Upper Limb Prosthetics

*** This policy was implemented in the absence of National Coverage Determinations (NCD) or Local Coverage Determinations (LCD) coverage criteria. This policy applies to all Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services. ***

Description of Procedure

Upper Limb Prosthetics 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 prostheses rely on manual repositioning, typically by moving it with the opposite arm and cannot restore function. It is the lightest of the 3 prosthetics and is thus generally the most comfortable. 
• 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 maybe 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. Member 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 the 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.
• A hybrid system, a combination of body-powered and myoelectric components, may be used for high-level amputations (i.e., 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. 

Policy Statement

Coverage will be provided for Myoelectric Upper Limb prosthetics when it is determined to be medically necessary when the medical criteria and guidelines shown below are met.

Benefit Application

Please refer to the member’s individual Evidence of Coverage (EOC) for benefit determination. Coverage will be approved according to the EOC limitations if the criteria are met.

Coverage decisions will be made in accordance with:

• The Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations (NCDs);
• General coverage guidelines included in Original Medicare manuals unless superseded by operational policy letters or regulations; and 
• Written coverage decisions of local Medicare carriers and intermediaries with jurisdiction for claims in the geographic area in which services are covered. 

Benefit payments are subject to contractual obligations of the Plan. If there is a conflict between the general policy guidelines contained in the Medical Coverage Policy Manual and the terms of the member’s particular Evidence of Coverage (EOC), the EOC always governs the determination of benefits.

Indications for Coverage

Myoelectric upper limb prosthetic components may be considered medically necessary when the following conditions are met:

1. Preauthorization by the Plan is required; 
2. The member has an amputation or missing limb at the wrist or above (forearm, elbow, etc.); 
3. Standard body-powered prosthetic devices cannot be used or are insufficient to meet the functional needs of the member in performing activities of daily living; AND 
4. The remaining musculature of the arm(s) contains the minimum microvolt threshold to allow operation of a myoelectric prosthetic device; AND 
5. The member has demonstrated sufficient neurological and cognitive function to operate the prosthesis effectively; AND 
6. The member is free of comorbidities that could interfere with function of the prosthesis (neuromuscular disease, etc.) AND
7. Functional evaluation indicates that with training, use of the myoelectric prosthesis is likely to meet the functional needs of the member (e.g. gripping, releasing, holding, and coordinating movement of the prosthesis) when performing activities of daily living. This evaluation should consider the member’s need for control, durability (maintenance), function (speed, work, capability) and usability. 

Passive and Body-Powered Prosthetics are covered to replace all or part of the function of permanently inoperative or malfunctioning upper limb extremity.

Replacement DME: Coverage determination for replacement is made according to the average life (in any case, it cannot be less than five years) of the product as established by the manufacturer. Replacement of lost or stolen equipment and repairs (instead of replacement) of purchased equipment are covered at the discretion of the Plan. DME can be replaced in cases of loss or irreparable damage; i.e., specific accident or a natural disaster.

Requests for replacement DME items are covered when:

1. The request is due to normal wear and tear. Replacement due to wear is not covered during the reasonable useful lifetime of the equipment; OR 
2. The ordering physician determines that the replacement device, or replacement part of such a device, is necessary due to any of the following: 
   1. A change in the member’s condition; OR
   2. An irreparable change in the condition of the device, or in a part of the device; OR
   3. The condition of the device, or the part of the device, requires repairs and the cost of such repairs would be more than 60 percent of the cost of a replacement device, or, as the case may be, of the part being replaced.

When Coverage Will Not Be Approved

• Myoelectric prosthetic components for the upper limb are considered not medically necessary in members who do not meet the criteria above.
• Advanced upper-limb prosthetic components with both sensor and myoelectric control (e.g. LUKE Arm) are considered investigational. 
• A prosthesis with individually powered digits, including but not limited to a partial hand prosthesis, is considered investigational. 
• Myoelectric controlled upper-limb orthoses are considered investigational 

Billing/ Coding/physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in the section does not guarantee reimbursement.

Applicable codes: L6026, L6715, L6880, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7009, L7180, L781, L7190, L7191, L7259, L8701, L8702

The Plan may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

Special Notes

Amputees should be evaluated by an independent trained prosthetic clinician 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 of the prosthesis in a real-life setting.

References:

1. Medicare Benefit Policy Manual Chp 15 section 110, 120 & 130: Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes. Revised on 10/01/2003. Viewed online at Medicare Benefit Policy Manual (cms.gov) on 06/21/2024. 
2. BCBSNC Corporate Medical Policy “Myoelectric Prosthetic Components for the Upper Limb” Effective 08/2010. Last Review Date 06/2023. Accessed via myoelectric_prosthetic_components_for_the_upper_limb (bluecrossnc.com) on 06/21/2024. 

Policy Implementation/Update Information:

New policy October 2017

Revision Date: April 22, 2020; Annual Review; No Updates, Minor Revisions Only. Remains Consistent with Corporate Medical Policy

Revision Date: April 13, 2022; Annual Review; No Updates. Minor Revisions Only. Remains Consistent with Corporate Medical Policy.

Revision Date: September 21, 2023: Annual Review; No CMS Updates. Additional reference added. Four (4) CPT codes added.

Revision Date: November 14, 2023: Added the following statement to the beginning of policy: “This policy was implemented in the absence of National Coverage Determinations (NCD) or Local Coverage Determinations (LCD) coverage criteria.” Statement added to align with the 2024 CMS Final Rule. Revision Date: July 18, 2024: Annual Review. Verbiage added to reflect the corporate policy and Benefit Manual. Reference link updated.

Approval Dates:

Medical Coverage Policy Committee: July 18, 2024

Physician Advisory Group: November 14, 2023

Policy Owner: Beth Sell BSN, RN, CCM, CPC-A Medical Policy Coordinator

Medical Coverage Policy: Upper Limb Prosthetics