BlueCross BlueShield of Tennessee Medical Policy Manual

Upper Limb Myoelectric Orthosis

DESCRIPTION

The upper limb myoelectric orthosis has been proposed as an assist device to enable individuals to self-initiate and control movements of a partially paralyzed or weakened arm and to regain the ability to perform activities of daily living. Sensors built into the custom, wearable device detect the electrical activity of muscles at rest in the affected arm in four locations - bicep/triceps and the forearm flexor/extensor muscle groups. These signals are amplified when a user initiates movement, driving small motors which allow the individual to extend/flex their elbow and open/close their thumb and fingers. The intent of the upper limb myoelectric orthosis device is to increase functional capacity and retain range of motion.

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION  

The evidence base for this technology consists of a few small studies which focused only on individuals with stroke. Additional studies with larger sample size are needed to determine the technology’s effect on health outcomes.

SOURCES 

Center for Medicare and Medicaid Services. CMS.gov. 2016 Durable Medical Equipment Prosthetics, Orthotics, and Supplies Healthcare Common Procedure Coding System (HCPCS) Code Jurisdiction List. Retrieved June 30, 2016 from: http://www.cms.hhs.gov.  

ECRI Institute. Health Technology Assessment information Service. Product Brief. (2017). MyoPro arm orthosis (Myomo, Inc.) for stroke rehabilitation. Retrieved May 18, 2017 from ECRI Institute. (22 articles and/or guidelines reviewed)

National Institute for Health and Care Excellence. (2013). Stroke rehabilitation in adults. Retrieved May 18, 2017 from www.nice.org.uk/guidance/cg162.

Page, S., Hill, V., & White, S. (2013). Portable upper extremity robotics is as efficacious as upper extremity rehabilitative therapy: a randomized controlled pilot trial. Clinical Rehabilitation, 27 (6), 494-503. (Level 2 evidence)

Peters, H., Page, S., & Persch, A. (2017). Giving them a hand: wearing a myoelectric elbow-wrist-hand orthosis reduces upper extremity impairment in chronic stroke. Archives of Physical Medicine and Rehabilitation, 2017 Jan 25. Doi: 10.1016j.apmr.2016.12.016. [Epub ahead of print]. Abstract retrieved May 17, 2017 from PubMed database.

U.S. Food and Drug Administration. (2007, April). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K062631. Retrieved May 18, 2017 from https://www.accessdata.fda.gov/cdrh_docs/pdf6/k062631.pdf.

Willigenburg, N., McNally, P., Hewett, T., & Page, S. (2017). Portable myoelectric brace use increases upper extremity recovery and participation but does not impact kinematics n chronic, poststroke hemiparesis. Journal of motor behavior, 49 (1), 46-54. Abstract retrieved May 18, 2017 from PubMed database.

ORIGINAL EFFECTIVE DATE:  11/14/2015

MOST RECENT REVIEW DATE:  6/8/2017

ID_BT

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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