L7181, Electronic elbow, microprocessor simultaneous control of elbow and terminal
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical documentation demonstrating inability of standard body-powered prosthesis to meet functional needs (e.g., trial notes, therapy reports).
- Objective evidence of adequate muscle signal (minimum microvolt threshold) to operate a myoelectric device (e.g., EMG or equivalent testing).
- Assessment documenting sufficient neurological and cognitive function to operate the prosthesis.
- Medical history and records documenting absence of comorbidities that would interfere with prosthesis function (e.g., neuromuscular disease).
Key Coverage Criteria
- Upper extremity prosthetic device is medically necessary when: (a) traumatic or surgical amputation or congenital absence; (b) prosthetic replaces all/part of missing limb; (c) prosthetic will help regain/maintain function; (d) device ordered by/under direction of physician; (e) needs evaluated by qualified professional annually; (f) patient willing/able to train; (g) rehabilitation potential with ADL/IADL assessment.
- 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
10 Active Policies
ANTHEM-GL-C169421, CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices
UHC-POL-upper-extremity-prosthetic-devices, Upper Extremity Prosthetic Devices
DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb
BCBSIL-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb
BCBSMT-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb
Related Codes
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