CORONAVIRUS (COVID-19)

Resources on COVID-19 and how BCBSND is responding to help protect all North Dakotans

Myoelectric Prosthetic Components for the Upper Limb

Section: Orthotic & Prosthetic Devices
Effective Date: January 01, 2020
Revised Date: November 14, 2019
Last Reviewed: November 14, 2019

Description

The myoelectric upper limb prosthesis is used for amputations at any level from above the wrist to the shoulder. The primary goals of the upper limb prosthesis are to restore natural appearance and function.

The myoelectric hand prosthesis imitates the true movement and accuracy of the human hand. The myoelectric hand has powered digits that have the ability to open and close around objects.

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 would be contraindicated and 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 are considered not medically necessary under all other conditions.

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.

Reimbursement 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.

High-definition silicone used to make a prosthesis resemble a individual’s skin is considered cosmetic and therefore, non-covered.

Procedure Codes

L6890 L6895 L7007 L7008 L7009 L7045 L7190
L7191 L7499

A prosthesis with individually powered digits, including a partial hand prosthesis is considered experimental/investigational and, therefore, non covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

Procedure Codes

L6026 L6715 L6880

Terminal devices may be considered medically necessary for work and when essential to activities of daily living. Terminal devices are considered not medically necessary when used solely for activities related to sports or recreation.

Procedure Codes

L6704 L6925 L6930 L6935 L6945 L6955 L6965
L6975 L7180 L7181

Diagnosis Codes

Q71.51 Q71.52 Q71.53 Q71.90 Q71.91 Q71.92 Q71.93
Q71.811 Q71.812 Q71.813 Q71.819 Q71.891 Q71.892 Q71.893
Q71.899 S48.011A S48.012A S48.019A S48.021A S48.022A S48.029A
S48.111A S48.112A S48.119A S48.121A S48.122A S48.129A S48.911A
S48.912A S48.919A S48.921A S48.922A S48.929A S58.011A S58.012A
S58.019A S58.021A S58.022A S58.029A S58.111A S58.112A S58.119A
S58.121A S58.122A S58.129A S58.911A S58.912A S58.919A S58.921A
S58.922A S58.929A S68.411A S68.412A S68.419A S68.421A S68.422A
S68.429A S68.711A S68.712A S68.719A S68.721A S68.722A S68.729A
Z44.001 Z44.002 Z44.009 Z44.011 Z44.012 Z44.019 Z44.021
Z44.022 Z44.029 Z89.111 Z89.112 Z89.119 Z89.121 Z89.122
Z89.129

Links