Aetna considers the NeuroControl Freehand System medically necessary for members with paralyzed hand(s) who meet all of the following criteria:
Aetna considers the NeuroControl Freehand System for members not meeting the afore-mentioned criteria experimental and investigational.
The NeuroControl Freehand System is a surgically implanted device that restores hand function in people with quadriplegia by neuroelectric stimulation of forearm and hand muscles.
The NeuroControl Freehand System involves transfers of multiple tendons together with the implantation of up to eight electrodes in the muscles of the forearm and hand of patients with quadriplegia (Johnson and Whitworth, 2002). The electrode wires are tunneled up the arm to a control box located under the skin in the pectoral region. A movement detector is placed externally on the opposite shoulder. When the patient elevates and depresses or protracts and retracts this shoulder the movement is relayed to the control box, which is programmed to coordinate the activity in the electrodes and cause the hand to open and close. The NeuroControl Freehand System allows for 2 different hand grasp positions. The lateral prehension grasp (key pinch) is designed to help with activities such as writing, editing, and grasping small objects. The palmar prehension grasp is designed to help people hold and release a large object, such as a cup, ball, or book.
Appropriate candidates for the NeuroControl Freehand System must have use of their shoulder, upper arm, and elbow; they may or may not have use of their wrist, and limited use of their hands. The patient must have adequate range of motion with forearm and hand muscles that respond to stimulation with electrical impulses. The person must be skeletally mature. Medically, these patients have injuries at the C5 and/or C6 level. It is also recommended that neurological stability be established. This can be done by means of serial neurological examinations over a period of 3 to 6 months, which fail to show progression of signs and symptoms referable to the area of injury or imaging of the spine that excludes the presence of a progressive lesion.
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|CPT codes covered if selection criteria are met:|
|64565||Percutaneous implantation of neurostimulator electrodes; neuromuscular|
|64580||Incision for implantation of neurostimulator electrodes; neuromuscular|
|Other CPT codes related to the CPB:|
|24301, 25310 - 25312, 25316, 26480 - 26498, 26510, 27098, 27400, 27690 - 27692||Tendon transfer|
|HCPCS codes covered if selection criteria are met:|
|C1767||Generator, neurostimulator (implantable), non-rechargeable|
|C1778||Lead, neurostimulator (implantable)|
|L8680||Implantable neurostimulator electrode, each|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator|
|ICD-10 codes covered if selection criteria are met:|
|G82.54||Quadriplegia, C5-C7 incomplete|
|G83.0||Diplegia of upper limbs|
|G83.20 - G83.24||Monoplegia of upper limb|