Myoelectric Upper-Limb Prosthetic Components
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This policy governs medical necessity, investigational determinations, and prior authorization requirements for myoelectric upper-limb prosthetic components for Blue Cross Blue Shield - Massachusetts members.
No material clinical or coverage changes in this revision.
Coverage Criteria
Coverage summary and evidence-based criteria
Coverage stance varies by device and evidence:
Based on comparative studies and systematic review indicating similar capability to body-powered prostheses for light work and improved appearance over passive devices.
Considered investigational pending further study.
Considered investigational/not supported by evidence.
Considered investigational until further evidence is available.
Advanced upper-limb prosthetic components that combine sensor and myoelectric control (for example, the LUKE Arm/DEKA) are designated investigational. The policy text specifies that devices combining multiple sensor modalities with myoelectric control have not demonstrated consistent improvements in net health outcomes and therefore are not standard covered items; these devices are listed among prostheses considered investigational and excluded from coverage. HCPCS codes for powered grip assist gloves, independently articulating digits, and powered range-of-motion assist devices are also identified in the policy's investigational code list.
A prosthesis with individually powered digits (including partial-hand devices with independently articulating fingers) is considered investigational. The policy explicitly states that no peer-reviewed functional outcome studies were identified for myoelectric prostheses with individually powered digits for amputations distal to the wrist, and such devices are treated as investigational and excluded from coverage.
Myoelectric-controlled upper-limb orthoses (externally worn powered orthotic devices that detect muscle activity to provide assisted movement) are likewise considered investigational and excluded from coverage under the policy language referencing investigational items.
The policy states that for myoelectric prostheses with individually powered digits (eg, devices that provide independently articulating fingers), no peer-reviewed publications evaluating functional outcomes in amputees were identified. Because of this absence of published functional outcome data, the evidence is judged insufficient to determine an improvement in net health outcome, and these devices are considered investigational.
Except where the policy lists specific medical necessity criteria for myoelectric upper-limb prosthetic components, myoelectric upper limb prosthetic components are considered investigational. The policy further clarifies that devices designated investigational (including advanced sensor-and-myoelectric systems, prostheses with individually powered digits, powered grip assist gloves, powered range-of-motion devices, and myoelectric orthoses) are excluded from coverage.
The policy concludes there is insufficient evidence that sensor-and-myoelectric controlled advanced prostheses (eg, the LUKE Arm) consistently improve function or quality of life; home-use and prototype studies produced mixed results and did not show consistent advantages over conventional prostheses. Similarly, studies of most myoelectric orthoses are small and inconsistent (the largest identified study had N=18 without device training). Given these limitations, the policy finds the current evidence inadequate to support coverage of these devices.
Coding
| 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). |
| L6925 | Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device. |
| L6935 | Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Block or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device. |
| L6945 | Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device. |
| L6955 | Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device. |
| L6965 | Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, 2 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, 2 batteries and one charger, myoelectronic control of |
| L7007 | Electric hand, switch or myoelectric controlled, adult. |
| L7008 | Electric hand, switch or myoelectric controlled, pediatric. |
| L7009 | Electric hook, switch or myoelectric controlled, adult. |
| L7045 | Electric hook, switch or myoelectric controlled, pediatric. |
| L7180 | Electronic elbow, microprocessor sequential control of elbow and terminal device. |
| L7181 | Electronic elbow, microprocessor simultaneous control of elbow and terminal device. |
| L7190 | Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled. |
| L7191 | Electronic elbow, child, Variety Village or equal, myoelectronically controlled. |
| F0DZ8UZ | Prosthesis Device Fitting using Prosthesis. |
| F0DZ8FZ | Prosthesis Device Fitting using Assistive, Adaptive, Supportive or Protective Equipment. |
| A8005 | Powered, cable driven grip assist glove, hand, finger, includes microprocessor, pressure sensors, all components and accessories, custom fitted. |
| A8006 | Powered, cable driven grip assist glove, hand, finger, includes pressure sensors, glove replacement only. |
| L6700 | Upper extremity addition, external powered feature, myoelectronic control module, additional EMG inputs, pattern-recognition decoding intent movement. |
| L6880 | Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s). |
| L8701 | Powered upper extremity range of motion assist device, elbow, wrist, hand with single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated. |
| L8702 | Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated. |
Provider Actions & Prior Authorization
Prior authorization required for inpatient and specified outpatient members
Precertification (prior authorization) is required for all inpatient services described in this policy. For outpatient services, prior authorization is required for Commercial Managed Care (HMO and POS) and Commercial PPO members; Medicare HMO and Medicare PPO outpatient prior authorization is not required. Providers must follow the payer's prior authorization processes (e.g., Authorization Manager) where requested.
