227 Form

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Medical Policy Myoelectric Prosthetic and Orthotic Components for the Upper Limb
Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 227

BCBSA Reference Number: 1.04.04 (For Plan internal use only) NCD/LCD: N/A Related Policies
• Functional Neuromuscular Electrical Stimulation, #201 • Microprocessor-Controlled Prostheses for the Lower Limb, #133 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Myoelectric upper limb prosthetic components may be MEDICALLY NECESSARY when all of the following conditions are met:

• The individual 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 individual has demonstrated sufficient neurological and cognitive function to operate the prosthesis effectively, and • The individual 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 individual’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.

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

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

Myoelectric controlled upper-limb orthoses are considered INVESTIGATIONAL.

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

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is required.
Commercial PPO
Prior authorization is required.
Medicare HMO BlueSM Prior authorization is not required. Medicare PPO BlueSM Prior authorization is not required.

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 888-282-0780.
CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

3 The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

HCPCS Codes HCPCS codes: Code Description 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 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 ICD-10 Procedure Codes ICD-10-PCS procedure codes: Code Description F0DZ8UZ Prosthesis Device Fitting using Prosthesis F0DZ8FZ Prosthesis Device Fitting using Assistive, Adaptive, Supportive or Protective Equipment

The following HCPCS code is considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

HCPCS Codes HCPCS codes: Code Description

4 A8005 Powered, cable driven grip assist glove, hand, finger, includes microprocessor, pressure sensors, all components and accessories, custom fitted A8006 Powered, cable driven grip assist glove, hand, finger, includes pressure sensors, glove replacement only L6700 Upper extremity addition, external powered feature, myoelectronic control module, additional EMG inputs, pattern-recognition decoding intent movement L6880 Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s) L8701 Powered upper extremity range of motion assist device, elbow, wrist, hand with single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated

Description Upper-Limb Amputation The need for a prosthesis can occur for a number of reasons, including trauma, surgery, or congenital anomalies.

Treatment The primary goals of the upper-limb prostheses are to restore function and natural appearance. Achieving these goals also requires sufficient comfort and ease of use for continued acceptance by the wearer. The difficulty of achieving these diverse goals with an upper-limb prosthesis increases with the level of amputation (digits, hand, wrist, elbow, shoulder), and thus the complexity of joint movement increases.

Upper-limb prostheses are classified into 3 categories depending on the means of generating movement at the joints: passive, body-powered, and electrically powered movement. All 3 types of prostheses have been in use for more than 30 years; each possesses unique advantages and disadvantages.

Passive Prostheses • The passive prostheses rely on manual repositioning, typically using the opposite arm and cannot restore function. This unit is the lightest of the 3 prosthetic types and is thus generally the most comfortable.

Body-Powered Prostheses • The body-powered prostheses use a body harness and cable system to provide functional manipulation of the elbow and hand. Voluntary movement of the shoulder and/or limb stump extends the cable and transmits the force to the terminal device. Prosthetic hand attachments, which may be claw-like devices that allow good grip strength and visual control of objects or latex-gloved devices that provide a more natural appearance at the expense of control, can be opened and closed by the cable system. Individual complaints with body-powered prostheses include harness discomfort, particularly the wear temperature, wire failure, and the unattractive appearance.

Myoelectric Prostheses • Myoelectric prostheses use muscle activity from the remaining limb for control of joint movement. Electromyographic 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. Commercially available examples are listed in the Regulatory Status section. • 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 for control of 2 joints at once (ie, 1

5 body-powered, 1 myoelectric) and are generally lighter and less expensive than a prosthesis composed entirely of myoelectric components.

Technology in this area is rapidly changing, driven by advances in biomedical engineering and by the U.S. Department of Defense Advanced Research Projects Agency, which is funding a public and private collaborative effort on prosthetic research and development. 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.

