Anthem Blue Cross Connecticut CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices Form

This document addresses the use of myoelectric prosthetic devices for individuals with an amputation or absence of a portion of an upper extremity at any level from the hand, including partial-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 residual muscles, EMG signals from those muscles relay information to electrodes that are built into the prosthesis. 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:

• OR-PR.00005 Upper Extremity Myoelectric Orthoses

Clinical Indications

Medically Necessary:

Myoelectric upper extremity prosthetic devices are considered medically necessary when ALL of the criteria set forth in (A) and (B) below have been met:

1. Selection criteria
   1. The individual has an amputation or absence of a portion of an arm; and
   2. The individual has sufficient ability to operate the higher level technology effectively; and
   3. A standard body-powered prosthetic device cannot be used or is insufficient to meet the functional goals and needs of the individual; and
   4. A myoelectric device is likely to help the individual regain or maintain function better than a standard body-powered prosthetic device; and
   5. The remaining musculature of the affected arm contains the minimum microvolt threshold to allow operation of a myoelectric device; and
   6. The following anatomy specific criteria apply:
      1. Transhumeral and Elbow:
         1. Amputation or absence of the limb at or above the elbow.
         2. Individual’s functional goals require functional analogue of elbow flexion and extension.
      2. Transradial and Wrist:
         1. Amputation or absence of the limb below the elbow or wrist disarticulation
         2. Individual’s functional goals require functional analogue of forearm rotation
      3. Partial-Hand:
         1. Amputation or absence of 1 to 5 digits, where the level of loss or deficiency is distal to the wrist and proximal to the metacarpophalangeal joint.
         2. Individual’s functional goals require prehension.
            and
2. Documentation and performance criteria:
   1. Complete multidisciplinary assessment of individual including an evaluation by a trained prosthetic clinician. The assessment must objectively document that all of the above selection criteria have been evaluated and met.

Repairs and replacements of a myoelectric upper extremity prosthetic devices are considered medically necessary when either A or B below are met:

1. Needed for normal wear or accidental damage; or
2. The changes in the individual’s condition warrant additional or different equipment, based on clinical documentation.

Not Medically Necessary:

Myoelectric upper extremity prosthetic devices are considered not medically necessary when any of the criteria above are not met.

Repairs and replacements of a myoelectric upper extremity prosthetic devices are considered not medically necessary when the criteria above have not been met.

Enhanced dexterity prosthetic arm myoelectric upper extremity prosthetic devices (for example, Life Under Kinetic Evolution [LUKE] Arm) are considered not medically necessary for all indications.