- Inpatient: precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
- Outpatient: Commercial Managed Care (HMO and POS) and Commercial PPO = prior authorization required; Medicare HMO and Medicare PPO outpatient = prior authorization not required.
- Follow payer prior authorization processes (Authorization Manager) and the policy history clarifications.
Follow payer prior authorization processes as clarified in policy history
Policy history clarifies prior authorization procedures; providers must submit requests using the payer's established processes (for example, Authorization Manager) and comply with updated coding and submission requirements documented in the policy history.
- Policy history entries note clarifications to prior authorization and Authorization Manager usage (see Policy History).
- Use the payer's current prior authorization process as requested.
Use Authorization Manager and enter facility and servicing provider NPIs
Use Authorization Manager to submit initial authorization requests and ensure accurate processing by entering the facility's NPI/provider ID for the service location and the servicing provider's NPI/provider ID (the surgeon or servicing provider), not the billing group.
- Submit initial authorization requests through Authorization Manager (available 24/7).
- Enter facility NPI/provider ID and the servicing provider's NPI/provider ID.
- Out-of-network providers should fax requests to 888-282-0780 and complete the Prior Authorization Request Form (973) in Authorization Manager.
Consider less complex alternatives before myoelectric components
When passive or body-powered prostheses are adequate to meet an individual’s functional needs, myoelectric components may be considered only if those less complex alternatives are insufficient.
- Policy requires that standard body-powered prosthetic devices cannot be used or are insufficient before myoelectric components are considered.
- Evidence summary indicates myoelectric components may be considered when passive or body-powered prostheses cannot meet activities of daily living.
Authorization submission requirements and form completion
Submit initial authorizations using Authorization Manager and complete the Prior Authorization Request Form (973); for accurate processing, enter the facility NPI/provider ID and the servicing provider’s NPI/provider ID. For commercial members, requests must meet medical policy guidelines; out-of-network providers should fax requests to 888-282-0780.
- Complete Prior Authorization Request Form for Myoelectric Prosthetic and Components for the Upper Limb (973) in Authorization Manager.
- For out-of-network providers, fax requests to 888-282-0780.
Include device and clinical justification in authorization documentation
Include device specification (for example, LUKE Arm/DEKA or MyoPro), level of amputation or description of weakness, and documentation that passive or body-powered prostheses are insufficient when applicable; provide evidence that the individual meets the medical necessity criteria (eg, minimum myoelectric signal, neurological/cognitive function, and functional evaluation results).
- Specify device type (eg, LUKE Arm/DEKA, MyoPro) in clinical documentation.
- Document amputation level or the nature/level of limb weakness.
- Demonstrate that passive or body-powered prostheses cannot be used or are insufficient and that remaining musculature meets the minimum microvolt threshold.
Investigational devices may be denied
Devices determined investigational are subject to denial of coverage; examples include advanced sensor-and-myoelectric controlled prostheses (eg, LUKE Arm), prostheses with individually powered digits, and myoelectric-controlled upper-limb orthoses.
- Advanced systems with both sensor and myoelectric control (LUKE Arm/DEKA) are considered investigational.
- Prostheses with individually powered digits (eg, independently articulating digits) are investigational.
- Myoelectric-controlled upper-limb orthoses are considered investigational.
Risk of denial when evidence is insufficient
There is insufficient evidence that sensor-and-myoelectric controlled advanced prostheses and most myoelectric orthoses improve net health outcome; submissions lacking evidence of benefit may be denied as investigational or not medically necessary.
- Summary of evidence for sensor-and-myoelectric controlled prostheses indicates mixed functional improvements and insufficient evidence of net health outcome benefit.
- Evidence for myoelectric orthoses is limited and inconsistent (largest study N=18); insufficient to determine improvement in net health outcome.
Background
Upper-limb amputation may result from trauma, surgery, or congenital conditions; prosthetic management aims to restore function and appearance. Prostheses range from passive (cosmetic) and body-powered systems (harness/cable-driven) to electrically powered myoelectric devices that use surface electromyographic signals to drive motors for the hand, wrist, or elbow.
Device complexity increases with higher levels of amputation. The LUKE Arm is described as the first commercially available myoelectric upper-limb capable of multiple simultaneous powered movements (elbow, wrist, hand) and incorporates electromyographic electrodes plus switches, movement and force sensors. Despite advanced capabilities, prototype and home-use evaluations to date have shown mixed functional benefits, which is reflected in the policy's cautious coverage stance for such high-complexity systems.
Clinical selection of prosthetic components in this policy emphasizes that myoelectric components may be considered medically necessary only when listed criteria are met (amputation at or proximal to the wrist, inadequate function with body-powered options, sufficient residual musculature signal, adequate neurologic/cognitive status, absence of interfering comorbidities, and a functional evaluation indicating likely benefit with training). Independent professional evaluation is required to verify these medical necessity criteria.
Definitions
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