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Upper Limb Prostheses
05.00.72j

Policy

State mandates do not automatically apply to all plans; therefore, individual benefits must be verified.
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MEDICALLY NECESSARY

Passive (manual) or body-powered (harness and cable) upper limb prostheses are considered medically necessary and, therefore, covered when all of the following criteria are met:
  • The individual has an amputation or a loss of an upper limb that occurs at any level from the finger to the shoulder.
  • A comprehensive evaluation is performed by a licensed professional provider and prosthetist.
    • An evaluation by a physical, occupational, or certified hand therapist is strongly encouraged.
  • The prosthesis is prescribed by a licensed professional provider.
  • The prosthesis is fitted and made by a certified or licensed prosthetist.
Externally powered (e.g., myoelectric) upper limb prostheses (including those parts of a hybrid system) are considered medically necessary and, therefore, covered when all of the following criteria are met:
  • The individual has an amputation or loss of an upper limb at the transmetacarpal level, wrist disarticulation, or proximal (above).
  • A comprehensive evaluation is performed by a licensed professional provider and prosthetist.
    • An evaluation by a physical, occupational, or certified hand therapist is strongly encouraged.
  • The prosthesis is prescribed by a licensed professional provider.
  • The prosthesis is fitted and made by a certified or licensed prosthetist.
  • A standard body-powered prosthetic device cannot be used or is insufficient to meet the functional needs of the individual in performing activities of daily living.
  • The individual with an upper limb amputation has the capacity to operate an externally powered upper limb prosthesis through myoelectric control (has demonstrated the capacity to generate the minimum microvolt threshold) and/or through alternate input mechanisms.
  • A functional evaluation indicates that, with training, the use of a myoelectric prosthesis is likely to meet the functional needs of the individual (e.g., gripping, releasing, holding, and coordinating movement of the prosthesis) when performing activities of daily living. This evaluation should consider the individual’s needs for control, durability (maintenance), function (speed, capability), and usability.
Terminal devices are considered medically necessary and, therefore, covered when used to perform an essential activity of daily living (e.g., eating, bathing).

NOT MEDICALLY NECESSARY

All other uses for an upper limb prosthetic and/or components not meeting the above criteria are considered not medically necessary and, therefore, not covered.

Terminal devices are considered not medically necessary and, therefore, not covered when used solely for activities not essential to an activity of daily living, such as, but not limited to, sports, recreation or employment.

EXPERIMENTAL/INVESTIGATIONAL

An upper limb prosthesis with individually powered digits, including but not limited to a partial hand prosthesis, is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

REPAIR AND REPLACEMENT

For information on the repair and/or replacement of prostheses, refer to the Company's policy on the repair and replacement of durable medical equipment (DME) and prosthetic devices.​

The repair or replacement of upper limb prostheses, supplies, or one or more of its components (parts) is covered and eligible for reimbursement consideration by the Company when the upper limb prosthesis itself is covered under the individual's medical benefits and all of the requirements for a repair or replacement are met.

The repair or replacement of upper limb prostheses or one or more of its components (parts) is considered non-covered and not eligible for reimbursement when the request is for a technologically advanced or newly released upgrade to an original device that still functions properly and/or there is no significant change in the individual's condition.

Requests for a different type of upper limb prosthesis or one or more of its components (parts) due to a change in medical and/or functional status, such that the upper limb prosthesis can no longer meet the individual’s needs for control, durability (maintenance), function (speed, work capability), and usability are considered new requests, not requests for replacement. These requests are evaluated against the medical necessity criteria for the new type of upper limb prostheses requested.

The Company may determine the reasonable useful lifetime of a specific external prosthetic device based on the manufacturer's recommendation or the Food and Drug Administration (FDA)-approved labeling.

In the absence of manufacturer's recommendations or FDA labeling, the Company may determine the reasonable useful lifetime of a specific external prosthetic device, but is generally not less than five years. Replacement due to misuse, abuse, or failure to adequately maintain or care for the item is excluded from coverage.

REQUIRED DOCUMENTATION

A specialty evaluation must be performed by a professional provider, including a physician and a prosthetist with specific training and experience in rehabilitation involving upper limb prostheses evaluations, who document the need for the prosthesis and or accessories. In addition, specialty evaluations should be performed by a licensed/certified physical therapist (PT), occupational therapist (OT), or Certified Hand Therapist (CHT) for externally powered upper limb prostheses.

Reimbursement for devices will be made only if there is sufficient documentation in the individual's medical record showing current functional capabilities and functional need for the technological or design features. Documentation should also include expected functional potential and an explanation if there is a difference between the individual's current status and expected potential. This information must be retained in the professional provider's or prosthetist's files, and be available upon request.

The prosthetist must retain documentation in the medical record of the prosthesis or prosthetic component replaced, the reason for replacement, and a description of the labor involved. It is recognized that there are situations where the reason for replacement includes but is not limited to: changes in the residual limb, functional need changes, or irreparable damage or wear/tear due to excessive patient weight or prosthetic demands of highly mobile amputees.

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

 STANDARD WRITTEN ORDER REQUIREMENTS

 Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective standard written order at the time of an audit or after an audit for submission as an original standard written order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY REQUIREMENTS

 Medical record documentation must include a contemporaneously prepared delivery confirmation or member's receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES (WHEN APPLICABLE)

 The DME supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual's medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

For specified DME items, documentation of a face-to-face encounter between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual's clinical condition supporting the need for the prescribed DME item(s), must be provided to and kept on file by the DME supplier.

If required documentation is not available on file to support a claim at the time of an audit or record request, the DME supplier may be required to reimburse the Company for overpayments.

Guidelines

The upper limb prosthesis must be prescribed and ordered by a qualified professional who is able to determine the most appropriate prosthetic components and control mechanism (e.g., passive, body-powered, myoelectric, or hybrid). A trial period may be indicated to evaluate the tolerability and efficacy of the prosthesis in a real-life setting.

The following should be considered when determining type of prosthesis:
  • The individual has demonstrated sufficient neurological and cognitive function to operate the prosthesis effectively.
  • The individual is free of comorbidities that could interfere with function of the prosthesis (e.g., neuromuscular disease).
AMPUTATION LEVELS
  • Transphalangeal amputation: resection of the thumb or fingers at distal interphalangeal (DIP), proximal interphalangeal (PIP), or metacarpophalangeal (MCP) levels or at any level in between.
  • Transmetacarpal amputation: resection through the metacarpals.
  • Transcarpal amputation: resection through the carpal bones.
    • Transmetacarpal and transcarpal amputations are less advised because, except for select circumstances, they provide for decreased functional outcomes.
  • Wrist disarticulation: transection between the carpals and radius/ulna.
  • Transradial amputation: below-elbow amputation (may be classified as long, medium, or short).
  • Elbow disarticulation: transection through the elbow joint.
  • Transhumeral amputation: above-elbow (standard length is 50 percent to 90 percent of humeral length).
  • Shoulder disarticulation: transection through the shoulder joint.
  • Interscapulothoracic disarticulation (forequarter): amputation removing the entire shoulder girdle (scapula and all or part of the clavicle) (some surgeons choose to leave part of the medial clavicle).
BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, upper limb prostheses and components are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

However, devices that are identified in this policy as experimental/investigational or not medically necessary are not eligible for coverage or reimbursement by the Company.

Coverage of the repair or replacement of prosthetic devices and associated supplies and components (parts) may vary by product and/or group contract. Therefore, individual member benefits must be verified.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

Manufacturers must register prostheses with the restorative devices branch of the US Food and Drug Administration (FDA) and keep a record of any complaints, but do not have to undergo a full FDA review.

MANDATES

For members enrolled in New Jersey products, refer to the applicable Orthotic and Prosthetic mandate.​

Description

An upper limb amputation is much less common than a lower limb amputation. The upper limb amputation is considered to be any amputation that occurs in the upper limb from an individual finger to the shoulder complex. The preferred level of amputation for the highest level of functional recovery is the below-elbow amputation (transradial). A prosthesis is a device that is designed to restore natural appearance and function of a missing limb or body part.

Upper limb prostheses are used for amputations that can occur at any level from finger or partial hand to the shoulder. The need for an upper limb prosthesis can result from congenital limb deficiencies or amputations secondary to tumors, medical diseases, elective surgery, or trauma. Most congenital deformities at birth do not adversely affect lifespan, so an individual with a congenital deformity may require prosthetic rehabilitation at any age. Amputations from tumors are most common among rapidly growing individuals during their teen years. Amputations as a result of trauma, the most common cause for upper limb amputations, usually occur in individuals from 15 years to 45 years of age. Upper-extremity amputations tend to be rare in individuals older than 60 years, but may be required secondary to tumor or medical disease.

The type of functional prosthesis available for people with upper limb amputations is dictated by their level of amputation. Furthermore, consideration must be given to associated co-morbidities, especially if the individual has bilateral upper limb amputations.

CATEGORIES OF UPPER LIMB PROSTHESES

There are five main categories of upper limb prostheses: passive (or functional aesthetic), body-powered, externally powered (e.g., myoelectric), hybrid-powered (e.g., a combination of body-powered and myoelectric components), and activity-specific (e.g., terminal devices).

PASSIVE PROSTHESES
The passive, also known as a functional aesthetic, prosthesis is the lightest in weight and is described as the most comfortable. Functional aesthetic prostheses are available as finger prostheses, partial-hand prostheses, hand prostheses all the way proximal to shoulder disarticulation, and interscapulothoracic prostheses. For individuals with digital and partial-hand amputations, these devices can provide desensitization, edema management, and restoration of the ability to grip surfaces in the affected hand, in addition to restoration of a natural appearance. For individuals with amputations at the wrist and proximal (above), a passive prosthesis must be positioned manually with the opposite arm. While a defining feature of functional aesthetic prostheses is that they have no active prehension at the hand, most have the ability to hold objects with a passive grasp when items are placed into the hand. This type of prosthesis restores the appearance of absent anatomy and provides the functional benefit of bimanual activities and support of an unaffected limb. Passive prostheses are generally contraindicated for people with bilateral upper limb amputations.

BODY-POWERED PROSTHESES
The body-powered prosthesis uses a harness and cable system to provide direct activation of prosthetic components. Voluntary movement of the shoulders and/or residual limb pull on a cable (or cables), which then transmits force to prosthetic components. Body-powered prostheses are available for individuals with amputations at the metacarpal phalangeal level and proximal (above). An advantage of a body-powered prosthesis is that wearers describe a direct biofeedback link between their motion and the device operation without delay. Body-powered prostheses have proven to be reliable and can be made to withstand heavy-duty activities, as well as rugged environments. For body-powered systems, the most functional terminal device is a split hook or prehensor, rather than a mechanical hand, because mechanical prosthetic hands are visually obstructive and lack fine tip prehension.

EXTERNALLY POWERED PROSTHESES
Externally powered prostheses (e.g., myoelectric and some terminal devices) obtain input from the wearer to generate electrical signals, which are in turn used to operate battery-powered components, including terminal devices, wrists, and elbows, as well as elbow and shoulder joint locks. Externally powered prostheses are available for individuals with transmetacarpal amputations and proximal. The primary method of input for an externally powered prosthesis is via muscle-activated, surface-mounted electrodes; however, switches, pressure pads, and buttons are also available as input sources.

In a myoelectric prosthesis, electromyographic (EMG) signals from the residual limb musculature are detected by surface electrodes, amplified, and then processed by a controller to drive battery-powered motors that move the hand, wrist, or elbow. Although upper-arm movement may be slow and can be limited to one joint at a time, myoelectric control of movement may be considered the most physiologically natural. Other advantages of externally powered devices are that they allow for reduction or elimination of harnessing, and can provide a strong grip and near-natural appearance and function.

Recent advances in prosthetic hand technology for individuals with partial hand and/or digit loss now allow for externally powered prosthetic hands to be programmed by a software interface that communicate via a Bluetooth® connection and can allow adjustments to be made to the prosthesis through a series of setting options that provide a highly functional compliant grip whereby the individual fingers of the device wrap around the object being grasped. Examples of these externally powered prosthetic hands are: the i-Limb™ Ultra, i-LIMB™ PULSE hand (Touch Bionics, Columbus, OH), Otto Bock myoelectric prosthesis, Michelangelo® Hand (Otto Bock), the LTI Boston Digital Arm™ System (Liberating Technologies) and the BeBionics™ Hand (SteeperUSA, San Antonio), ProDigits™ (Touch Bionics, Columbus, OH).

HYBRID-POWERED PROSTHESES
A hybrid prosthesis combines the use of body-powered (harness and cable) and externally powered (e.g., myoelectric) control strategies. Hybrid prostheses are available for individuals with amputations at the elbow disarticulation level and proximal. The hybrid system allows for control of two components simultaneously; for example, the terminal device may be controlled myoelectrically, and the elbow may be operated through a body-powered harness/cabling system. Hybrid prostheses may be lighter in weight than prostheses that are entirely externally powered.

ACTIVITY-SPECIFIC PROSTHESES
Activity-specific prostheses are devices designed for a specific functional, vocational, or avocational activity. Because they are designed for a specific functional task, they do not restore an aesthetic/natural appearance. An example of an activity-specific prosthesis would be one for operating a particular piece of machinery or equipment, for swimming, for weight-lifting, or for a particular sport such as golfing or ball sports.

