A myoelectric upper limb prosthesis is used for amputations at any level from above the wrist to the shoulder. The primary goal of an upper limb prosthesis is to restore function.
A myoelectric hand prosthesis imitates the true movement and accuracy of the human hand. A myoelectric hand has powered digits that have the ability to open and close around objects.
Myoelectric upper arm prosthetic components and myoelectric hand prostheses may be considered medically necessary when ALL of the following conditions are met:
Upper myoelectric prostheses and myoelectric hand prostheses are considered not medically necessary in EITHER of the following circumstances:
Myoelectric upper limb prosthetic components not meeting the criteria as indicated in this policy are considered not medically necessary.
High-definition silicone used to make a prosthesis resemble an individual’s skin is considered cosmetic and, therefore, non-covered.
NOTE: Because of expected normal growth and development, pediatric upper extremity amputees typically require upper extremity prosthesis replacement or refitting at 18-month intervals.
Amputees should be evaluated by an independent qualified professional (physiatrist or orthopedic surgeon with training and experience in providing rehabilitation of upper extremity amputees along with a prosthetist also with training and experience in fitting/fabrication of upper extremity myoelectric prosthetics) to determine the most appropriate prosthetic components and control mechanism. Consideration should be given to the amputee’s needs for control, durability (maintenance), function (speed, work capability), and usability.
Reimbursement may be made only if there is sufficient documentation in the individual’s medical record showing functional need for the myoelectric upper limb prosthesis. This information must be retained in the physician’s or prosthetist’s files and be available upon request.
L6890 |
L6895 |
L7007 |
L7008 |
L7009 |
L7045 |
L7190 |
L7191 |
L7499 |
|
|
|
|
|
Hand prosthesis with individually powered and independently controlled myoelectric digits, including, but not limited to including a partial hand prosthesis, are considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.
L6026 |
L6715 |
L6880 |
|
|
|
|
Terminal devices may be considered medically necessary for work and when essential to activities of daily living.
Terminal devices are considered not medically necessary when used solely for activities related to sports or recreation.
L6704 |
L6925 |
L6930 |
L6935 |
L6945 |
L6955 |
L6965 |
L6975 |
L7180 |
L7181 |
|
|
|
|
Covered diagnosis codes for L6890, L6925, L6930, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191, and L7499
Q71.00 |
Q71.01 |
Q71.02 |
Q71.03 |
Q71.10 |
Q71.11 |
Q71.12 |
Q71.13 |
Q71.20 |
Q71.21 |
Q71.22 |
Q71.23 |
Q71.40 |
Q71.41 |
Q71.42 |
Q71.43 |
Q71.50 |
Q71.51 |
Q71.52 |
Q71.53 |
Q71.90 |
Q71.91 |
Q71.92 |
Q71.93 |
Q71.811 |
Q71.812 |
Q71.813 |
Q71.819 |
Q71.891 |
Q71.892 |
Q71.893 |
Q71.899 |
S48.011A |
S48.011D |
S48.011S |
S48.012A |
S48.012D |
S48.012S |
S48.019A |
S48.019D |
S48.019S |
S48.021A |
S48.021D |
S48.021S |
S48.022A |
S48.022D |
S48.022S |
S48.029A |
S48.029D |
S48.029S |
S48.111A |
S48.111D |
S48.111S |
S48.112A |
S48.112D |
S48.112S |
S48.119A |
S48.119D |
S48.119S |
S48.121A |
S48.121D |
S48.121S |
S48.122A |
S48.122D |
S48.122S |
S48.129A |
S48.129D |
S48.129S |
S48.911A |
S48.911D |
S48.911S |
S48.912A |
S48.912D |
S48.912S |
S48.919A |
S48.919D |
S48.919S |
S48.921A |
S48.921D |
S48.921S |
S48.922A |
S48.922D |
S48.922S |
S48.929A |
S48.929D |
S48.929S |
S58.011A |
S58.011D |
S58.011S |
S58.012A |
S58.012D |
S58.012S |
S58.019A |
S58.019D |
S58.019S |
S58.021A |
S58.021D |
S58.021S |
S58.022A |
S58.022D |
S58.022S |
S58.029A |
S58.029D |
S58.029S |
S58.111A |
S58.111D |
S58.111S |
S58.112A |
S58.112D |
S58.112S |
S58.119A |
S58.119D |
S58.119S |
S58.121A |
S58.121D |
S58.121S |
S58.122A |
S58.122D |
S58.122S |
S58.129A |
S58.129D |
S58.129S |
S58.911A |
S58.911D |
S58.911S |
S58.912A |
S58.912D |
S58.912S |
S58.919A |
S58.919D |
S58.919S |
S58.921A |
S58.921D |
S58.921S |
S58.922A |
S58.922D |
S58.922S |
S58.929A |
S58.929D |
S58.929S |
S68.411A |
S68.411D |
S68.411S |
S68.412A |
S68.412D |
S68.412S |
S68.419A |
S68.419D |
S68.419S |
S68.421A |
S68.421D |
S68.421S |
S68.422A |
S68.422D |
S68.422S |
S68.429A |
S68.429D |
S68.429S |
S68.711A |
S68.711D |
S68.711S |
S68.712A |
S68.712D |
S68.712S |
S68.719A |
S68.719D |
S68.719S |
S68.721A |
S68.721D |
S68.721S |
S68.722A |
S68.722D |
S68.722S |
S68.729A |
S68.729D |
S68.729S |
Z44.001 |
Z44.002 |
Z44.009 |
Z44.011 |
Z44.012 |
Z44.019 |
Z44.021 |
Z44.022 |
Z44.029 |
Z89.111 |
Z89.112 |
Z89.119 |
Z89.121 |
Z89.122 |
Z89.129 |
|
|
|
|
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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.