Anthem Blue Cross Connecticut Commercial Clinical Policy

Anthem Blue Cross Connecticut OR-PR.00005 Upper Extremity Myoelectric Orthoses Form

Effective Date

06/28/2023

Last Reviewed

05/11/2023

Original Document

  Reference



This document addresses the use of upper extremity myoelectric orthoses (for example, the MyoPro®, MyoMo, Inc., Cambridge, MA), which are intended to augment the function of individuals with upper arm weakness or partial paralysis due to neurological conditions, trauma, or other problems. Such devices use neurologic sensors, microprocessor units, and electric motors to provide self-initiated movement of the affected limb. These devices should not be confused with prosthetic devices, which are intended to replace or compensate for a missing limb or other body part.

Note: For more information regarding upper extremity myoelectric devices, please refer to:

  • CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices

Position Statement

Investigational and Not Medically Necessary:

The use of myoelectric upper extremity orthotic devices is considered investigational and not medically necessary for all indications, including but not limited to use by individuals with stroke, trauma, or neurological disorders.