The LUKE Arm (previously known as the DEKA Arm System) was developed in a joint effort between DEKA Research & Development and the U.S. Department of Defense Advanced Research Projects Agency program. It is the first commercially available myoelectric upper-limb that can perform complex tasks with multiple simultaneous powered movements (eg, movement of the elbow, wrist, and hand at the same time). In addition to the electromyographic electrodes, the LUKE Arm contains a combination of mechanisms, including switches, movement sensors, and force sensors. The primary control resides with inertial measurement sensors on top of the feet. The prosthesis includes vibration pressure and grip sensors. Myoelectric Orthoses The MyoPro (Myomo) is a myoelectric powered upper-extremity orthotic. This orthotic device weighs about 1.8 kilograms (4 pounds), has manual wrist articulation, and myoelectric initiated bi-directional elbow movement. The MyoPro detects weak muscle activity from the affected muscle groups. A therapist or prosthetist/orthoptist can adjust the gain (amount of assistance), signal boost, thresholds, and range of motion. Potential users include individuals with traumatic brain injury, spinal cord injury, brachial plexus injury, amyotrophic lateral sclerosis, and multiple sclerosis. Use of robotic devices for therapy has been reported. The MyoPro is the first myoelectric orthotic available for home use.

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

Summary of Evidence For individuals who have a missing limb at the wrist or higher who receive myoelectric upper-limb prosthesis components at or proximal to the wrist, the evidence includes a systematic review and comparative studies. Relevant outcomes are functional outcomes and quality of life. The goals of upper- limb prostheses relate to restoration of both appearance and function while maintaining sufficient comfort for continued use. The identified literature focuses primarily on individual acceptance and rejection; data are limited or lacking in the areas of function and functional status. The limited evidence suggests that, when compared with body-powered prostheses, myoelectric components possess the similar capability to perform light work; however, myoelectric components could also suffer a reduction in performance when operating under heavy working conditions. The literature has also indicated that the percentage of amputees who accept the use of a myoelectric prosthesis is approximately the same as those who prefer to use a body-powered prosthesis, and that self-selected use depends partly on the individual’s activities of daily living. Appearance is most frequently cited as an advantage of myoelectric prostheses, and for individuals who desire a restorative appearance, the myoelectric prosthesis can provide greater function than a passive prosthesis with equivalent function to a body-powered prosthesis for light work. Because of the different advantages and disadvantages of currently available prostheses, myoelectric components for persons with an amputation at the wrist or above may be considered when passive, or body-powered prostheses cannot be used or are insufficient to meet the functional needs of the individual in activities of daily living. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

6 For individuals who have a missing limb at the wrist or higher who receive sensor and myoelectric controlled upper-limb prosthetic components, the evidence includes a series of publications from a 12- week home study. Relevant outcomes are functional outcomes and quality of life. The prototypes for the advanced prosthesis were evaluated by the U.S. military and Veterans Administration. Demonstration of improvement in function has been mixed. After several months of home use, activity speed was shown to be similar to the conventional prosthesis, and there were improvements in the performance of some activities, but not all. There were no differences between the prototype and the participants’ prostheses for outcomes of dexterity, prosthetic skill, spontaneity, pain, community integration, or quality of life. Study of the current generation of the sensor and myoelectric controlled prosthesis is needed to determine whether newer models of this advanced prosthesis lead to consistent improvements in function and quality of life. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. For individuals who have a missing limb distal to the wrist who receive a myoelectric prosthesis with individually powered digits, no peer-reviewed publications evaluating functional outcomes in amputees were identified. Relevant outcomes are functional outcomes and quality of life. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. For individuals with upper-extremity weakness or paresis who receive a myoelectric powered upper-limb orthosis, the evidence includes a small within-subject study. Relevant outcomes are functional outcomes and quality of life. The largest study (N=18) identified tested participants with and without the orthosis but did not provide any training with the device. Performance on the tests was inconsistent. Studies are needed that show consistent improvements in relevant outcome measures. Results should also be replicated in a larger number of patients. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. Policy History Date Action 4/2026 Policy updated with literature review through January 15, 2026; reference added. Policy statements unchanged. 4/2026 Clarified coding information. 5/2025 Annual policy review. References updated. Policy statements unchanged. 4/2025 Clarified coding information. 5/2024 Annual policy review. Policy updated with literature review through January 29, 2024; no references added. Minor editorial refinements to policy statements; intent unchanged. 9/2023 Policy clarified to include prior authorization requests using Authorization Manager.
5/2023 Annual policy review. Description, summary and references updated. Policy statements unchanged. 6/2022 Prior authorization information clarified for PPO plans. Effective 6/1/2022. 5/2022 Annual policy review. Not medically necessary policy statement updated to Investigational for policy standardization purposes. Clarification added that second policy statement pertains to advanced prosthetic components with both sensor and myoelectric control (e.g., LUKE Arm). Policy intent unchanged. 4/2021 Annual policy review. Policy statements unchanged. 5/2020 Annual policy review. Description, summary and references updated. Policy statements unchanged. 4/2019 Annual policy review. Description, summary and references updated. Policy statements unchanged. 1/2019 Clarified coding information. 8/2018 Annual policy review.
Investigational statements added for myoelectric orthoses and prostheses with both sensor and myoelectric control. Title changed. Clarified coding information. Effective 8/1/2018.

