Aetna considers myoelectric upper limb prostheses and hand prostheses (e.g., the Dynamic Mode Control hand, the i-LIMB, the Liberty Mutual Boston Elbow prosthetic device, the Otto Bock System Electrohand, and the Utah Elbow System) medically necessary for members with traumatic amputation or congenital absence of upper limb at the wrist or above (e.g., forearm or elbow) when the following criteria are met:

• Person has adequate cognitive ability to utilize a myoelectric prosthetic device.
• The remaining musculature of the arm(s) contains the minimum microvolt threshold to allow operation of a myoelectric prosthetic device.
• A standard body-powered prosthetic device can not be used or is insufficient to meet the functional needs of the person in performing activities of daily living.
  

Aetna considers myoelectric upper limb and hand prostheses experimental and investigational for all other indications becauase their effectiveness for indications other than the ones listed above has not been established.

Aetna considers partial-hand myoelectric prostheses experimental and investigational because their effectiveness has not been established.

For myoelectric prostheses of the lower extremity see CPB 0578 - Lower Limb Prostheses.

The myoelectric hand prosthesis is an alternative to conventional hook prostheses for patients with traumatic or congenital absence of forearm(s) and hand(s).  The myoelectric prostheses are user controlled by contraction of specific muscles triggering prosthesis movement through electromyographic (EMG) signals. These prostheses have a stronger pinch force, better grip, and are more flexible and easier to use than conventional hooks.

Myoelectric control is used to operate electric motor-driven hands, wrist, and elbows.  Surface electrodes embedded in the prosthesis socket make contact with the skin and detect and amplify muscle action potentials from voluntarily contracting muscle in the residual limb.  The amplified electrical signal turns on an electric motor to provide a function (e.g., terminal device operation, wrist rotation, elbow flexion).  The newest electronic control systems perform multiple functions, and allow for sequential operation of elbow motion, wrist rotation and hand motions.

Myoelectric hand prostheses provide improved function and range of functional position as compared to “hook” prostheses.  Myoelectrical hand prostheses can be used for patients with congenital limb deficiencies and for patients with amputations sustained as a result of trauma or surgery.  The device is appropriate for both above-the-elbow and below-the-elbow amputees, and for both unilateral and bilateral amputees.  Patients must possess a minimum microvolt threshold (i.e., minimum strength of microvolt signals emitting from the remaining musculature of the arm) and pass a control test to be considered a candidate.

Myoelectrical hand prostheses are indicated for persons at least 1 year of age or older.  Children with congenital absence of the forearm(s) and hand(s) are usually fitted with a conventional passive prosthesis until approximately age 12 to 16 months, at which time they may be fitted with a myoelectrical prosthesis.

Myoelectrical hand prostheses generally come with a 1-year warranty for parts and labor.  The motor and drive mechanisms typically last 2 to 3 years and may need to be replaced after this period.  When used on a child, the sockets may need to be replaced every 12 to 18 months due to growth.  With heavy use the entire prosthesis might require replacement by the 5th year.

The Work Loss Data Institute's clinical guideline on "Shoulder (acute & chronic)" (2011) listed myoelectric upper extremity (hand and/or arm) prosthesis as one of the interventions/procedures that were considered and recommended.

Ostlie and colleagues (2012) described patterns of prosthesis wear, perceived prosthetic usefulness, as well as the actual use of prostheses in the performance of activities of daily life (ADL) tasks in adult acquired upper-limb amputees (ULAs).  Cross-sectional study analyzing population-based questionnaire data (n = 224) and data from interviews and clinical testing in a referred/convenience sample of prosthesis-wearing ULAs (n = 50).  Effects were analyzed using linear regression; 80.8 % wore prostheses and 90.3 % reported their most worn prosthesis as useful.  Prosthetic usefulness profiles varied with prosthetic type.  Despite demonstrating good prosthetic skills, the amputees reported actual prosthesis use in only about 50 % of the ADL tasks performed in everyday life.  In unilateral amputees, increased actual use was associated with sufficient prosthetic training and with the use of myoelectric versus cosmetic prostheses, regardless of amputation level.  Prosthetic skills did not affect actual prosthesis use.  No background factors showed significant effect on prosthetic skills.  The authors concluded that most major ULAs wear prostheses.  They stated that individualized prosthetic training and fitting of myoelectric rather than passive prostheses may increase actual prosthesis use in ADL.

There are many brands of myoelectric hand prostheses on the market. Brands of myoelectrical hand prostheses include the Otto Bock myoelectrical prosthesis (Otto Bock, Minneapolis, MN), the Liberty Mutual Boston Elbow prosthetic device (Liberty Mutual, Boston, MA), and the Utah Elbow System (Motion Control, Salt Lake City, UT).

Partial-hand myoelectric prostheses are designed to replace the function of digits in individuals missing 1 or more fingers as a result of a partial-hand amputation.  This type of prosthetic device requires a very specific range of amputation, i.e., amputation level through, or just proximal to, the metacarpal-phalangeal level of 1 or more digits.

Putzi (1992) reported the case of a young man who had 2 traumatic amputations and burns covering 80 % of his body.  Due to his severe burns, fitting a conventional prosthesis was a problem because normal procedures did not apply in his case.  The patient was fitted with a myoelectric partial-hand prosthesis.  The author concluded that this reconstruction of the myoelectric prosthesis was a satisfactory solution in providing the patient with as much hand and arm mobility as possible in light of his condition.  By using basic principles of orthotics and prosthetics, and exercising ingenuity in using existing proven components, it is possible to provide improvement in function and cosmetics to an individual with a partial-hand amputation.

Lake (2009) provided a review of progressive partial-hand prosthetic management.  The author noted that partial-hand prosthetic management represents an exciting new frontier in the specialty of upper limb prosthetics.  The application and benefit of treating this level are apparent.  Presently, this level is very difficult because of the vast surgical presentations, traumatic nature of the resultant limb difference, as well as the complicated biomechanics present as a result of the afore-mentioned 2 issues.  Lake (2009) noted that electric prosthetic management requires specialized care that does not have its foundation rooted in any of the current, yet progressive upper limb care protocols used by today's specialists.  Future research will entail electronic handling, fabrication, fitting protocols and techniques, as well as surgical considerations.  As fitting techniques and componentry evolve, so will the clinical protocols.  The author stated that an unique opportunity exists at the partial-hand level as this specialty enters a new prosthetic paradigm where evidence-based rehabilitation and sound research practices are expected by both the medical community as well as reimbursement agencies.

Currently, there is insufficient peer-reviewed evidence that examined the clinical value (e.g., improved function and health-related quality of life) of partial-hand myoelectric prostheses.