Clinical UM Guideline


Subject:  Myoelectric Upper Extremity Prosthetic Devices
Guideline #:  CG-OR-PR-05Current Effective Date:  04/15/2014
Status:RevisedLast Review Date:  02/13/2014

Description

This document addresses the use of myoelectric upper extremity (i.e., hand and/or arm) prostheses.  This type of prosthesis is differentiated from standard upper extremity prostheses by the incorporation of an external power source, electric motors and microprocessing units.

For information on related prostheses, please refer to the following documents:

Clinical Indications

Medically Necessary:

The use of myoelectric upper extremity prosthetic devices is considered medically necessary when ALL of the following criteria have been met:

  1. The individual has sufficient neurological, myocutaneous and cognitive function to operate the prosthesis effectively; and
  2. The individual has an amputation or missing limb at the wrist or above (i.e., forearm, elbow, etc); and
  3. The individual is free of comorbidities that could interfere with maintaining function of the prosthesis (i.e., neuromuscular disease, etc); and
  4. The individual retains sufficient microvolt threshold in the residual limb to allow proper function of the prosthesis; and
  5. Standard body powered prosthetic devices cannot be used (for example, but not limited to, brachial plexus injury, shoulder tendinitis or other shoulder injury, unable to wear harness) or are insufficient to meet the functional needs of the individual (for example, but not limited to, need to do regular overhead activity); and
  6. 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).

Not Medically Necessary: 

The use of myoelectric upper extremity prosthetic devices is considered not medically necessary when any of the criteria above are not met.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS 
 Prostheses
L6925Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device
L6935Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device
L6945Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device
L6955Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device
L6965Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device
L6975Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device
 Additions
L6611Addition to upper extremity prosthesis, external powered, additional switch, any type
L6677Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow
L6880Electric hand, switch or myolelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s)
L6881Automatic grasp feature, addition to upper limb electric prosthetic terminal device
L6882Microprocessor control feature, addition to upper limb prosthetic terminal device
L7007Electric hand, switch or myoelectric controlled, adult [when specified as myoelectric]
L7008Electric hand, switch or myoelectric controlled, pediatric [when specified as myoelectric]
L7009Electric hook, switch or myoelectric controlled, adult [when specified as myoelectric]
L7045Electric hook, switch or myoelectric controlled, pediatric [when specified as myoelectric]
L7180Electronic elbow, microprocessor sequential control of elbow and terminal device
L7181Electronic elbow, microprocessor simultaneous control of elbow and terminal device
L7190Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled
L7191Electronic elbow, child, Variety Village or equal, myoelectronically controlled
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
755.20-755.27Reduction deformities of upper limb (congenital absence)
887.0-887.7Traumatic amputation of arm and hand (complete) (partial)
V49.64-V49.67Upper limb amputation status
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2014]
Q71.00-Q71.93Reduction deformities of upper limb
S48.011A-S48.929STraumatic amputation of shoulder and upper arm
S58.011A-S58.929STraumatic amputation of elbow and forearm
S68.011A-S68.729STraumatic amputation of wrist, hand and fingers
Z89.121-Z89.239Acquired absence of limb
  
Discussion/General Information

Myoelectric prostheses of the upper extremity are sophisticated alternatives to standard body-powered devices used for the replacement of upper extremities absent due to trauma, disease or congenital causes.  This type of prosthesis uses an external battery pack to supply power to electric motors and microprocessors that enable movement of the prosthetic elbow, wrist, and/or fingers in several planes.  Several benefits of myoelectric upper extremity prostheses have been proposed, including greater pinch and grip force over standard prosthetic devices, and more realistic appearance.

Myoelectric prosthetic devices operate through the use of surface electrodes embedded in the socket of the prosthesis.  When these electrodes come into contact with the skin they are able to detect and amplify the electrical activity of muscle groups in the residual limb.  These potentials are translated though the microprocessor units into limb movement via the electric motors in the limb function (e.g., terminal device operation, wrist rotation, elbow flexion).  The newest electronic control systems perform multiple functions and allow for sequential operation of elbow motion, wrist rotation and hand motion.  Sensation cannot be attained by a myoelectric prosthesis.

