Myoelectric upper limb prosthetic devices

Coverage decision

Myoelectric prosthesis for the upper limb is a covered benefit with conditions for State Fund, Self-Insured and Crime Victims claims.

Description

Myoelectric prosthetics are powered by electric motors with an external power source. The movement (at the elbow, wrist, and/or fingers) is driven by micro-processed electrical activity in the muscles of the remaining limb.

Hybrid systems are those that use a combination of body-powered and myoelectric components and are used for amputations at or above the elbow. Hybrid systems allow control of two joints at once (i.e., one body-powered and one myoelectric).

Prior authorization criteria

Use the L&I Prosthetic Device Request Form, with addendum for microprocessor.

The recommendation for the myoelectric prosthesis must come from a board-certified physician (MD or DO) who specializes in functional rehabilitation of amputees.

  • To meet the criteria for coverage, the worker must have:
    • Condition of amputation at the hand or above allowed on the claim.
    • Adequate skin integrity: no current skin breakdown, open wounds or infections, or frequent history of such.
    • Actual or anticipated ability to tolerate wearing prosthesis for at least 6 hours per day.
    • Ability to don and doff the limb independently.
    • Documented history of compliance with rehabilitative medical care.
    • Access to a prosthetist with documented experience and knowledge of the proposed device and the capacity of performing the necessary maintenance and repairs.
    • Sufficient upper body strength to keep prosthesis stable.
    • A successful trial using the device, or prior experience if it is a replacement.
    • Documentation that, if the necessity is mostly related to conditions other than the amputation, (i.e. limitations on the sound side), this issue cannot be resolved with further treatment.
    • Functional evaluation by a qualified professional e.g., prosthetist, occupational therapist.
      • Evaluation includes:
        • Verification of sufficient cognitive ability to learn how to properly use the proposed device in the course of normal daily living.
        • Verification that the remaining musculature contains the minimum microvolt threshold to allow operation of a myoelectric prosthetic device as demonstrated by testing.
        • Description of how a myoelectric prosthesis is able to meet the specific functional needs of the individual to perform activities of daily living (ADL) and/or work activities:
          • Addressing frequency and nature of essential activities.
          • Addressing needs related to durability, control of device, coordination, performance, and usability.
        • Description of how the specific device was chosen and what alternatives (body powered and myoelectric) were ruled out and why.
        • Proposed training goals/plan.
      • Agreement to use the device within manufacturer’s specifications, including but not limited to:
        • Weight limits: both the worker’s body weight and the weight lifted or carried do not exceed the lifting/carrying/force capacity of the device.
        • Environmental exposures: some devices should not be used in high levels of moisture, humidity, heat, dust, and chemicals.

Additional criteria required for individually controlled finger myoelectric prosthesis:

  • Demonstration that a standard myoelectric hand is not adequate for the individual’s daily activities and/or job duties.  Include specific self-care and/or work-related activities the individual is unable to perform that the individually controlled finger prosthesis will allow. 
  • Access to training with a therapist knowledgeable about the requested device.

Additional information

Higher consideration may be given:

  • If the myoelectric prosthetic would increase the likelihood of returning the individual back to work and/or ability to perform work related tasks.
  • For high-functioning patients with recent traumatic amputation based on provider recommendation. 

Coverage of both a myoelectric prosthesis and body powered prosthesis will be made on a case by case basis.

Partial hand myoelectric devices are considered on a case by case basis.

If more than one prosthetic device meets the functional needs, benefits are only available for the prosthetic device that meets the minimum specifications for the individual.

Non-covered Devices:

Myoelectric upper limb prosthetic components for an existing functioning prosthetic device are considered not medically necessary under all other conditions (e.g., as an "upgrade" for a prosthesis that still functions and fits).

Devices for the primary purpose of sports, recreational, and/or leisure activities. 

Background

This coverage decision is based on the best available evidence and expert opinion, including a physiatrist with expertise in amputations and prosthetics, professional  prosthetists , and L&I occupational therapy staff. It uses similar criteria to the coverage decision on microprocessor lower extremity prostheses, which was guided by an assessment done by the Washington State Health Technology Assessment Program.

Billing and payment

Primary Codes:
L6025 Part hand disarticulation myoelectric
L6880 Electric hand individual articulating digits
L6882 Microprocessor controlled upper limb
L6925 Wrist disarticulation myoelectronic
L6935 Below elbow myoelectronic
L6945 Elbow disarticulation myoelectronic
L6955 Above elbow myoelectronic
L6965 Shoulder Disarticulation myoelectronic
L6975 Interscapular Thoracic myoelectronic
L7007 Adult electric hand
L7009 Adult electric hook
L7170 Electronic elbow hosmer swit
L7180 Electronic elbow sequential
L7181 Electronic elbow simultaneous
L7185 Electronic elbow adolescent sw
 L7190 Elbow adolescent myoelectronic

Common add on codes:
L6715 Terminal device, multi articulation digits
L7260 Electronic wrist rotator otto
L7261 Electronic wrist rotator utah
L6611 Additional switch, ext power
L6646 Multipo locking shoulder jnt
L6648 Ext powered shoulder lock/unlock
L6881 Terminal device auto grasp feature
L6882 Microprocessor control upper limb
L6920 Wrist disarticul switch ctrl
L6925 Wrist disart myoelectronic c
L6930 Below elbow switch control
L6935 Below elbow myoelectronic c
L6940 Elbow disarticulation switch
L6945 Elbow disart myoelectronic c
L6950 Above elbow switch control
L6955 Above elbow myoelectronic c
L6960 Shoulder disartic switch control
L6965 Shoulder disartic myoelectronic
L6970 Interscapular-thor switch ct
L6975 Interscapular-thor myoelectronic
L7040 Prehensile actuator
L7368 Lithium ion battery charger
L8465 Shrinker upper limb

For more information:
Contact information.

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