CurrentBlue Cross Blue Shield - MassachusettsPolicy N/A

Myoelectric Upper Limb Prosthetic Devices and Components - Coverage Criteria

Coverage and prior authorization requirements for myoelectric prosthetic devices and components for upper limb amputations or missing limbs at/above the wrist for Blue Cross Blue Shield Massachusetts members; applies to providers requesting authorization and submitting clinical documentation.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyMyoelectric Upper Limb Prosthetic Devices and Components - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization via Authorization Manager using form 973 and include clinical documentation demonstrating medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1authorization form referenced (973)

multipleHCPCS codes listed

listedinvestigational items

Coverage Criteria for Myoelectric Upper Limb Prosthetics

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Primary medical necessity criteria: The patient has an amputation or missing limb at the wrist or above (eg, forearm, elbow); standard body-powered prosthetic devices cannot be used or are insufficient to meet the functional needs of the individual in performing activities of daily living; the remaining musculature of the arm(s) contains the minimum microvolt threshold to allow operation of a myoelectric prosthetic device; the patient has demonstrated sufficient neurological and cognitive function to operate the prosthesis effectively; the patient is free of comorbidities that could interfere with function of the prosthesis (eg, neuromuscular conditions); functional evaluation indicates that with training the myoelectric prosthesis is likely to meet the functional needs of the individual (eg, gripping, releasing, holding, coordinating movement) when performing activities of daily living; and an independent qualified professional has evaluated the amputee and verified that the amputee meets all medical necessity criteria for the device.

All elements listed must be documented

The following advanced myoelectric components are considered investigational and are not covered: devices that combine both advanced sensors and myoelectric control (for example, the LUKE Arm). Additionally, myoelectric upper-limb prosthetic components are considered investigational under all other conditions not meeting the listed medical necessity criteria.

Coding — HCPCS / Diagnosis Codes

Covered HCPCS Codes (listed)HCPCSCovered

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
L6925	Wrist disarticulation, external power; self-suspended inner socket; removable forearm shell; electrodes, cables, 2 batteries and one charger, myoelectric control of terminal device
L6935	Below elbow, external power; self-suspended inner socket; removable forearm shell; electrodes, cables, 2 batteries and one charger, myoelectric control of terminal device
L6945	Elbow disarticulation, external power, molded inner socket, removable humeral shell; outside locking hinges, electrodes, cables, 2 batteries and one charger; myoelectric control of terminal device
L6955	Forearm myoelectric control components, electrodes, cables, batteries and charger
L6965	Shoulder disarticulation, external power, molded inner socket; removable shoulder shell; batteries and charger; myoelectric control of terminal device
L6975	Interscapular-thoracic, external power, molded inner socket; removable shoulder shell; shoulder bulkhead, humeral section, mechanical elbow; forearm, electrodes, cables, 2 batteries and one charger, myoelectric control of terminal device
L7007	Electric hand, switch or myoelectric controlled, adult
L7008	Electric hand, switch or myoelectric controlled, pediatric
L7009	Electric hook, switch or myoelectric controlled, adult

1–10 of 15

1/2

Diagnosis / other relevant codes (placeholders)ICD-10

No codes listed

Provider Actions — Authorization & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Myoelectric Prosthetic and Components for the Upper Limb. Use Authorization Manager to submit initial authorization requests and supporting clinical documentation. Complete the Prior Authorization Request Form for Myoelectric Prosthetic and Components for the Upper Limb (Form 973) in Authorization Manager. For out-of-network providers, fax requests to BCBSMA Members: 888-282-0780 or Medicare Advantage Members: 800-447-2994.

Use Authorization Manager (available 24/7) to request prior authorization, submit clinical documentation, check case status, and view/print decision letters.
Enter the servicing surgeon's NPI/provider ID as the servicing provider (not the billing group) and the facility's NPI/provider ID for the service site.
Form: Prior Authorization Request Form for Myoelectric Prosthetic and Components for the Upper Limb (973).