PROSTHETIC COMPONENTS

TERMINAL DEVICES
Terminal devices are the component at the end of a prosthesis that is designed to substitute hand function or to perform a specific function. Terminal devices can be classified as hooks, prehensors, or hands, and are either active or passive. Hooks and prehensors can be either body-powered or externally powered, and are very functional for grasping activities because they offer minimal visual obstruction. However, they may be rejected by individuals on the basis of their appearance. Body-powered hooks and prehensors can be further subdivided into voluntary opening (VO: pull-to-open with elastic closure) or voluntary closing (VC: pull-to-close with elastic opening).

PROSTHETIC HANDS
Prosthetic hands can be passive, body-powered, or externally powered. Passive terminal devices restore an aesthetic appearance and can be used to stabilize objects during bimanual activities. Body-powered (also known as mechanical) hands may also be either VO or VC in operation. Both body-powered and externally powered prosthetic hands restore natural appearance, but they tend to be heavy and more costly. Most prosthetic hands require gloves for protection and aesthetics that need to be replaced periodically. The terminal device chosen is based on the individual and the intended function. As no one individual terminal device can replace the multiple deficits associated with hand loss, provision of more than one terminal device may be indicated depending on the individual's unique presentation, vocation, and life circumstances.

WRIST UNITS
Wrist units included in upper limb prostheses come in different shapes and offer a number of functional features, including wrist flexion/extension, pronation/supination, and quick disconnect. Wrist flexion/extension and pronation/supination are valuable features because they allow for the terminal device to be optimally positioned for grasping and object-manipulation tasks. The quick-disconnect feature of a wrist unit allows for multiple terminal devices to be easily exchanged so that a single prosthesis can utilize a hook, prehensor, or prosthetic hand, depending on the activity in which the wearer is engaged. Body-powered prostheses can have wrist units with wrist flexion/extension, pronation/supination, and/or quick-disconnect, as long as the amputation is transradial (below elbow) or proximal. Externally powered prostheses can have wrist units with powered wrist pronation/supination or with quick-disconnect features. Powered wrist flexion/extension prostheses are currently not available.

PROSTHETIC ELBOWS
Prosthetic elbows are passive, body-powered, or externally powered. Passive elbows are lightweight and light-to-moderate duty and require the unaffected hand for positioning and locking. Body-powered elbows are reliable, require minimal maintenance, and can be operated through body motions. They tend to have limited life lift capacity but once positioned can withstand loading. Externally powered elbows can be operated myoelectrically or through switches and can have a live lift capacity of up to 13 pounds.

TECHNOLOGY DEVELOPMENT
Prosthetic research and development are rapidly changing due to advances in biomedical engineering and funding by the U.S. Department of Defense Advanced Research Projects Agency (DARPA). Some areas being developed are skin-like silicone elastomer gloves, "artificial muscles," and sensory feedback, in addition to smaller motors, implantable myoelectric sensors, and reinnervation of remaining muscle fibers to allow improved fine motor control. Lighter batteries and newer materials are being incorporated into myoelectric prosthetics to improve individual comfort. Restoring sensation to the prosthetic limb remains a major challenge to full integration of the limb into the individual's self image.

PREPROSTHETIC EVALUATION AND MANAGEMENT

Preprosthetic evaluation and management of a new upper limb amputee is vital for optimal rehabilitation outcomes. The cause of the amputation will determine the best approach for preprosthetic management. Care is coordinated by a multidisciplinary team approach, which may involve a prosthetist, a surgeon, nurses, physical and occupational therapists, and others as needed. Most preprosthetic evaluation and management is initiated following wound closure for someone with a new upper-extremity amputation.

Components of a preprosthetic evaluation and management program may include the following:
  • Completing a comprehensive evaluation to guide the team in determining an appropriate prosthetic plan
  • Shaping and controlling volume of the residual limb effectively
  • Minimizing scar tissue
  • Desensitizing the limb in preparation for wearing the prosthetic device
  • Achieving full range of motion in remaining joints of the residual limb
  • Strengthening the muscles of the residual limb to maximize potential for effective prosthetic use
  • Developing appropriate interventions for rehabilitation of associated injuries
  • Assisting the individual in developing some independence in performing basic activities of daily living
ADDITIONAL CONSIDERATIONS FOR PEDIATRICS

Most pediatric prosthetic evaluation and management occurs as the result of trauma or congenital limb deficiency. An upper limb prosthesis related to a congenital deficiency may be easier to fit than one resulting from trauma because the child with a traumatic amputation may experience boney overgrowth and will have to adjust their body image to the loss of their amputated limb. In addition, throughout their childhood and adolescence, pediatric individuals may utilize prostheses full time, part time, or totally reject prosthetic wear, depending on their developmental and social milestones.

