Aetna considers myoelectric hand prostheses medically necessary for members with traumatic or congenital absence of forearm(s) and hand(s). Aetna considers myoelectric hand prostheses experimental and investigational for all other indications.
The myoelectric hand prosthesis is an alternative to conventional hook prostheses for patients with traumatic or congenital absence of forearm(s) and hand(s). 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 one 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 one-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 12-18 months due to growth. With heavy use the entire prosthesis might require replacement by the fifth year.
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).
CPT Codes / HCPCS Codes / ICD-9 Codes
Other CPT codes related to the CPB:
24900 - 24935, 25900 - 25931, 26910 - 29652
27880 - 27889, 28800 - 28825
HCPCS codes covered if selection criteria are met:
L6925
Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device
L6935
Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two 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, two 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, two 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, two 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, two batteries and one charger, myoelectronic control of terminal device
HCPCS codes not covered for indications listed in the CPB:
L5856
Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type
L5857
Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type
L5858
Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type
ICD-9 codes covered if selection criteria are met:
755.20 - 755.29
Reduction deformities of upper limb
887.0 - 887.7
Traumatic amputation of arm and hand (complete) (partial)
V49.60 - V49.67
Upper limb amputation status
ICD-9 codes not covered for indications listed in the CPB:
755.30 - 755.39
Reduction deformities of lower limb
896.0 - 897.7
Traumatic amputation of foot and leg(s) (complete) (partial)
V49.70 - V49.77
Lower limb amputation status
The above policy is based on the following references:
Nader M. The artificial substitution of missing hands with myoelectrical prostheses. Clin Orthop. 1990;(258):9-17.
Silcox DH, Rooks MD, Vogel RR, et al. Myoelectric prostheses. A long-term follow-up and a study of the use of alternative prostheses. J Bone Joint Surg Am. 1993;75(12):1781-1789.
Weaver SA, Lange LR, Vogts VM. Comparison of myoelectric and conventional prostheses for adolescent amputees. Am J Occup Ther. 1988;42(2):87-91.
Scott RN, Parker PA. Myoelectric prostheses: State of the art. J Med Eng Technol. 1988;12(4):143-151.
Kritter AE. Myoelectric prostheses. J Bone Joint Surg Am. 1985;67(4):654-657.
Stein RB, Walley M. Functional comparison of upper extremity amputees using myoelectric and conventional prostheses. Arch Phys Med Rehabil. 1983;64(6):243-248.
Leonard JA, Meier RH. Upper and lower extremity prosthetics. In: Rehabilitation Medicine: Principles and Practice. 2nd ed. JA DeLisa, ed. Philadelphia, PA: J.B. Lippincott Co.; 1993:507, 514-515.
Otto Bock, Inc. Myoelectrical prostheses. Minneapolis, MN: Otto Bock; 1999. Available at: http://www.ottobockus.com/. Accessed June 11, 2001.
Motion Control, Inc. The Utah Arm. Salt Lake City, UT: Motion Control; 1999. Available at: http://www.utaharm.com/. Accessed June 11, 2001.
Routhier F, Vincent C, Morissette MJ, et al. Clinical results of an investigation of paediatric upper limb myoelectric prosthesis fitting at the Quebec Rehabilitation Institute. Prosthet Orthot Int. 2001;25(2):119-131.
Esquenazi A. Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration. Disabil Rehabil. 2004;26(14-15):831-836.
Martinez K, Mipro RC. Upper limb prosthetics. eMedicine Physical Medicine and Rehabilitation Topic 174. Omaha, NE: eMedicine.com; updated September 30, 2004. Available at: http://www.emedicine.com/pmr/topic174.htm. Accessed June 17, 2005.
Hsu MJ, Nielsen DH, Lin-Chan SJ, Shurr D. The effects of prosthetic foot design on physiologic measurements, self-selected walking velocity, and physical activity in people with transtibial amputation. Arch Phys Med Rehabil. 2006;87(1):123-129.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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