Coverage of Conditions and Treatments (Coverage Decisions)
Myoelectric prostheses for the upper limbs are a covered benefit with conditions.
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 information
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