Recommendations for early fitting for upper limb congenital defects in children varies in the literature, but clinicians agree that early fitting and involvement of the impacted side will allow development of functional patterns that utilize the deficient extremity to the maximum, in addition to minimizing abnormalities and asymmetries of posture that are secondary to substitution patterns of young upper-extremity amputees. Some studies report that fitting before age 2 years is less likely to result in a rejection by the child, than if fitting after 2 years of age. Many clinicians agree that the ability to sit independently or the age of at least 6 months are frequently cited indicators for a first fitting for infants with a congenital limb deficiency. Starting early will help to improve symmetry with weight on the limb, and give the infant experiences necessary to master crawling, rolling and pulling-up to stand, and then walking. Literature suggests that 15-18 months of age is the optimal time to convert from a passive prosthesis to a prosthesis that includes an actively controlled terminal device. During this time frame, toddlers are performing more activities that require bimanual grasp and release. Fitting of upper limb prostheses related to traumatic amputations would be based upon the healing and preparation of the amputation site. Whether congenital or trauma-related, the child's motor, cognitive, and perceptual development should be considered to determine the best type of prosthesis for the child.

Due to growth, the socket of the prosthesis should be assessed about every 3 months until the child is around 8 to 10 years of age, and a little less frequently thereafter. The socket of the prosthesis may need to be replaced every 9 months to 2 years depending on the growth of the child. This depends upon skeletal growth (especially a challenge with pediatric traumatic amputations due to boney overgrowth), as well as general growth because of changes in muscle and body mass.

In school-age children, consideration should be given to ensure that the growing child's socket is large enough for a comfortable fit and adequate prosthetic control. Therapy sessions would focus on putting on and taking off the prosthesis independently, as well as independent dressing and recreational activities. In addition, the child should learn to grasp firm and fragile objects without dropping or crushing them. Parents should focus the child on becoming independent with daily activities and play (e.g., playing cards, tying shoes, food preparation and games). Older children and adolescents should be able to incorporate the prosthesis into school activities. Activity-specific prostheses are designed to allow participation in group activities, and such activities should be encouraged. Simple adaptations or multiple terminal devices may be required to allow the individual to maneuver or participate in certain activities, such as playing an instrument or participating in basketball. Older adolescents may be involved in exploring various vocations, job training, and learning to drive. The type of specialized terminal device chosen should be based on the individual's capabilities and interests.

SCIENTIFIC EVIDENCE

There are significant challenges emerging that are unique to implementing the use of advanced upper limb prosthetic technology, such as upper limb prostheses with individually powered digits, including the myoelectric hand with individual control of digits. Currently, there is insufficient available published peer-reviewed literature that examines clinical value (e.g., improved function and health-related quality of life) of upper limb prostheses with individually powered digits. Although the availability of a myoelectric hand with individual control of digits has been reported in lay technology reports, video clips, and basic science reports, there is no currently available published peer-reviewed literature found to evaluate functional outcomes of individual digit control in amputees. According to the American Academy of Orthotists and Prosthetists (Wright 2009), in the research and development phase in the adult literature in particular, there has been a clear focus on biomechanical or impairment-based evaluations of innovative prosthetic hands; however, with a few exceptions, there is little accompanying evidence of the validation status of the hand function tools used. Although the assessment emphasis on hand skills is appropriate given the complexity and uniqueness of many of the prostheses being evaluated and the need to identify which features work and which ones need refinement, it fails to bridge the important link to higher level upper limb function. Lack of use of validated instruments also limits the interpretability of the results. Lake (2009) provided a review of progressive partial hand prosthetic management. Lake concluded that externally powered myoelectric prosthetic management requires specialized care that does not have its foundation rooted in any of the current, though progressive, upper limb protocols used today. Future research will include fitting protocols and techniques, fabrication, surgical considerations, and electronic handling, along with opportunities to formulate research methods and protocols from the ground up, rather than retrospective clinical findings.

References

American Academy of Orthotists and Prosthetists (AAOP). Differences in Myoelectric and body-powered upper limb prostheses. [AAOP Web site]. 2015. Available at: https://www.oandp.org/resource/resmgr/Files/Evidence_Notes/Evidence_Note_Myo_BP_Carey.pdf. Accessed June 13, 2024.

American Academy of Orthotists and Prosthetists (AAOP). Upper-limb prosthetic outcome measures. [AAOP Web site]. 2013. Available at: https://cdn.ymaws.com/www.oandp.org/resource/resmgr/Files/Evidence_Notes/upper-limb_prosthetic_outcom.pdf. Accessed June 13, 2024.

