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Medical Policy: 01.01.19
Original Effective Date: April 2011
Reviewed: March 2012
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Upper limb prostheses are used for amputations at any level from the hand 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 prosthesis are to restore function and natural appearance.
Myoelectric prostheses are one category of upper extremity prosthetics that 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.
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.
Available myoelectric technologies include the Otto Bock myoelectric prosthesis (Otto Bock), the LTI Boston Digital Arm™ System (Liberating Technologies Inc.), the Utah Arm Systems (Motion Control), and the i-LIMB™ hand and ProDigits™ (Touch Bionics).
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Prior Approval:
Prior approval is recommended. Submit a prior approval now
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Policy:
Myoelectric upper limb prosthetic components may be considered medically necessary when the following conditions are met:
- 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 by a licensed occupational or physical therapist 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.
Myoelectric upper limb prosthetic components are considered not medically necessary under all other conditions.
Myoelectric upper limb prosthetic accessories that are primarily indicated to improve appearance are considered not medically necessary. Some examples of these accessories include, but are not limited to:
- LIVINGSKIN™
- DermaHair™
- SeasonGuard™
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- L6025 Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, 2 batteries, charger, myoelectric control of terminal device
- L6611 Addition to upper extremity prosthesis, external powered, additional switch, any type
- L6646 Upper extremity addition, shoulder joint, multipositional locking, flexion, adjustable abduction friction control, for use with body powered or external powered system
- L6881 Automatic grasp feature, addition to upper limb electric prosthetic terminal device
- L6882 Microprocessor control feature, addition to upper limb prosthetic terminal device
- L6920 Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, 2 batteries and 1 charger, switch control of terminal device
- L6925 Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device
- L6930 Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device
- L6935 Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device
- L6940 Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device
- L6945 Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device
- L6950 Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device
- L6955 Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device
- L6960 Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device
- L6965 Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device
- L6970 Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device
- L6975 Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device
- L7007 Electric hand, switch or myoelectric controlled, adult
- L7008 Electric hand, switch or myoelectric, controlled, pediatric
- L7009 Electric hook, switch or myoelectric controlled, adult
- L7040 Prehensile actuator, switch controlled
- L7045 Electric hook, switch or myoelectric controlled, pediatric
- L6880 Electric hand, switch or myolelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s
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Selected References:
- The Medical Policy Reference Manual (MPRM) developed by the Blue Cross and Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
- Egermann M, Kasten P, Thomsen M. Myoelectric hand prostheses in very young children. Int Orthop 2009; 33(4): 1101-5.
- Lindner HY, Linacre JM, Norling Hermansson LM. Assessment of capacity for myoelectric control: evaluation of construct and rating scale. J Rehabil Med 2009; 41(6):467-74.
- ECRI Institute. Myoelectric upper-extremity prostheses. Plymouth Meeting (PA): ECRI Institute; 2010 Jul 3. 9p. [ECRI hotline response]. Also available: http://www.ecri.org.
- Health technology forecast [database online]. Plymouth Meeting (PA): ECRI Institute; 2010 Jul 6. Advanced prosthetic arm technology. Available: http://www.ecri.org.
- ECRI Institute. Advanced prosthetic arm technology. Plymouth Meeting (PA): ECRI Institute; 2011 June 15. [Health Technology Forecast]. Also available: http://www.ecri.org.
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Policy History:
Date Reason Action
April 2011 Literature review New policy
March 2012 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.
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