BlueCross BlueShield of Tennessee Medical Policy Manual

Upper Limb Myoelectric Orthosis

DESCRIPTION

The upper limb myoelectric orthosis (e.g., MyoPro®) 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 with inconsistent outcomes.  Additional studies with larger numbers of participants are needed that show consistent improvements in relevant outcome measures to determine the technology’s effect.

SOURCES

BlueCross BlueShield Association. Evidence Positioning System. (3:2018). Myoelectric prosthetic and orthotic components for the upper limb (1.04.04). Retrieved March 19, 2019 from https://www.evidencepositioningsystem.com. (13 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, 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.

Willigenburg, N., McNally, P., Hewett, T., & Page, S. (2017). Portable myoelectric brace use increases upper extremity recovery and participation but does not impact kinematics in 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:  4/11/2019

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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