American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC). Scope of Practice May 2024. [ABC Web site]. 2024. Available at: https://www.abcop.org/publication/scope-of-practice. Accessed June 13, 2024.

Biddiss E, Chau T. Upper-limb prosthetics: critical factors in device abandonment. Am J Phys Med Rehabil. 2007;86(12):977-87.

Biddiss EA, Chau TT. Upper limb prosthesis use and abandonment: a survey of the last 25 years. Prosthet Orthot Int. 2007;31(3):236-57.

Carey, SL. PhD; Derek J. Lura, DJ. PhD, Highsmith MJ. DPT, PhD, CP, FAAOP .Differences in myoelectric and body-powered upper-limb prostheses: Systematic literature review. J. Rehabil. Res. Dev. Vol.52. Number 3, 2015. Pages 247— 262. website; [Department of Veterans Affairs. Department of Defense]. Available at https://www.rehab.research.va.gov/jour/2015/523/pdf/jrrd-2014-08-0192.pdf. Accessed June 13, 2024.

Department of Veterans Affairs (VA). Department of Defense (DoD). VA/DoD Clinical Practice Guideline for the Management of Upper Extremity Amputation Rehabilitation. Version 1.0 – 2014. Available at: http://www.healthquality.va.gov/guidelines/Rehab/UEAR/VADoDCPGManagementOfUEAR090214FINAL2508.pdf. Accessed June 13, 2024.

Dietl H. New developments in upper limb prosthetics. In: Smith DG, Michale JW, Bowker JH. eds. Atlas of Amputations and Limb Deficiencies: Surgical, Prosthetic and Rehabilitation Principles. 3rd ed. Rosemont, IL American Academy of Orthopedic Surgeons.; 2004: 343-349.

Dillingham T, Pezzin L, MacKenzie E. Limb amputation and limb deficiency: epidemiology and recent trends in the United States. South Med J. 2002;95:875-83.

Edelstein JE. Rehabilitation for children with limb deficiencies. In: Lusardi MM, Nielsen CC. eds. Orthotics and Prosthetics in Rehabilitation. 2nd ed. St. Louis, Missouri: Elsevier Inc.; 2007: 817-836.

Edelstein JE, Berger N. Performance comparison among children fitted with myoelectric and body-powered hands. Arch Phys Med Rehabil. 1993;74(4):376-80.

Egermann M, Kasten P, Thomsen M. Myoelectric hand prostheses in very young children. Int Orthop. 2009;33(4):1101-5.

Edwards SG. Elbow and Above-Elbow Amputations. Medscape [online]. Updated: December 1, 2022. Available at: http://emedicine.medscape.com/article/1237886-overview. Accessed June 13, 2024.

Fougner A. Control of upper limb prostheses: terminology and proportional myoelectric control-a review. IEEE Trans Neural Syst Rehabil En.2012;20(5):663-677.

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James MA, Bagley AM, Brasington K, et al. Impact of prostheses on function and quality of life for children with unilateral congenital below-the-elbow deficiency. J Bone Joint Surg Am. 2006;88(11):2356-65. Also available at: https://iprmd.org/wp-content/uploads/2021/01/Impact_of_Prostheses_on_Function_and_Quality_of.6.pdf. Accessed June 13, 2024.

Kruger LM, Fishman S. Myoelectric and body-powered prostheses. J Pediatr Orthop. 1993;13(1):68-75.

Lake C. Experience with electric prostheses for the partial hand presentation: An eight-year retrospective. J Prosthet Orthot. 2009;21(2):125-130.

Lindner HY, Linacre JM, Norling Hermansson LM. Assessment of capacity for myoelectric control: evaluation of construct and rating scale. J Rehabil Med. 2009;41(6):467-74.

Miguelez, JM. CP, Miguelez, MD. JD, Alley RD., CP. American Academy of Orthopaedic Surgeons. Chapter 21. Page 263-273.[online]. Amputations About the Shoulder: Prosthetic Management. Available at: https://www.armdynamics.com/research-and-technology/published-journal-articles/amputations-about-the-shoulder-prosthetic-management. Accessed June 13, 2024.

McFarland LV, Hubbard Winkler SL, Heinemann AW, et al. Unilateral upper-limb loss: satisfaction and prosthetic-device use in veterans and service members from Vietnam and OIF/OEF conflicts. J Rehabil Res Dev. 2010; 47(4):299-316.

