Myoelectric Prosthetic and Orthotic Components for the Upper Limb Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 09|21|2022 POLICY LAST UPDATED: 07|16|2025

OVERVIEW Myoelectric orthotic devices use neurologic sensors, microprocessor units, and electric motors to provide self-initiated movement. 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.

MEDICAL CRITERIA Not applicable

PRIOR AUTHORIZATION
Not applicable

POLICY STATEMENT Medicare Advantage Plans and Commercial Products The following are considered not covered for Medicare Advantage Plans and not medically necessary for Commercial Products as the evidence is insufficient to determine that the technology results in an improvement in the net health outcome:
• Myoelectric controlled upper-limb orthoses
• Advanced upper-limb prosthetic components with both sensor and myoelectric control (e.g., LUKE Arm)

COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable not medically necessary/not covered benefits/coverage.

BACKGROUND Myoelectric Orthoses A powered upper extremity range of motion assist device is intended to restore function to arms and hands of patients who have sustained an injury, or who suffer from cerebral palsy, neuromuscular disease, or stroke. It is a custom fabricated upper arm orthosis that has noninvasive sensors on the surface of the skin. The sensors read the nerve signals and activate small motors in the orthosis, allowing the patient to move their arm or hand. It consists of the custom fabricated orthosis; noninvasive sensors, motors, and electronics that amplify and process the nerve signals; and batteries.

MyoPro (Myomo)
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 patients 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.

Intent Decoding Modules by Coapt, LLC Medical Coverage Policy | Myoelectric Prosthetic and Orthotic Components for the Upper Limb

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

Intent Decoding Modules (IDM) uses pattern-recognition-based approaches from three or more electromyographic (EMG) signals to decode complex EMG patterns in determining an individual’s real-time movement intent and translate it into command signals for the prosthesis. IDMs use academically developed algorithms with an array of three or more EMG sensors to decode the individual’s muscle activity patterns. This module technology enables more intuitive and precise operation of the prosthetic upper limb, allowing individuals to perform a wide range of activities of daily living with greater ease and efficiency. IDMs eliminate the need for mode switching and can use at-home calibration to accommodate muscle signal changes associated with muscle fatigue, co-activity, or electrode impedance changes.

The MyoPro by Myomo is a powered arm and hand orthosis designed to assist individuals with paralyzed or weakened upper extremities. It uses myoelectric technology to amplify weak muscle signals, enabling users to regain control over their movements for rehabilitation and daily activities. On the other hand, Coapt's Intent Decoding Modules are advanced pattern recognition systems that decode natural muscle signal patterns to provide intuitive control for upper limb prostheses. This technology enhances the functionality of prosthetic devices, making them feel more like a natural extension of the user's body. While MyoPro focuses on amplifying existing muscle signals for rehabilitation, Coapt's modules emphasize intuitive control and integration with prosthetic limbs.

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 the effects of the technology on health outcomes.

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.

CODING Medicare Advantage Plans and Commercial Products The following HCPCS code(s) are not covered for Medicare Advantage Plans and not medically necessary for Commercial Products: L6700 Upper extremity addition, external powered feature, myoelectronic control module, additional EMG inputs, pattern-recognition decoding intent movement (New Code Effective 4/1/2025) 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

RELATED POLICIES Not applicable

PUBLISHED Provider Update, September 2025

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

Provider Update, August 2024 Provider Update, May 2023 Provider Update, November 2022 Provider Update, June 2021

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. Jan-Feb 1993;13(1):68-75. PMID 8416358
3. Silcox DH, 3rd, 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):1781-1789. PMID 8258548
4. 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
5. Sjoberg L, Lindner H, Hermansson L. Long-term results of early myoelectric prosthesis fittings: A prospective case-control study. Prosthet Orthot Int. Sep 1 2017:309364617729922. PMID 28905686
6. Egermann M, Kasten P, Thomsen M. Myoelectric hand prostheses in very young children. Int Orthop. Aug 2009;33(4):1101-1105. PMID 18636257
7. 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
8. 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
9. 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
10. 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
11. 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
12. 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
13. Peters HT, Page SJ, Persch A. Giving them a hand: wearing a myoelectric elbow-wrist-hand orthosis reduces upper extremity impairment in chronic stroke. Ann Rehabil Med. Sep 2017;98(9):1821-1827. PMID 28130084

14. Optum Encoder HCPCS Code Detail - L8702. Optum Encoderpro.com - Professional. (2020, October 1). https://www.encoderpro.com/epro/hcpcsHandler.do?_k=102%2AL8702&_a=viewDetail. Accessed June, 2025. i

    This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS