Point32Commercial Clinical Policy

Point32 Prosthetic Devices – Upper Limb Prostheses Form


Initial Upper Limb Prostheses Authorization

Notes: A trial of upper limb prosthesis may be covered with supporting documentation.

Indications

(420483) Has a comprehensive evaluation been performed by a board certified prosthetist and the proscribed prosthesis/component(s) is based on their recommendation? 
(420484) Does the functional evaluation indicate that the requested device meets but does not exceed the medical necessity to adequately meet the functional needs of the patient? 
(420485) Does the patient have sufficient cognitive, neurological, cardiovascular, and musculoskeletal ability to effectively utilize the requested device for activities of daily living (ADL's)? 
(420486) Is it predicted that the patient will reach or maintain an improved functional state within a reasonable period of time with the use of the prescribed prosthesis? 

Myoelectric Prosthesis

Indications

(420487) Does the patient have adequate neurological, musculoskeletal, myocutaneous, and cognitive function to operate a myoelectric prosthesis efficiently? 

YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

NA

Last Reviewed

02/22

Original Document

  Reference



3. Melton D. Physiatrist Perspective on Upper-Limb Prosthetic Options: Using Practice Guidelines to Promote Patient Education in the Selection and the Prescription Process.

J Prosthet Orthot. 2017; 29:40–P44.

4. Cordella F, Cianco AL, et.al. Literature Review on Needs of Upper Limb Prosthesis Users.

Frontiers in Systems Neuroscience. 2016 May; 10(209):1-14.

5. KJ Zuo, JL Olson. The evolution of functional hand replacement: From iron prostheses to hand transplantation.

Plast Surg 2014; 22(1):44-51.

6. Geethanjali P. Myoelectric control of prosthetic hands: state-of-the-art review.

Dove Press Journal. Medical Devices: Evidence and Research 2016:9 247–255 Accessed February 5, 2019.

HPHC Medical Policy

Public Domain

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Upper Limb Prostheses

Upper Limb Prostheses

VA01JUL22P

VA01JUL22P

HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g. Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

7. Lindner HYN, Natterlund BS, et.al. Upper limb prosthetic outcome measures: Review and content comparison based on International Classification of Functioning, Disability and Health.

Prosthetics and Orthotics International 2010; 34(2): 109–128.

8. Pasquina PF, Carvalho AJ, et.al. Ethics in Rehabilitation: Access to Prosthetics and Quality Care Following Amputation.

AMA Journal of Ethics, 2015; 17(6): 535-546.

9. Soyer K, Unver B, Tamer S, Ulger O. The importance of rehabilitation concerning upper extremity amputees: A Systematic Review.

Pak J Med Sci. 2016; 32(5):1312-1319. doi: dx.doi.org/10.12669/pjms.325.9922

10. MassHealth 130 CMR 428.000: Prosthetics Services.

Accessed February 17, 2019 mass.gov/regulations/130-CMR-428000-prosthetics-services

11. Local Coverage Determination (LCD) L33787: Lower Limb Prostheses.

Noridian Healthcare Solutions, LLC. Accessed on October 12, 2021January 2, 2022 at med.noridianmedicare.com/documents/2230703/7218263/Lower+Limb+Prostheses+LCD+and+PA/d3244c51-74d3-4214-a789-7481bc2e03d5

12. 130 CMR 409.000: Durable Medical Equipment Services accessed on January 2, 2022

@ mass.gov/regulations/130-CMR-409000-durable-medical-equipment-services

13. General Laws of Massachusetts - Chapter 176G Health Maintenance Organizations - Section 4S Coverage for prosthetic devices and repairs.

Section 4S accessed on January 2, 2022 @ malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter176G/Section4S