973 Form

Myoelectric Prosthetic and Components for the Upper Limb Prior Authorization Request Form #973

Medical Policy #227 Myoelectric Prosthetic and Components for the Upper Limb

CLINICAL DOCUMENTATION ▪ Clinical documentation that supports the medical necessity criteria for Myoelectric Prosthetic and Components for the Upper Limb must be submitted.
▪ If the patient does not meet all the criteria listed below, please submit a letter of medical necessity with a request for Clinical Exception (Individual Consideration) explaining why an exception is justified.

Requesting Prior Authorization Using Authorization Manager Providers will need to use Authorization Manager to submit initial authorization requests for services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines.

To ensure the request is processed accurately and quickly: • Enter the facility’s NPI or provider ID for where services are being performed. • Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

Authorization Manager Resources Refer to our Authorization Manager page for tips, guides, and video demonstrations.

Complete Prior Authorization Request Form for Myoelectric Prosthetic and Components for the Upper Limb (973) using Authorization Manager.

For out of network providers: Requests should still be faxed to: BCBSMA Members: 888-282-0780

Medicare Advantage Members: 800-447-2994

Patient Information Patient Name:

Today’s Date: BCBSMA ID#:

Date of Treatment: Date of Birth:

Place of Service: Outpatient  Inpatient 

Physician Information Facility Information Name:

Name:
Address:

Address: Phone #:

Phone #: Fax#:

Fax#: NPI#:

NPI#:

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  Please check off if the prosthetic being requested is the following:

  Myoelectric upper limb prosthetic. 

  Please check off if the patient meets ALL of the following conditions for myoelectric upper limb prosthetic components:

  The patient has an amputation or missing limb at the wrist or above (eg, forearm, elbow), and

   Standard body-powered prosthetic devices cannot be used or are insufficient to meet the functional needs of the individual in performing activities of daily living, and

   The remaining musculature of the arm(s) contains the minimum microvolt threshold to allow operation of a myoelectric prosthetic device, and

   The patient has demonstrated sufficient neurological and cognitive function to operate the prosthesis effectively, and

   The patient is free of comorbidities that could interfere with function of the prosthesis (eg, neuromuscular disease), and

   Functional evaluation indicates that with training, use of a myoelectric prosthesis is likely to meet the functional needs of the individual (eg, gripping, releasing, holding, coordinating movement of the prosthesis) when performing activities of daily living. This evaluation should consider the patient’s needs for control, durability (maintenance), function (speed, work capability), and usability, and

   The amputee has been evaluated by an independent qualified professional to determine the most appropriate prosthetic components and control mechanism (eg, body-powered, myoelectric, or combination of body- powered and myoelectric). The independent qualified professional has verified that the amputee meets all the medical necessity criteria for the device.

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  Note: Advanced upper-limb prosthetic components with both sensor and myoelectric control (e.g., LUKE Arm) are considered INVESTIGATIONAL.

  Note: A prosthesis with individually powered digits, including but not limited to a partial hand prosthesis, is considered INVESTIGATIONAL.

  Note: Myoelectric controlled upper-limb orthoses are considered INVESTIGATIONAL.

  Note: Myoelectric upper limb prosthetic components are considered INVESTIGATIONAL under all other conditions.

  CPT CODES/ HCPCS CODES

  Please check off all the relevant HCPCS codes:
  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, 2 batteries and one charger, myoelectronic control of terminal device  L6935 Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Block or equal electrodes, cables, 2 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, 2 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, 2 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, 2 

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  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, 2 batteries and one charger, myoelectronic control of 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 

  Providers should enter the relevant diagnosis code(s) below: Code Description

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  Providers should enter other relevant code(s) below: Code Description

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