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Date Printed: August 22, 2017: 06:55 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-L0000-07

Original Effective Date: 04/15/07

Reviewed: 02/23/17

Revised: 03/15/17

Subject: Myoelectric Prosthetic Components for the Upper Limb

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Myoelectric prostheses are powered by electric motors with an external power source. The joint movement of an upper-limb prosthesis (eg, hand, wrist, and/or elbow) is driven by microchip-processed electrical activity in the muscles of the remaining limb stump.

Myoelectric prostheses use muscle activity from the remaining limb for 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 1 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. A hybrid system, a combination of body-powered and myoelectric components, may be used for high-level amputations (at or above the elbow). Hybrid systems allow control of 2 joints at once (ie, 1 body-powered, 1 myoelectric) and are generally lighter than a prosthesis composed entirely of myoelectric components.

Technology in this area is rapidly changing. Areas of development include the use of skin-like silicone elastomer gloves, “artificial muscles,” and sensory feedback. Smaller motors, microcontrollers, implantable myoelectric sensors, and reinnervation 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.

POSITION STATEMENT:

Myoelectric upper limb prosthetic components meet the definition of medical necessity when ALL of the following criteria are met:

Myoelectric upper limb prosthetic components do not meet the definition of medical necessity if all criteria listed above are not met.

A prosthesis with individually powered digits, including but not limited to a partial hand prosthesis, is considered experimental or investigational. The evidence is insufficient to determine the effects of the technology on health outcomes.

BILLING/CODING INFORMATION:

HCPCS Coding

Prostheses

 

L6026

Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device(s)

L6925

Wrist 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

L6935

Below 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

L6945

Elbow 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

L6955

Above 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

L6965

Shoulder 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

L6975

Interscapular-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

L6611

Addition to upper extremity prosthesis, external powered, additional switch, any type

L6677

Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow

L6715

Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement

L6880

Electric hand, switch, or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s)

L6881

Automatic grasp feature, addition to upper limb prosthetic terminal device

L6882

Microprocessor control feature, addition to upper limb prosthetic 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

L7045

Electric hook, switch or myoelectric controlled, pediatric

L7180

Electronic elbow, microprocessor sequential control of elbow and terminal device

L7181

Electronic elbow, microprocessor simultaneous control of elbow and terminal device

L7190

Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled

L7191

Electronic elbow, child, Variety Village or equal, myoelectronically controlled

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Lower Limb Microprocessor-Controlled Prosthetics, 09-L0000-06

OTHER:

None applicable.

REFERENCES:

  1. American Academy of Orthopedic Surgeons: “Extremity War Injuries: State of the Art and Future Directions” Presentation Abstracts; Session IV: Amputee Care: Presentation 33; Military LEAP; Ellen MacKenzie, PhD (09/06/06).
  2. Blue Cross and Blue Shield Association Medical Policy Reference Manual, 1.04.04 Myoelectric Prosthetic Components for the Upper Limb, 12/16.
  3. Carey, SL, Lura, DJ, Highsmith, MJ. Differences in myoelectric and body-powered upper-limb prostheses: Systematic literature review. United States, 2015. p. 247-62.
  4. ECRI, Custom Hotline Response. “Microprocessor Controlled Upper Extremity Prostheses”; 06/23/06.
  5. ECRI, Custom Hotline Resposne. “Myoelectric Upper-extremity Prostheses”; 02/19/08.
  6. Kilgore KL, Hoyen HA, Bryden AM, Hart RL, Keith MW, Peckham PH. An implanted upper-extremity neuroprosthesis using myoelectric control. J Hand Surg Am. 2008 Apr;33(4):539-50.
  7. Kuiken, TA, et al. The use of targeted muscle reinnervation for improved myoelectric prosthesis control in bilateral shoulder disarticulation amputee. Prosthe Orthot Int, 02-Dec-2004; 28(3): 245-53.
  8. Kyberd, Peter J. The Southampton Hand: An intelligent myoelectric prosthesis. J Rehab Research and Dev. Nov 1994; 31(4): 326-34.
  9. Lake, C, Miguelez, J. Comparative Analysis of Microprocessors in Upper Limb Prosthetics. J Prosthe and Orthot; 2003; 15(2): p 48.
  10. 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.
  11. MD Consult: What Patients are Reading; “Technology for hand and arm prosthetics has fallen behind”; 10/07/05.
  12. Motion Control, Inc., The Utah Arm, Salt Lake City UT; website accessed 03/12/09.
  13. Otto Bock, Inc. Myoelectrical Prosthesis. Minneapolis, MN: Otto Bock, 1999.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 02/23/17.

GUIDELINE UPDATE INFORMATION:

04/15/07

New Medical Coverage Guideline.

06/15/07

Reformatted guideline.

05/15/09

Scheduled review; no change to position statement; references updated.

05/15/11

Scheduled review; position statement unchanged; references updated.

01/01/12

Annual HCPCS coding update: added L6715 and L6880.

05/11/14

Revision: Program Exceptions section updated.

01/01/15

Annual coding update: Removed L6025; added L6026

03/15/17

Revision; Position statement updates include revision to functional evaluation criterion and an investigational statement regarding prosthesis with individually powered digits was added; description section and references updated.

Date Printed: August 22, 2017: 06:55 AM