Natural Academies of Sciences, Engineering and Medicine and Health and Medicine Division. Upper Extremity Prostheses. In: Jette AM, Spicer CM, et al., eds. The promise of assistive technology to enhance activity and work participation. 1st ed. Washington, DC: National Academies Press; 2017: 99-163.


New Jersey (NJ) Legislature. P.L. 2007, Chapter 345. Senate No. 502. Requires health benefits coverage by health insurers and SHBP for orthotic and prosthetic appliances and provides reimbursement. [NJ State Legislature Web site]. 01/13/08. Available at: http://www.njleg.state.nj.us/2006/Bills/AL07/345_.PDF. Accessed July 23, 2024. 

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Pylatiuk C, Schulz S, Doderlein L. Results of an Internet survey of myoelectric prosthetic hand users. Prosthet Orthot Int. 2007;31(4):362-70.

Radocy R. Prosthetic adaptations in competitive sports and recreation. In: Smith DG, Michale JW, Bowker JH. eds. Atlas of Amputations and Limb Deficiencies: Surgical, Prosthetic and Rehabilitation Principles. 3rd ed. Rosemont, IL American Academy of Orthopedic Surgeons.; 2004: 327-337.

Reddy MP. Nerve entrapment syndromes in the upper extremity contralateral to amputation. Arch Phys Med Rehab. 1984;65:24-6.

Schultz AE . Neural interfaces for control of upper limb prostheses: the state of the art and future possibilities. PM R.2011;3(1):55-67.

Silcox DH 3rd, Rooks MD, Vogel RR, et al. Myoelectric prostheses. A long-term follow-up and a study of the use of alternate prostheses. J Bone Joint Surg Am. 1993;75(12):1781-9.

Sjoberg L, Lindner H, Hermansson L. Long-term results of early myoelectric prosthesis fittings: A prospective case-control study. Prosthet Orthot Int. 2018;42(5): 527-533.

Uellendahl JE. Bilateral upper limb prostheses. In: Smith DG, Michale JW, Bowker JH. eds. Atlas of Amputations and Limb Deficiencies: Surgical, Prosthetic and Rehabilitation Principles. 3rd ed. Rosemont, IL American Academy of Orthopedic Surgeons.; 2004: 311-325.

US Department of Veterans Affairs Rehabilitation and Prosthetic Services. (VA). Amputation system of care (ASoC). [VA prosthetics Web site]. Available at: https://www.prosthetics.va.gov. Accessed June 13, 2024.

US Food and Drug Administration (FDA). Medical Devices. Physical Medicine Devices. [FDA Website]. 01/13/2020. Available at:https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=bd16b79337110dfded3bff9700e9f9a8&ty=HTML&h=L&mc=true&n=pt21.8.890&r=PART. Accessed June 13, 2024.

Zenie JR. Prosthetics Options for persons with upper limb extremity amputation. In: Lusardi MM, Nielsen CC. eds. Orthotics and Prosthetics in Rehabilitation. 2nd ed. St. Louis, Missouri: Elsevier Inc.; 2007: 837-858. ​

Coding

CPT Procedure Code Number(s)
N/A
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
N/A
HCPCS Level II Code Number(s)
See Attachment A.
Revenue Code Number(s)
N/A


Coding and Billing Requirements

Policy History

Revisions From 05.00.72j:
04/01/2026​

​Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time.

This policy has been identified for a HCPCS code update, effective 04/01/2026.

The following HCPCS code has been added to attachment A of this policy:

  • L7499 upper extremity prosthetic devices, not otherwise specified

The following HCPCS codes have been deleted from attachment A of this policy:

  • L6000 Partial hand, thumb remaining
  • L6010 Partial hand, little and/or ring finger remaining
  • L6020 Partial hand, no finger remaining

The following HCPCS code has been revised in attachment A of this policy:

  • L6028 Partial hand, finger, and thumb prosthesis without prosthetic digit(s) /thumb, amputation at metacarpal level, including flexible or non-flexible interface, molded to patient model, for use without external power and/or passive prosthetic digit/thumb, not including inserts described by l6692​
Revisions From 05.00.72i:
​10/01/2025
​This policy has been identified for a HCPCS code update, effective 10/01/2025.

