L7025
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Myoelectric upper extremity prosthetic devices are consideredmedically necessarywhen ALL of the criteria below have been met:
- The individual has an amputation or absence of a portion of an arm;and
- Clinical records, including assessment by a trained prosthetic clinician, support that the individual has sufficient ability to operate the myoelectric technology effectively;and
- A body-powered prosthetic device cannot be used or is insufficient to meet the functional goals and needs of the individual;and
- A myoelectric device is likely to help the individual regain or maintain function better than a standard body-powered prosthetic device;and
- The remaining musculature of the affected arm contains the minimum microvolt threshold to allow operation of a myoelectric device;and
1 Active Policy
ANTHEM-GL-C169421 — CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices
Related Codes
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