Myoelectric Controlled Upper-Limb Orthoses Coverage Policy
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Policy governs coverage and medical necessity determinations for myoelectric controlled upper-limb orthoses for members of Blue Cross Blue Shield - Rhode Island, including Medicare Advantage and Commercial products.
No material clinical or coverage changes in this revision.
Coverage Determination
Coverage determination and evidence summary
Covered when ALL of the following are met:
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For members enrolled in Medicare Advantage Plans, myoelectric controlled upper-limb orthoses are not covered. The policy states that the available evidence is insufficient to determine the effects of this technology on health outcomes. Providers should expect claims for these devices (including those billed to HCPCS codes L8701 and L8702) to be denied under Medicare Advantage benefits unless a contract specifies otherwise.
For Commercial products, myoelectric controlled upper-limb orthoses are considered not medically necessary. The rationale is that the evidence is insufficient to determine the effect of the technology on health outcomes. The policy specifically identifies HCPCS codes L8701 and L8702 as not medically necessary for Commercial products.
HCPCS / Billing Codes
| 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 and Billing Guidance
Prior Authorization
Prior authorization not required for this service. Verify member benefits and eligibility before submission as coverage may vary by contract.
- Prior authorization: Not applicable
Denial Risk
For Medicare Advantage members, myoelectric controlled upper-limb orthoses are not covered. For Commercial members, myoelectric controlled upper-limb orthoses are not medically necessary. Claims may be denied consistent with these policy determinations.
- Medicare Advantage: Not covered
- Commercial: Not medically necessary
Documentation and Benefit Verification
Benefits and coverage can differ by group and contract. Before providing services or submitting a claim, review the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to confirm whether the service is a covered benefit for that member.
- Refer to the member's Benefit Booklet / Evidence of Coverage / Subscriber Agreement
- For member-specific benefits or eligibility questions, contact the provider call center
Provider Notice
This medical policy is informational and does not guarantee payment. If services are determined to be not medically necessary or non-covered, do not bill the member unless they have provided written consent to self-pay after being informed. BCBSRI may revise this policy at any time.
- Do not charge members for non-covered or not medically necessary services unless documented written consent is obtained
- Policy superseded by member's subscriber agreement / employer agreement for benefit determination
Background and Evidence
Myoelectric orthoses are custom-fabricated, powered upper-extremity range-of-motion assist devices intended to restore or support arm and hand function for patients with upper-extremity weakness. They use noninvasive surface sensors and a microprocessor to detect residual muscle activity and to initiate motor-driven assistance for elbow, wrist, and hand movement. Examples described in the source include devices with adjustable signal gain, thresholds, and range-of-motion settings; one commercially referenced device (Myomo/MyPro) weighs about 1.8 kg, has manual wrist articulation and myoelectric bi-directional elbow movement, and includes motors, electronics, and batteries.
Definitions
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