation or congenital absence at the wrist or above when the patient has adequate cognitive and neurologic ability, sufficient residual musculature meeting minimum EMG signal thresholds, and when a body-powered device is inadequate to meet activities of daily living. Emerging interventions such as partial‑hand myoelectric systems, implantable myoelectric sensors, pattern‑recognition control without real‑time validation, and targeted muscle re‑innervation require further real‑world, multi‑day evidence to establish clinical effectiveness.

Key Definitions

Myoelectric upper limb prosthesis (inv-33)

DefinitionAn externally powered prosthesis that uses electrical signals from residual musculature to control powered terminal devices and components.

Typical componentsSurface electrodes embedded in the socket, a controller to amplify/process EMG signals, rechargeable batteries, and motor-driven terminal devices.

IndicationsConsidered medically necessary for traumatic amputation or congenital absence at the wrist or above when candidacy criteria are met.

MRADL (inv-34)

AcronymMRADL

MeaningMobility related activities of daily living.

ContextUsed as the functional goal that prosthetic devices must significantly improve or restore to meet medical necessity criteria.

Myoelectric prosthesis (inv-35)

DefinitionA prosthesis that uses electromyographic signals from residual limb muscles, detected by surface electrodes, amplified and processed to drive motors that move terminal devices, wrist, or elbow.

Signal acquisitionSurface electrodes embedded in the socket detect muscle action potentials from voluntarily contracting residual muscles.

FunctionAmplified EMG signals activate electric motors to provide terminal device operation, wrist rotation, and elbow motion.

Implantable Myoelectric Sensors (IMES) (inv-36)

DefinitionSmall implantable electrodes intended to detect and wirelessly transmit EMG signals from residual muscles to a prosthetic device to provide more stable, multi-site signal acquisition than surface EMG.

PurposeDesigned to capture EMG signals from multiple residual limb muscles and transmit them to a prosthetic hand for intuitive multi-degree-of-freedom control.

Evidence statusEarly clinical trial data are preliminary; IMES remain investigational pending further evidence and coding/coverage determinations.

Targeted Muscle Re-innervation (TMR) (inv-37)

DefinitionSurgical transfer of severed motor nerves to denervated target muscles to create additional EMG control sites and potentially improve prosthetic control and address neuroma-related pain.

MechanismRe-innervated target muscles contract in response to neural commands for the missing limb, creating additional, intuitive EMG control sites and reducing the need to switch control modes.

Clinical usePerformed extensively in high-level amputations with demonstrated improvement in functional prosthesis control; investigational in more distal amputations and for neuroma prevention/treatment.