The following HCPCS codes are explicitly listed as not covered for Medicare Advantage Plans and as not medically necessary for Commercial Products: 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; and 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.

For Commercial products, myoelectric controlled upper-limb orthoses are considered not medically necessary because the evidence is insufficient to determine the effects of the technology on health outcomes. Claims submitted with HCPCS codes L8701 or L8702 for Commercial members will be processed as not medically necessary per this policy.

Myoelectric orthoses are custom-fabricated, powered upper-extremity devices that use noninvasive surface neurologic sensors, microprocessors, and motors to detect and amplify weak muscle activity and assist bi-directional movement. They are intended for patients with upper-extremity weakness or paresis from conditions such as stroke, cerebral palsy, traumatic brain injury, spinal cord injury, brachial plexus injury, neuromuscular disease, amyotrophic lateral sclerosis, or multiple sclerosis. Available evidence is limited to small studies with inconsistent results; for example, device descriptions note a typical device weight of about 1.8 kg (4 lb) and features such as manual wrist articulation and myoelectric-initiated elbow motion, but clinical effectiveness has not been established.