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.
Myoelectric upper arm prosthetic components and myoelectric hand prostheses may be considered medically necessary when ALL of the following conditions are met:
Upper myoelectric prostheses and myoelectric hand prostheses would be contraindicated and not medically necessary in EITHER of the following circumstances:
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.
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.
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.