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.
No material clinical/coverage changes
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).
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