Myoelectric Upper-Limb Prosthetic Components — Coverage and Medical Necessity
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Coverage and medical necessity criteria for myoelectric upper-limb prosthetic components and related devices for Commercial and Medicare members of Blue Cross Blue Shield of Massachusetts.
Clarified coding information.
Investigational statements added for myoelectric orthoses and prostheses with both sensor and myoelectric control.
Prior authorization information clarified for PPO plans and inclusion of Authorization Manager for prior authorization requests.
Coverage and Medical Necessity Criteria
Medical Necessity (Commercial Members)
Covered when ALL of the following are met:
From Commercial Members criteria
Investigational / Unproven
Devices considered investigational:
Investigational devices listed in policy
Evidence-based coverage determinations
Summary of evidence and coverage stance as presented in this section:
Based on systematic review and comparative studies (chunk 20).
Based on 12-week home study and related publications (chunks 20-21).
No peer-reviewed publications identified (chunk 21).
Largest within-subject study N=18; inconsistent results (chunk 21).
Myoelectric upper limb prosthetic components that do not meet the specific medical necessity criteria in this policy are considered investigational under all other conditions. Examples of HCPCS codes associated with devices or features identified as investigational in the policy include, but are not limited to, L6880 (electric hand with independently articulating digits), L8701 and L8702 (powered upper extremity range-of-motion assist devices with microprocessor and sensors), and codes for advanced pattern-recognition or additional EMG input modules (e.g., L67oo).
The investigational designation means these devices or components are not covered when used outside the policy’s stated medical necessity criteria.
No peer-reviewed publications were identified evaluating functional outcomes for myoelectric prostheses with individually powered digits for amputations distal to the wrist. Because of this lack of published evidence, the policy considers such devices to have insufficient evidence to determine improvement in net health outcome and treats them as investigational.
Use of myoelectric upper limb prosthetic components that do not meet the policy’s stated medical necessity criteria is considered not medically necessary. Providers should confirm that all required criteria are met before requesting coverage or submitting claims; devices failing to meet those criteria are not eligible for coverage under this policy.
When evidence is incomplete or inconsistent for advanced devices—specifically sensor plus myoelectric controlled prostheses (for example, advanced prototypes evaluated in home studies) and myoelectric-powered upper-limb orthoses (eg, devices intended to augment movement in paresis)—the policy deems these technologies investigational or insufficient. The available studies report mixed or inconsistent functional improvements, limited sample sizes (largest within-subject orthosis study N=18), and no consistent quality-of-life benefits; therefore, these devices are not considered to have demonstrated net health benefit.
Coding and Procedure Codes
| 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 myoelectronic control of terminal device. |
| L6935 | Below elbow, external power; self-suspended inner socket; removable forearm shell, control of terminal device. |
| L6945 | Elbow disarticulation, external power, molded inner socket; removable humeral shell; and one charger, myoelectronic control of terminal device. |
| L6955 | Above elbow, external power; molded inner socket; removable humeral shell, internal locking elbow; forearm, charger, myoelectronic control of terminal device. |
| L6965 | Shoulder disarticulation, external power; molded inner socket; removable shoulder 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, electrodes, cables, 2 batteries and one charger; myoelectronic 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. |
| L7180 | Electronic elbow, microprocessor sequential control of elbow and terminal device. |
| L7190 | Electronic elbow, adolescent, myoelectronically controlled. |
| 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. |
| L67oo | Upper extremity addition, external powered feature, myoelectronic control module, additional EMG inputs pattern-recognition decoding intent movement. |
| FODZ8UZ | Prosthesis Device Fitting using Prosthesis. |
| FODZ8FZ | Prosthesis Device Fitting using Assistive, Adaptive, Supportive or Protective Equipment. |
| No codes listed |
Provider Requirements, Prior Authorization, and Billing Guidance
Prior Authorization Required
Prior authorization must be requested via Authorization Manager for many commercial products. Precertification/preauthorization is required when the procedure is performed inpatient. For outpatient settings, prior authorization requirements vary by product: Commercial Managed Care (HMO and POS) outpatient = Prior authorization is required; Commercial PPO outpatient = Prior authorization is required; Medicare PPO outpatient = Prior authorization is not required.
- Precertification/preauthorization is required for inpatient procedures described in this policy.
- Outpatient prior authorization requirements vary by product — see payer-specific rules above.
Requesting Prior Authorization Using Authorization Manager
Providers must submit initial authorization requests using Authorization Manager (available 24/7). Authorization Manager is the preferred and quickest method to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. Out-of-network providers should fax requests to 888-282-0780 when Authorization Manager is not available.
- Use Authorization Manager to submit initial authorization requests for commercial members.
- Out-of-network providers: fax requests to 888-282-0780.
Authorization Submission, Required Identifiers, and Coding Documentation
To ensure authorization requests are processed accurately and quickly, include required provider and facility identifiers and follow coding guidance when submitting both authorization requests and claims. Enter the individual surgeon’s NPI or provider ID as the servicing provider (do not enter the group), and enter the facility’s NPI or provider ID for the location where services will be performed. Follow the most recent coding guidance when completing authorization and claim documentation.
- Enter the servicing provider's individual NPI or provider ID (not the group).
- Enter the facility’s NPI or provider ID for the service location.
- Include accurate, updated coding on the authorization request and supporting documentation; follow clarified coding guidance from policy history.
Background
Upper-limb prostheses are designed to restore appearance and function after trauma, surgery, or congenital absence. Prostheses are classified broadly as passive, body-powered, or electrically powered (myoelectric), with complexity and difficulty of achieving functional use increasing with higher levels of amputation. The goals of prosthetic fitting include improving function (grip, release, holding, coordinated movement), appearance, and comfort to support continued use, and device selection should consider the individual’s amputation level, residual musculature, functional needs, and ability to operate the chosen control system.
Definitions
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