CurrentKaiser PermanentePolicy N/A

clinical-review-upper-extremity-prosthetics-ga.pdf

Defines indications, contraindications, clinical considerations, device types, components, and review guidance used by Quality Resource Management to determine medical necessity for upper extremity prostheses. Includes clinical background, fitting/timing recommendations, and references to myoelectric prosthesis coverage criteria from other payers.

Policy Summary

PayerKaiser Permanente

Policyclinical-review-upper-extremity-prosthetics-ga.pdf

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review Date02/13/2023

Key ActionRecord diagnosis and clinical rationale that prosthesis will provide needed basic arm/hand function and that body-powered devices are insufficient when requesting an externally powered/myoelectric device.

POLICY UPDATE CHANGES

No material clinical/coverage changes

2Primary Covered Indications

2Primary Contraindications

1High-end review threshold ($30k)

Coverage Summary

This policy addresses upper extremity prosthetics and the Quality Resource Management criteria used to determine medical necessity. Primary covered indications include congenital limb deficiency and amputation (traumatic or secondary to tumor or vascular problem). The coverage stance is mixed — standard and preparatory prostheses are generally supported when indications are met, while higher-end externally powered/myoelectric devices require additional review. Physician review is required for myoelectric devices and high-end prosthesis review is suggested when cost > $30,000. Effective/last reviewed dates: last review 2023-02-13 (no effective or next review date listed).

Indications and Contraindications (Medical Necessity)

Indications and Contraindications

Covered when ALL of the following indications are met and NONE of the contraindications are present:

ALL of the following

Diagnosis consistent with upper extremity limb loss or deficiency (congenital limb deficiency or amputation traumatic or secondary to tumor or vascular problem)
Document applicable ICD/CPT/HCPCS diagnosis codes listed in section 2.0
ONE of
- Fitting for and training to use a prosthetic that will provide basic function of the arm and hand (general eligibility statement)
- Externally powered (myoelectric) prosthesis may be indicated when a standard powered prosthetic device cannot be used or is insufficient to meet the functional needs of the person performing activities of daily living
  These require physician review; consider sending to MCMC for high-end prosthesis review when cost > $30,000
Patient has adequate cognitive and neurologic ability to utilize a myoelectric prosthetic device
From referenced Aetna criteria
Remaining musculature contains minimum microvolt threshold to allow operation of a myoelectric prosthetic device
From referenced Aetna criteria
Absence of comorbidity that would interfere with maintaining function of the prosthesis (e.g., neuromuscular disease)
From referenced Aetna criteria

Provider Actions & Authorization

Prior Authorization

Physician review and high-end prosthesis review for costly devices

Externally powered/myoelectric prostheses require physician review; consider sending to MCMC for high-end prosthesis review when cost > $30,000.

Cost threshold: $30,000
Consider referral to MCMC for high-end prosthesis review

Documentation Required

Document diagnosis and functional need

Record diagnosis (congenital limb deficiency or amputation) and clinical rationale that prosthesis will provide needed basic arm/hand function and that body-powered devices are insufficient when requesting an externally powered/myoelectric device.

Diagnosis (congenital limb deficiency or amputation)
Clinical rationale that device provides needed basic arm/hand function
Explanation why body-powered devices are insufficient

Documentation Required

Assess patient suitability for myoelectric device

Document cognitive/neurologic ability, sufficient residual muscle microvolt thresholds, and absence of comorbidities that would interfere with prosthesis function.

Cognitive and neurologic ability to utilize a myoelectric prosthetic device
Remaining musculature meets minimum microvolt thresholds for device operation
Absence of comorbidities that could interfere with maintaining prosthesis function (e.g., neuromuscular disease)

Denial Risk

Contraindication-based denial risk

Claims may be denied if residual limb infection is present or patient is resistant to using a prosthetic.

Residual limb infection
Patient resistance to using a prosthetic

Clinical Background

Clinical overview: upper extremity prosthetics range from primarily cosmetic to highly functional devices including cosmetic, body-powered (cable-controlled), and externally powered/myoelectric (and switch-controlled) systems. Typical components include sockets, suspension systems, control systems/cables, and terminal devices. Body-powered devices use cable control and harnessing; externally powered devices use batteries, motors, and control systems (myoelectric or switch control). Terminal devices (hooks or prosthetic hands) provide key grips and vary by function and cosmesis. Fitting and timing: prostheses may be preparatory (temporary) or definitive (permanent); fitting a preparatory body-powered prosthesis within 7–30 days after amputation is advisable to improve acceptance and outcomes, while definitive fitting may be delayed until the residual limb is mature. Perioperative and rehabilitation considerations include pre-amputation rehabilitation team involvement, intraoperative techniques to optimize residual limb function (e.g., myoplasty/myodesis, bone beveling, nerve handling), acute postoperative wound and pain management, edema control, desensitization, psychological support, and staged prosthetic training and functional reintegration.

Term	Definition
Residual limb	The preferred term for the remaining portion of the amputated limb
Terminal device	The most distal part of a prosthesis that substitutes for the hand
Myodesis	Direct suturing of residual muscle or tendon to bone/periosteum
Myoplasty	Suturing of agonist-antagonist muscle pairs to each other

Evidence and references: Aetna policy cited for myoelectric prosthesis medical necessity (Aetna CPB: Myoelectric Upper Limb Prosthesis, 8/2021) and MCG 23rd Ed. Myoelectric UE Prosthesis A-0701. The source lists Aetna criteria items for myoelectric eligibility (cognitive/neurologic ability, sufficient residual muscle microvolt thresholds, insufficiency of standard body-powered device, absence of interfering comorbidity).