The following HCPCS codes have been revised in Attachment A of this policy :

From:

​L6028 Partial hand including fingers, flexible or non-flexible interface, endoskeletal system, molded to patient model, for use without external power, not including inserts described by L6692        

To:

​Partial hand, finger, and thumb prosthesis without prosthetic digit(s)/thumb, amputation at metacarpal level, including flexible or non-flexible interface, molded to patient model, including palm, for use without external power and/or passive prosthetic digit/thumb, not including inserts described by L6692

From:

​L7406 Addition to upper extremity, user adjustable, mechanical, residual limb volume management system

To:

​Addition to upper extremity prosthesis, user adjustable, mechanical, residual limb volume management system (with or without lamination kit)


The following HCPCS codes have been added to Attachment A of this policy:

  • L6034 Partial hand, finger, and thumb prosthesis without prosthetic digit(s)/thumb, amputation at transmetacarpal level, including flexible or non-flexible interface, molded to patient model, for use without external power and/or passive prosthetic digit/thumb, not including inserts described by l6692
  • L6035 Single prosthetic digit, mechanical, can include metacarpophalangeal (mcp), proximal interphalangeal (pip), and/or distal interphalangeal (dip) joint(s), with or without locking mechanism, can include flexion or extension assist, any material, attachment, initial issue or replacement
  • L6036 Prosthetic thumb, mechanical, can include metacarpophalangeal (mcp), interphalangeal (ip) joint(s), with or without locking mechanism, can include flexion or extension assist, any material, attachment, initial issue or replacement​
  • L6038 Addition to single prosthetic digit or thumb, mechanical, attachment, multiaxial and/or internal/external rotation/abduction/adduction mechanism, with or without locking feature, any material
  • L6039 Passive prosthetic digit or thumb prosthesis not including hand restoration partial hand, full or partial, custom made, any material, initial or replacement, per single passive prosthetic digit or thumb​​​​
Revisions From 05.00.72h:
​09/03/2025
​This policy has been reissued in accordance with the Company's annual review process. ​
​04/01/2025

​Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time.

This policy has been identified for the HCPCS code update, effective 04/01/2025.
The following HCPCS codes have been revised: 
FROM:  

L6692 Upper extremity addition, silicone gel insert or equal, each

TO:​

L6692  Upper extremity addition, silicone gel insert or equal, with or without locking mechanism, each​

FROM:

L6698 Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insert

TO:

L6698 Addition to upper extremity prosthesis, lock mechanism, excludes socket insert​

The following HCPCS codes have been added to the medically necessary section of this policy:
  • L6028 Partial hand including fingers, flexible or non-flexible interface, endoskeletal system, molded to patient model, for use without external power, not including inserts described by l6692
  • L6029 Upper extremity addition, test socket/interface, partial hand including fingers
  • L6030 Upper extremity addition, external frame, partial hand including fingers
  • L6031 Replacement socket/interface, partial hand including fingers, molded to patient model, for use with or without external power
  • L6032 Addition to upper extremity prosthesis, partial hand including fingers, ultralight material (titanium, carbon fiber or equal)
  • L6033 Addition to upper extremity prosthesis, partial hand including fingers, acrylic material
  • L6037 Immediate post-surgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, partial hand including fingers
  • L6700 Upper extremity addition, external powered feature, myoelectronic control module, additional emg inputs, pattern-recognition decoding intent movement​
  • L7406 Addition to upper extremity, user adjustable, mechanical, residual limb volume management system​​

Revisions From 05.00.72g:
08/26/2024​
​This version of the policy will become effective 08/26/2024.

The policy has been reviewed to communicate the Company's continuing position on Upper Limb Prostheses.

Revisions From 05.00.72f:
​11/01/2023​
​This policy has been reissued in accordance with the Company's annual review process.​​
11/02/2022This policy has been reissued in accordance with the Company's annual review process.​​
​04/07/2021

​The policy has been reviewed and updated to communicate the Company’s continuing position on Upper Limb Prostheses.​
​02/26/2020

​The policy has been reviewed and updated to communicate the Company’s continuing position on Upper Limb Prostheses.​
​04/15/2019
​The version of this policy will become effective 04/15/2019.
  • The policy has been updated in consideration of revision of language within the US Food and Drug Administration.
  • The following criteria has been added to this policy for the Repair and Replacement an upper limb prosthesis: The repair or replacement of upper limb prostheses, supplies, or one or more of its components (parts) is covered and eligible for reimbursement consideration by the Company when the upper limb prosthesis itself is covered under the individual's medical benefits and all of the requirements for a repair or replacement are met.
  • The following CPT code has been deleted from this policy: L7368.

Revisions From 05.00.72e:
01/01/2018This policy has been identified for the HCPCS code update, effective 01/01/2018.

The following HCPCS codes have been added to this policy:
  • L7700 Gasket or seal, for use with prosthetic socket insert, any type, each

Effective 10/05/2017 this policy has been updated to the new policy template format.

4/1/2026
4/1/2026
05.00.72
Medical Policy Bulletin
Commercial
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No
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