Clinical UM Guideline

 

Subject: Myoelectric Upper Extremity Prosthetic Devices
Guideline #:  CG-OR-PR-05 Publish Date:    02/27/2019
Status: Reviewed Last Review Date:    01/24/2019

Description

This document addresses the use of myoelectric prosthetic devices for individuals with amputations of the upper extremity (that is, from the hand to the shoulder). A myoelectric prosthetic is controlled by electromyographic (EMG) signals generated naturally by an individual’s own muscles. When an individual engages muscles in a residual limb, EMG signals from those muscles relay information to electrodes that are built into the prosthetic. The information is then sent to a controller, which translates the information and sends it to electric motors that move the prosthetic. The electric motors are powered by a rechargeable battery pack.

Note: For information on related devices, 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 (that is, forearm, elbow, etc.); and
  3. The individual is free of comorbidities that could interfere with maintaining function of the prosthesis (that is, 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 (that is, 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

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

L6880

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

L6881

Automatic grasp feature, addition to upper limb electric prosthetic terminal device

L6882

Microprocessor control feature, addition to upper limb prosthetic terminal device

L7007

Electric hand, switch or myoelectric controlled, adult [when specified as myoelectric]

L7008

Electric hand, switch or myoelectric controlled, pediatric [when specified as myoelectric]

L7009

Electric hook, switch or myoelectric controlled, adult [when specified as myoelectric]

L7045

Electric hook, switch or myoelectric controlled, pediatric [when specified as myoelectric]

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

 

 

ICD-10 Diagnosis

 

Q71.00-Q71.93

Reduction deformities of upper limb

S48.011A-S48.929S

Traumatic amputation of shoulder and upper arm

S58.011A-S58.929S

Traumatic amputation of elbow and forearm

S68.011A-S68.729S

Traumatic amputation of wrist, hand and fingers

Z89.121-Z89.239

Acquired 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 due to trauma, disease or congenital causes. A myoelectric prosthetic is controlled by EMG signals generated naturally by an individual’s own muscles. 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 a 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 (for instance, 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 colleagues (2012) evaluated the use of prosthetic arms in a convenience sample of 50 subjects. A total of 21 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 of the myoelectric arm prosthesis and was not designed or powered to provide such data.

Salminger and colleagues (2018) studied functional outcome scores in below-elbow amputees who were fitted with a myoelectric prosthetic. A total of 17 subjects were evaluated using the following function tests: Action Research Arm Test (ARAT), Southampton Hand Assessment Procedure (SHAP), the Clothespin-Relocation Test (CPRT) and the Box and Block Test (BBT). The tests were chosen to evaluate gross and fine manual dexterity, activities of daily living, repeatability, and full arm motion. Tests were observed by the same physical therapist for all subjects. The mean results were the following: ARAT 35.06 ± 4.42 of 57, SHAP 65.12 ± 13.95 points, CPRT 22.57 ± 7.50 seconds, and BBT 20.90 ± 5.74. The authors stated:

Overall success of prosthetic rehabilitation should be based on a combination of objective function, rated performance in daily-life activities, wearing time, patient satisfaction and participation. As concluded by different working groups, this will not be possible with one single standard measure, but with a combination of assessment tools evaluating function and activities as well as questionnaires for reporting participation and quality of life.

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, Lesjo 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. Salminger S, Vujaklija I, Sturma A, et al. Functional outcome scores with standard myoelectric prostheses in below-elbow amputees. Am J Phys Med Rehabil. 2018 Aug 27; [Epub ahead of print]. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30153123. Accessed on November 27, 2018.
  6. 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.
  7. Stein RB, Walley M. Functional comparison of upper extremity amputees using myoelectric and conventional prostheses. Arch Phys Med Rehab. 1983; 64(6):243-248.
  8. Uellendahl JE. Upper extremity myoelectric prosthetics. Phys Med Rehabil Clin N Am. 2000; 11(3):639-652.
  9. Weaver SA, Lange LR, Vogts VM. Comparison of myoelectric and conventional prostheses for adolescent amputees. Am J Occup Ther. 1988; 42(2):87-91.
  10. Wright TW, Hagen AD, Wood MB. Prosthetic usage in major upper extremity amputations. J Hand Surg [Am]. 1995; 20(4):619-622.
Index

Arm
Bebionic
DEKA Arm System
DynamicArm®
Elbow
Electrohand 2000
i-LIMB
LTI Boston Digital Arm System
LUKE Arm
Michelangelo®
Myoelectric Prosthesis
SensorHand
Utah Arm

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.

History

Status

Date

Action

Reviewed

01/24/2019

Medical Policy & Technology Assessment Committee (MPTAC) review. Description, Discussion/General Information, and References sections updated.

Reviewed

02/27/2018

MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Description, Discussion/General Information, and Index sections updated.

Reviewed

02/02/2017

MPTAC review.

Reviewed

02/04/2016

MPTAC review. Removed ICD-9 codes from Coding section.

Reviewed

02/05/2015

MPTAC review.

Revised

02/13/2014

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.

Reviewed

02/14/2013

MPTAC review. Updated Discussion and References sections.

 

07/10/2012

Updated Coding section to remove codes L6025, L6715 now addressed in a separate document.

Reviewed

02/16/2012

MPTAC review. Updated Index section.

 

01/01/2012

Updated Coding section with 01/01/2012 HCPCS changes.

Reviewed

02/17/2011

MPTAC review.

Reviewed

02/25/2010

MPTAC review.

Reviewed

02/26/2009

MPTAC review.

Reviewed

02/21/2008

MPTAC review.

Reviewed

03/08/2007

MPTAC review.

 

01/01/2007

Updated coding section with 01/01/2007 CPT/HCPCS changes; removed HCPCS L7025, L7030, L7035 deleted 12/31/2006.

New

03/23/2006

MPTAC initial document development.

Pre-Merger Organizations Last Review Date Document Number

Title

Anthem Connecticut 09/01/2004  

CT DME Coverage Guidelines, Section G: Prostheses: Upper and Lower Limb