In one of the only available studies addressing the use of myoelectric arm prostheses, Ostlie and others evaluated the use of prosthetic arms in a convenience sample of 50 subjects (2012). Twenty one of these subjects used myoelectric devices, 19 were unilateral amputees and the other 2 were bilateral amputees.  Subjects were asked to perform a battery of physical tasks as well as complete a questionnaire and be interviewed by investigators regarding use patterns.  Unfortunately the authors provide no data to demonstrate the benefits of separate types of prosthetic devices in the physical tests.  Using the Actual Use Index (AUI), a composite score that measures the actual daily use of the prosthetic device, the authors constructed a multiple linear regression model.  They reported that when controlling for all covariates, only the use of myoelectric prosthesis and sufficient prosthetic training were predictive of increased prosthesis use.  The study did not focus on the benefits the myoelectric arm prosthesis and was not designed or powered to provide such data.

References

Peer Reviewed Publications:

  1. Crandall RC, Tomhave W. Pediatric unilateral below-elbow amputees: retrospective analysis of 34 patients given multiple prosthetic options. J Pediatr Orthop. 2002; 22(3):380-383.
  2. Kritter AE. Myoelectrical protheses. J Bone Joint Surg Am. 1985; 67(4):654-657.
  3. Nader, M. The artificial substitution of missing hands with myoelectrical prostheses. Clin Orthop. 1990; 258:9-17.
  4. Ostlie K, Lesjø IM, Franklin RJ, et al. Prosthesis use in adult acquired major upper-limb amputees: patterns of wear, prosthetic skills and the actual use of prostheses in activities of daily life. Disabil Rehabil Assist Technol. 2012; 7(6):479-493.
  5. Silcox DH Rooks MD, Vogel RR, et al. Myoelectrical Prostheses. A long term follow up and a study of the use of alternative prostheses. J Bone Joint Surg Am. 1993; 75(12):1781-1789.
  6. Stein RB, Walley M. Functional comparison of upper extremity amputees using myoelectric and conventional prostheses. Arch Phys Med Rehab. 1983; 64(6):243-248.
  7. Uellendahl JE.  Upper extremity myoelectric prosthetics. Phys Med Rehabil Clin N Am. 2000; 11(3):639-652.
  8. Weaver SA, Lange LR, Vogts VM. Comparison of myoelectric and conventional prostheses for adolescent amputees. Am J Occup Ther. 1988; 42(2):87-91.
  9. Wright TW, Hagen AD, Wood MB.  Prosthetic usage in major upper extremity amputations. J Hand Surg [Am]. 1995; 20(4):619-622.
Index

Arm
Elbow
i-LIMB™
LTI Boston Digital Arm™ System
Myoelectric
Prosthesis
Utah Arm Wrist

History
StatusDateAction
Revised02/13/2014Medical Policy & Technology Assessment Committee (MPTAC) review.  Changed document number from CG-DME-28 to CG-OR-PR-05.  Clarified medically necessary criteria #5. Clarified the not medically necessary statement.
Reviewed02/14/2013MPTAC review.  No change to position statement. Updated Discussion and Reference sections.
 07/10/2012Updated Coding section to remove codes L6025, L6715 now addressed in a separate document.
Reviewed02/16/2012MPTAC review.  No change to position statement. Updated Index section.
 01/01/2012Updated Coding section with 01/01/2012 HCPCS changes.
Reviewed02/17/2011MPTAC review. No change to position statement.
Reviewed02/25/2010MPTAC review. No change to position statement.
Reviewed02/26/2009MPTAC review. No change to position statement.
Reviewed02/21/2008MPTAC review. No change to position statement.
Reviewed03/08/2007MPTAC review. No changes to position statement.
 01/01/2007Updated coding section with 01/01/2007 CPT/HCPCS changes; removed HCPCS L7025, L7030, L7035 deleted 12/31/2006.
New03/23/2006MPTAC initial document development. 

 

Pre-Merger Organizations
Last Review DateDocument Number

Title

 

Anthem Connecticut

 

09/01/2004 CT DME Coverage Guidelines, Section G: Prostheses: Upper and Lower Limb