Myoelectric Prosthetic Components for the Upper Limb
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.
Myoelectric upper limb prosthetic components to restore upper limb function are considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
A prosthetic with individually powered digits, including, but not limited to partial hand prosthesis, is considered investigational.
Myoelectric upper limb prosthetic components are considered medically appropriate when ALL of the following criteria are met:
Individual has missing limb at the wrist or above
Standard body-powered prosthesis cannot be used or is insufficient to meet the functional needs for performing activities of daily living
Remaining musculature of the arm(s) contains the minimum microvolt threshold to allow operation of a myoelectric prosthesis
Adequate cognitive and neurological function to operate the prosthesis effectively
No underlying neuromuscular disease
Functional evaluation indicates a myoelectric prosthesis is likely to meet the functional needs of the individual
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
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.
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
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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