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DESCRIPTIONMyoelectric prostheses are powered by electric motors with an external power source. The joint movement of an upper limb prosthesis (e.g., hand, wrist, and/or elbow) is driven by microchip-processed electrical activity in the muscles of the remaining limb stump.
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.
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.
POLICYMyoelectric upper limb prosthetic components may be considered medically necessary when the following conditions are met:
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.
POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
POLICY GUIDELINESAmputees should be evaluated by an independent qualified professional to determine the most appropriate prosthetic components and control mechanism (e.g., body-powered, myoelectric, or combination of body-powered and myoelectric). A trial period may be indicated to evaluate the tolerability and efficacy of the prosthesis in a real life setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member’s specific benefit plan language.
POLICY HISTORY2/4/2009: Policy added
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.
09/03/2013: Policy title changed from "Myoelectric Prosthesis for the Upper Limb" to "Myoelectric Prosthetic Components for the Upper Limb." Policy statement unchanged. Added HCPCS codes L6880, L7190, and L7191 to the Code Reference section.
SOURCESBlue Cross Blue Shield Association policy # 1.04.04
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.