A8005, Powered, cable driven grip assist glove, hand, finger, includes microprocessor,
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Coverage determinations must include review of the member's benefit contract or SPD for coverage vs. non-coverage, exclusions, and limitations (e.g., dollar or duration caps).
- Documentation must include demonstration that residual musculature meets the minimum microvolt threshold, shown by functional testing using a physical or computer model prosthesis.
- Documentation must include a functional evaluation by a qualified professional (e.g., prosthetist) concluding that, with training, a myoelectric prosthesis is necessary to meet the individual's functional needs; the evaluation should address control, durability, function, and usability, and affirm both subcriteria (device necessary for functional needs and not primarily for leisure).
Key Coverage Criteria
- Myoelectric upper-limb prosthetic components are medically necessary when the patient has an amputation or missing limb at the wrist or above, cannot use standard body-powered devices to meet functional needs, has sufficient microvolt threshold and neurologic/cognitive function, lacks interfering comorbidities, and demonstrates through functional evaluation that with training the prosthesis meets daily living needs.
- Myoelectric upper-limb prosthetic components may be considered medically necessary when the patient has a wrist-or-above amputation and thttps://...
- Upper-limb amputees should be evaluated by an independent qualified professional to determine appropriate prosthetic components and control mechanism; a trial period may be indicated to assess tolerability and efficacy.
- Myoelectric upper-limb prosthesis is covered when all criteria A–F are met: amputation at wrist or above; body-powered devices are insufficient; residual musculature meets minimum microvolt threshold demonstrated by functional testing; adequate neurological/cognitive function; absence of comorbidities that would interfere; and a qualified professional's functional evaluation indicates device is necessary for functional needs and not primarily for leisure/recreation.
- Replacement (all or part) of an existing myoelectric upper-limb prosthesis is medically necessary when the device is malfunctioning, irreparable and no longer under warranty, or when it no longer meets functional needs due to a significant physiological change.
5 Active Policies
BCBSIL-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb
BCBSMT-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb
BCBSNM-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb
BCBSOK-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb
REGENCE-DME80, Myoelectric and Microprocessor Prosthetic and Orthotic Components for the Upper Limb
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