7 1/2015 Clarified coding information. 6/2014 Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/2015. 4/2014 Clarified coding information. 12/2013 Annual policy review. Title changed. 2/2013 Annual policy review. New investigational indications described. Effective 2/4/2013. 11/2011-4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates.
No changes to policy statements.
9/2010 Medical Policy 227 effective 9/1/2010 describing covered and non-covered indications. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

1. Biddiss EA, Chau TT. Upper limb prosthesis use and abandonment: a survey of the last 25 years. Prosthet Orthot Int. Sep 2007; 31(3): 236-57. PMID 17979010
2. Kruger LM, Fishman S. Myoelectric and body-powered prostheses. J Pediatr Orthop. 1993; 13(1): 68-
3. PMID 8416358
4. Silcox DH, Rooks MD, Vogel RR, et al. Myoelectric prostheses. A long-term follow-up and a study of the use of alternate prostheses. J Bone Joint Surg Am. Dec 1993; 75(12): 1781-9. PMID 8258548
5. McFarland LV, Hubbard Winkler SL, Heinemann AW, et al. Unilateral upper-limb loss: satisfaction and prosthetic-device use in veterans and servicemembers from Vietnam and OIF/OEF conflicts. J Rehabil Res Dev. 2010; 47(4): 299-316. PMID 20803400
6. Sjöberg L, Lindner H, Hermansson L. Long-term results of early myoelectric prosthesis fittings: A prospective case-control study. Prosthet Orthot Int. Oct 2018; 42(5): 527-533. PMID 28905686
7. Egermann M, Kasten P, Thomsen M. Myoelectric hand prostheses in very young children. Int Orthop. Aug 2009; 33(4): 1101-5. PMID 18636257
8. Resnik LJ, Borgia ML, Acluche F. Perceptions of satisfaction, usability and desirability of the DEKA Arm before and after a trial of home use. PLoS One. 2017; 12(6): e0178640. PMID 28575025
9. Resnik L, Cancio J, Klinger S, et al. Predictors of retention and attrition in a study of an advanced upper limb prosthesis: implications for adoption of the DEKA Arm. Disabil Rehabil Assist Technol. Feb 2018; 13(2): 206-210. PMID 28375687
10. Resnik L, Klinger S. Attrition and retention in upper limb prosthetics research: experience of the VA home study of the DEKA arm. Disabil Rehabil Assist Technol. Nov 2017; 12(8): 816-821. PMID 28098513
11. Resnik LJ, Borgia ML, Acluche F, et al. How do the outcomes of the DEKA Arm compare to conventional prostheses?. PLoS One. 2018; 13(1): e0191326. PMID 29342217
12. Resnik L, Acluche F, Lieberman Klinger S, et al. Does the DEKA Arm substitute for or supplement conventional prostheses. Prosthet Orthot Int. Oct 2018; 42(5): 534-543. PMID 28905665
13. Resnik L, Acluche F, Borgia M. The DEKA hand: A multifunction prosthetic terminal device-patterns of grip usage at home. Prosthet Orthot Int. Aug 2018; 42(4): 446-454. PMID 28914583
14. Peters HT, Page SJ, Persch A. Giving Them a Hand: Wearing a Myoelectric Elbow-Wrist-Hand Orthosis Reduces Upper Extremity Impairment in Chronic Stroke. Arch Phys Med Rehabil. Sep 2017; 98(9): 1821-1827. PMID 28130084
15. Androwis GJ, Engler A, Craven C, et al. Effectiveness of myoelectric wearable orthoses for upper extremity functional recovery in spinal cord injury- a pilot study. J Neuroeng Rehabil. Dec 02 2025; 23(1): 6. PMID 41331457