Documentation Required

Independent Evaluation Required

An independent qualified professional must evaluate the amputee and verify that the selected prosthetic components and control mechanism are the most appropriate for the patient (for example, body-powered, myoelectric, or a combination). The independent evaluation must confirm that the amputee meets all medical necessity criteria for the requested device.

Evaluation must determine appropriate prosthetic components and control mechanism.
Independent qualified professional must verify that medical necessity criteria are met.

Documentation Required

Clinical Documentation & Submission Route

Clinical documentation that supports medical necessity must be submitted with the authorization request. If the patient does not meet all required clinical criteria, submit a Letter of Medical Necessity with a request for a Clinical Exception (Individual Consideration) explaining why an exception is justified.

Documentation must demonstrate: level of amputation (wrist or above), insufficiency of standard body-powered devices, adequate residual musculature microvolt threshold to operate a myoelectric device, sufficient neurological and cognitive function to operate the prosthesis, absence of comorbidities that would interfere with prosthesis function, and functional evaluation indicating likely benefit with training.
If criteria are not met, include a Letter of Medical Necessity and request Clinical Exception (Individual Consideration).
Submit all supporting documentation via Authorization Manager or by the out-of-network fax numbers when applicable.

Denial Risk

Clinical Criteria Not Met

If the clinical criteria for coverage are not met, coverage may be denied unless an exception is granted. In such cases, providers should submit a Letter of Medical Necessity and request a Clinical Exception (Individual Consideration) explaining why the exception is justified and include all supporting clinical information.

Absent meeting all listed criteria, request an Individual Consideration (Clinical Exception) with a detailed Letter of Medical Necessity.
Failure to provide required documentation or justification for an exception may result in denial of the request.

Background

A myoelectric upper limb prosthesis is an externally powered prosthetic system that uses electrical signals from the patient’s remaining limb musculature to control terminal devices and components for functions such as grasping, releasing, holding, and coordinating movement. Candidate selection requires documentation that the patient has an amputation at or above the wrist; sufficient residual musculature signal (minimum microvolt threshold) to operate the device; adequate neurological and cognitive function to use the prosthesis effectively; absence of comorbidities that would interfere with function; and a functional evaluation indicating that, with training, the myoelectric device is likely to meet the individual’s activities-of-daily-living needs. An independent qualified professional must evaluate the amputee and verify that all medical necessity criteria are met.

Definitions

Myoelectric upper limb prosthetic — definition and key functions

DefinitionAn externally powered prosthesis controlled by electrical signals from residual musculature used for grasping, releasing, holding, and coordinating movement for activities of daily living.

Indication thresholdPatient has an amputation or missing limb at or above the wrist (eg, forearm, elbow).

Functional requirementsStandard body-powered prosthetic devices cannot be used or are insufficient to meet activities of daily living. Remaining musculature contains the minimum microvolt threshold to operate a myoelectric device; patient has sufficient neurological and cognitive function; patient is free of comorbidities that could interfere with prosthesis function.

Evaluation requirementFunctional evaluation indicates that with training the myoelectric prosthesis is likely to meet the individual’s functional needs (eg, gripping, releasing, holding, coordinating movement).

Coverage exceptionsAdvanced upper-limb prosthetic components with both sensor and myoelectric control (eg, LUKE Arm), prostheses with individually powered digits (including some partial hand devices), and myoelectric-controlled upper-limb orthoses are considered investigational and not covered unless meeting specific criteria.

Independent qualified professional — definition and role

DefinitionA clinician who evaluates the amputee to determine the most appropriate prosthetic components and control mechanism (eg, body-powered, myoelectric, or combination) and verifies that the amputee meets all medical necessity criteria for the device.

Role in coverage decisionsPer policy, the independent qualified professional must evaluate and verify that medical necessity criteria are met before coverage is approved.

Evaluation scopeAssessment includes residual musculature signal adequacy (microvolt threshold), cognitive/neurological ability to operate the device, comorbidities affecting function, and functional benefit compared with alternatives.

DocumentationThe independent qualified professional’s evaluation must be documented as part of the clinical record submitted for prior authorization and coverage determination.