Criteria
Myoelectric upper arm prosthetic components and myoelectric hand prostheses may be considered medically necessary when
ALL
of the following conditions are met:
-
The individual has an amputation or missing limb at the wrist or above (forearm, elbow, etc.);
and
-
Standard body-powered prosthetic devices cannot be used or are insufficient to meet the functional needs of the individual in performing activities of daily living;
and
-
Evaluation indicates that a myoelectric prosthesis meets the functional needs of the individual in performing activities of daily living and that the individual has demonstrated sufficient physiological and cognitive function to allow effective operation of a myoelectric prosthetic device;
and
-
The individual must be able to tolerate the weight of the upper extremity myoelectric prosthesis;
and
-
The individual retains sufficient microvolt threshold in the residual limb to allow proper function of the prosthesis or can utilize appropriate switch control;
and
-
The individual does not function in an environment that would inhibit function of the prosthesis (i.e., a wet environment) or a situation involving electrical discharges that would affect the prosthesis;
and
- The individual is free of comorbidities that could interfere with the function of the prosthesis (neuromuscular disease, etc.)
Upper myoelectric prostheses and myoelectric hand prostheses are considered not medically necessary in
EITHER
of the following circumstances:
-
Individuals that routinely lift heavy items;
or
- Environmental exposure to dirt, dust, grease, water and solvents.
Myoelectric upper limb prosthetic components not meeting the criteria as indicated in this policy are considered not medically necessary.
High-definition silicone used to make a prosthesis resemble an individual's skin is considered cosmetic and, therefore, non-covered.
NOTE:
Because of expected normal growth and development, pediatric upper extremity amputees typically require upper extremity prosthesis replacement or refitting at 18-month intervals.
Amputees should be evaluated by an independent qualified professional (physiatrist or orthopedic surgeon with training and experience in providing rehabilitation of upper extremity amputees along with a prosthetist also with training and experience in fitting/fabrication of upper extremity myoelectric prosthetics) to determine the most appropriate prosthetic components and control mechanism. Consideration should be given to the amputee's needs for control, durability (maintenance), function (speed, work capability), and usability.
Coverage may be made only if there is sufficient documentation in the individual's medical record showing functional need for the myoelectric upper limb prosthesis. This information must be retained in the physician's or prosthetist's files, and be available upon request.
Procedure Codes
| L6882 | L6890 | L6895 | L7007 | L7008 | L7009 | L7045 |
| L7190 | L7191 | L7499 |
