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:

• CG-DME-13 Lower Limb Prosthesis

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 prostheses (i.e., neuromuscular disease, etc); and
4. The individual retains sufficient microvolt threshold in the residual limb to allow proper function of the prostheses; and
5. 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
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 all the criteria above are not met.

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.

Future ICD-10 coding (effective 10/01/2013)
A draft of ICD-10 Coding related to this document, as it might look today, is available for reference and comments at: Appendix 1: Future ICD-10 coding

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.

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. 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.
5. Stein RB, Walley M. Functional comparison of upper extremity amputees using myoelectric and conventional prostheses. Arch Phys Med Rehab. 1983; 64(6):243-248.
6. Uellendahl JE.  Upper extremity myoelectric prosthetics. Phys Med Rehabil Clin N Am. 2000; 11(3):639-652.
7. Weaver SA, Lange LR, Vogts VM. Comparison of myoelectric and conventional prostheses for adolescent amputees. Am J Occup Ther. 1988; 42(2):87-91.
8. Wright TW, Hagen AD, Wood MB.  Prosthetic usage in major upper extremity amputations. J Hand Surg [Am]. 1995; 20(4):619-622.

Arm
Elbow
Myoelectric
Prosthesis
Wrist