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Upper limb prostheses are used for amputations at any level from above the wrist to the shoulder. The need for a prosthesis can occur for a number of reasons, including trauma, surgery, or congenital anomalies. The primary goals of the upper limb prosthesis are to restore natural appearance and function. Achieving these goals also requires sufficient comfort and ease of use for continued acceptance by the wearer. The difficulty of achieving these diverse goals with an upper arm prosthesis increases as the level of amputation (hand, wrist, elbow and shoulder), and thus the complexity of joint movement, increases.

Upper limb prostheses are classified into 3 categories depending on the means of generating movement at the joints: passive, body-powered and electrically-powered movement. All 3 types of prostheses have been in use for over 30 years; each possesses unique advantages and disadvantages.

• The passive prosthesis is the lightest of the three types and is described as the most comfortable. Since the passive prosthesis must be repositioned manually, typically by moving it with the opposite arm, it cannot restore function.
• The body-powered prosthesis uses a body harness and cable system to provide functional manipulation of the elbow and hand. Voluntary movement of the shoulder and/or limb stump extends the cable and transmits the force to the terminal device. Prosthetic hand attachments, which may be claw-like devices that allow good grip strength and visual control of objects or latex-gloved devices that provide a more natural appearance at the expense of control, can be opened and closed by the cable system. Patient complaints with body-powered prostheses include harness discomfort, particularly the wear temperature, wire failure, and the unattractive appearance.
• Myoelectric prostheses use muscle activity from the remaining limb for the control of joint movement. Electromyographic (EMG) signals from the limb stump are detected by surface electrodes, amplified, and then processed by a controller to drive battery-powered motors that move the hand, wrist, or elbow. Although upper arm movement may be slow and limited to one joint at a time, myoelectric control of movement may be considered the most physiologically natural. Myoelectric hand attachments are similar in form to those offered with the body-powered prosthesis, but are battery powered. An example of recently available technology is the SensorHand™ by Advanced Arm Dynamics, which is described as having an AutoGrasp feature, an opening/closing speed of up to 300 mm/second, and advanced EMG signal processing. Patient dissatisfaction with myoelectric prostheses includes the increased cost, maintenance (particularly for the glove), and weight.
• A hybrid system, a combination of body-powered and myoelectric components, may be used for high-level amputations (at or above the elbow). Hybrid systems allow control of two joints at once (i.e., one body-powered and one myoelectric) and are generally lighter and less expensive than a prosthesis composed entirely of myoelectric components.

Technology in this area is rapidly changing, driven by advances in biomedical engineering and by the U.S. Department of Defense Advanced Research Projects Agency (DARPA), which is funding a public and private collaborative effort on prosthetic research and development. Areas of development include the use of skin-like silicone elastomer gloves, “artificial muscles”, and sensory feedback. Smaller motors, microcontrollers, implantable myoelectric sensors and reinervation of remaining muscle fibers are being developed to allow fine movement control. Lighter batteries and newer materials are being incorporated into myoelectric prostheses to improve comfort.

Manufacturers must register prostheses with the Food and Drug Administration's (FDA) restorative devices branch and keep a record of any complaints, but do not have to undergo a full FDA review. Available myoelectric devices include the Otto Bock myoelectric prosthesis (Otto Bock), the LTI Boston Digital Arm™ System (Liberating Technologies Inc.), and the Utah Arm Systems (Motion Control).

Also, see the related medical policies, Microprocessor-Controlled Prosthetic Knees and Functional Neuromuscular Stimulation to Provide Ambulation.

• The patient 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
• The remaining musculature of the arm(s) contains the minimum microvolt threshold to allow operation of a myoelectric prosthetic device; AND
• The patient has demonstrated sufficient neurological and cognitive function to operate the prosthesis effectively; AND
• The patient is free of comorbidities that could interfere with function of the prosthesis (neuromuscular disease, etc.); AND
• Functional evaluation indicates that with training, use of a myoelectric prosthesis is likely to meet the functional needs of the individual (e.g., gripping, releasing, holding, and coordinating movement of the prosthesis) when performing activities of daily living. This evaluation should consider the patient’s needs for control, durability (maintenance), function (speed, work capability), and usability.

A prosthesis with individually powered digits, including but not limited to a partial hand prosthesis, is considered investigational.

Myoelectric upper limb prosthetic components are considered not medically necessary under all other conditions.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member’s specific benefit plan language.

04/23/2010: Policy description updated regarding device availability; added links to related medical policies. Policy statement expanded to include conditions that must be met for myoelectric upper limb prosthetic components to be considered medically necessary, such as remaining musculature, neurological function, and absence of comorbidities that could interfere with the function of the prosthesis. Statement regarding trial period added to the policy guidelines. FEP verbiage added to the Policy Exceptions section.

04/19/2012: Policy title changed from "Myoelectric Prosthesis for the Upper Limb" to "Myoelectric Prosthetic Components for the Upper Limb." Policy statement unchanged. 

07/19/2012:  Policy title changed back to "Myoelectric Prosthesis for the Upper Limb."  Added the following policy statement:  A prosthesis with individually powered digits, including but not limited to a partial hand prosthesis, is considered investigational.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes     

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