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Clinical Policy Bulletin:
Myoelectric Upper Limb Prostheses
Number: 0399


Policy

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 LTI Boston Digital Arm™ System, 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 (e.g., ProDigits™) experimental and investigational because their effectiveness has not been established.

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



Background

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.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
Other CPT codes related to the CPB:
24900 - 24935, 25900 - 25931, 26910 - 29652
HCPCS codes covered if selection criteria are met:
L6629 Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal
L6632 Upper extremity addition, latex suspension sleeve, each
L6680 Upper extremity addition, test socket, wrist disarticulation or below elbow
L6687 Upper extremity addition, frame type socket, below elbow or wrist disarticulation
L6810 Addition to terminal device, precision pinch device
L6880 Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s)
L6882 Microprocessor control feature, addition to upper limb prosthetic terminal device
L6890 Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment
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
L7368 Lithium ion battery charger, replacement only
L7400 Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal)
L7403 Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material
L8465 Prosthetic shrinker, upper limb, each
HCPCS codes not covered for indications listed in the CPB:
L6025 Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device
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


The above policy is based on the following references:
  1. Nader M. The artificial substitution of missing hands with myoelectrical prostheses. Clin Orthop. 1990;(258):9-17.
  2. 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.
  3. Weaver SA, Lange LR, Vogts VM. Comparison of myoelectric and conventional prostheses for adolescent amputees. Am J Occup Ther. 1988;42(2):87-91.
  4. Scott RN, Parker PA. Myoelectric prostheses: State of the art. J Med Eng Technol. 1988;12(4):143-151.
  5. Kritter AE. Myoelectric prostheses. J Bone Joint Surg Am. 1985;67(4):654-657.
  6. Stein RB, Walley M. Functional comparison of upper extremity amputees using myoelectric and conventional prostheses. Arch Phys Med Rehabil. 1983;64(6):243-248.
  7. 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.
  8. Otto Bock, Inc. Myoelectrical prostheses. Minneapolis, MN: Otto Bock; 1999. Available at: http://www.ottobockus.com/. Accessed June 11, 2001.
  9. Motion Control, Inc. The Utah Arm. Salt Lake City, UT: Motion Control; 1999. Available at: http://www.utaharm.com/. Accessed June 11, 2001.
  10. 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.
  11. Esquenazi A. Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration. Disabil Rehabil. 2004;26(14-15):831-836.
  12. 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.
  13. Butter M, Rensma A, van Boxsel J, et al. Robotics for Healthcare. Final Report. Version 5. Prepared by TNO for the European Commission, DG Information Society. Delft, The Netherlands: Netherlands Organization for Applied Scientific Research (TNO); October 3, 2008.
  14. Egermann M, Kasten P, Thomsen M. Myoelectric hand prostheses in very young children. Int Orthop. 2009;33(4):1101-1105.
  15. Kelly BM, Pangilnan PH Jr, Rodriguez GM, et al. Upper limb prosthetics. eMedicine Physical Medicine and Rehabilitation. New York, NY: Medscape; January 14, 2009.
  16. Castellini C, Fiorilla AE, Sandini G. Multi-subject/daily-life activity EMG-based control of mechanical hands. J Neuroeng Rehabil. 2009;6:41.
  17. Otr OV, Reinders-Messelink HA, Bongers RM, et al. The i-LIMB hand and the DMC plus hand compared: A case report. Prosthet Orthot Int. 2010;34(2):216-220.
  18. Putzi R. Myoelectric partial-hand prosthesis. J Prosthet Orthot. 1992;4(2):103-108.
  19. Lake C. Experience with electric prostheses for the partial hand presentation: An eight-year retrospective. J Prosthet Orthot. 2009;21(2):125-130.
  20. Work Loss Data Institute. Shoulder (acute & chronic). Encinitas, CA: Work Loss Data Institute; 2011.
  21. Ostlie K, Lesjo IM, Franklin RJ, et al. Prosthesis use in adult acquired major upper-limb amputees: Patterns of wear, prosthetic skills and the actual use of prostheses in activities of daily life. Disabil Rehabil Assist Technol. 2012;7(6):479-493.


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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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