BlueCross BlueShield of Tennessee Medical Policy Manual

Myoelectric Prosthetic Components for the Upper Limb

DESCRIPTION

Upper limb prostheses are used for amputations at any level from the hand to the shoulder. The need for a prosthesis occurs for a number of reasons, including trauma, surgery, or congenital anomalies. The goals of upper limb prostheses relate to restoration of both appearance and function while maintaining sufficient comfort for continued use.

Myoelectric prostheses use muscle activity from the remaining limb for control of joint movement. Electromyographic (EMG) signals from the limb stump 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 limited to 1 joint at a time, myoelectric control of movement may be considered the most physiologically natural. Myoelectric hand attachments are similar in form to those offered with the body-powered prosthesis, but are battery powered.

Examples of myoelectric devices include the Otto Bock myoelectric prosthesis, the LTI Boston Digital Arm™ System, and the Utah Arm Systems.  Manufacturers must register prostheses with the restorative devices branch of the U.S. Food and Drug Administration (FDA) and keep a record of any complaints, but do not have to undergo a full FDA review.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

Although the availability of a myoelectric hand with individual control of digits has been widely reported in lay technology reports; however, no peer-reviewed publications were found that evaluate functional outcomes of individual digit control in amputees.

SOURCES 

BlueCross BlueShield Association. Medical Policy Reference Manual. (9:2017). Myoelectric prosthetic components for the upper limb (1.04.04). Retrieved December 18, 2017 from BlueWeb. (9 articles and/or guidelines reviewed)

Carey, S., Lura, D., & Highsmith, J. (2015). Differences in myoelectric and body-powered upper-limb prostheses: systematic literature review. Journal of Rehabilitation Research & Development, 52 (3), 247-262. (Level 1 evidence)

Chadwell, A., Kenney, L., Thies, S., Galpin, A., & Head, J. (2016, August). The reality of myoelectric prostheses: Understanding what makes these devices difficult for some users to control. Frontiers in Neurorobotics, 10 (7). (Level 4 evidence)

ECRI Institute. Health Technology Assessment Information Service™. (2011, June). Advanced prosthetic arm technology. Retrieved November 14, 2014 from ECRI Institute. (31 articles and/or guidelines reviewed)

Egermann, M., Kasten, P., & Thomsen, M. (2009). Myoelectric hand prostheses in very young children. International Orthopaedics, 33 (4), 1101-1105. (Level 5 evidence)

Lake, C. (2009). Experience with electric prostheses for the partial hand presentation: An eight-year retrospective. American Academy of Orthotists and Prosthetists, 21 (2), 125-130. (Level 5 evidence)

Schiefer, M., Tan, D., Sidek, S. M., & Tyler, D. J. (2016). Sensory feedback by peripheral nerve stimulation improves task performance in individuals with upper limb loss using a myoelectric prosthesis. Journal of Neural Engineering, 13 (1). Abstract retrieved January 24, 2017 from PubMed database.

Thies, S., Kenney, L., Sobuh, M., Galpin, A., Kyberd, P., Stine, R., et al. (2017, September) Skill assessment in upper limb myoelectric prosthesis users: validation of a clinically feasible method for characterizing upper limb temporal and amplitude variability during the performance of functional tasks. Medical Engineering & Physics, (47), 137-43. Abstract retrieved December 18, 2017 from PubMed database.

U. S. Food and Drug Administration. (2017, December). Center for Devices and Radiological Health. Code of Federal Regulations Title 21. Volume 8. Sec. 890.3420 External limb prosthetic component. Retrieved December 18, 2017 from http://www.accessdata.fda.gov.

ORIGINAL EFFECTIVE DATE:  11/13/2010

MOST RECENT REVIEW DATE:  1/25/2018

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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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