L8701 — Powered upper extremity range of motion assist device, elbow, wrist, hand with single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- No specific documentation requirements are stated in the provided text segment.
- For provision of myoelectric elbow orthoses (MEO/MyoPro/MEWHO): documentation of detectable volitional EMG signals from paretic muscles (explicit requirement in studies providing MEO to BPI patients with detectable EMG).
- Baseline and follow-up clinical assessments as used in cited studies (examples that may be required/expected in clinical documentation): Fugl-Meyer Assessment — Upper Limb (FM-UL), Disabilities of the Arm, Shoulder and Hand (DASH), Wolf Motor Function Test–Orthopedic version (WMFT-O), Modified Ashworth Scale (MAS), Box and Block (BB) test, range of motion (goniometer), muscle strength testing, visual analog pain scale (VAS).
- For studies/devices claiming neurophysiological effects: EEG and surface EMG (sEMG) recordings (resting and task conditions) where applicable.
Key Coverage Criteria
- None — Aetna considers robotic-assisted rehabilitation of the upper limb and lower limb experimental and investigational because of insufficient evidence of its effectiveness.
- Upper-limb robot-assisted therapy (UL-RAT) / exoskeleton-assisted rehabilitation (e.g., ArmeoPower) for motor recovery after subacute stroke, aimed at improving activities of daily living (ADL), arm and hand function, and muscle strength (study: multicenter RCT protocol in subacute stroke).
- Upper-limb home-based robotic rehabilitation (e.g., iCONE device) for chronic stroke patients to improve robot-evaluated indices (e.g., Independence, Size for Circle Drawing, Movement Duration for Point-to-Point) and to reduce spasticity (MAS) — pilot, no control group.
- Home-based overground robotic-assisted gait training (O-RAGT) in combination with usual care physiotherapy for individuals with chronic stroke (3 months to 5 years post-stroke) to improve vascular health measures (reduction in carotid-femoral pulse wave velocity, cfPWV) and increase physical activity.
- Assistive robotic training added to conventional occupational and physical therapy for patients after proximal humeral fracture (PHF) early after surgical treatment to potentially improve shoulder/upper-arm functional outcomes (primary outcome: DASH; secondary: WMFT-O) — randomized trial protocol.
- Portable myoelectric elbow-wrist-hand orthosis (MEWHO) as an assistive and/or therapeutic device for chronic, stable, moderately impaired stroke survivors to reduce upper-extremity (UE) impairment (Fugl-Meyer) and improve functional task performance and gross manual dexterity.
9 Active Policies
AMBETTER-CP.MP.107 — Durable Medical Equipment and Orthotics and Prosthetics Guidelines
AETNA-CPB-0778 — Robotic-assisted Rehabilitation of the Extremities
ANTHEM-MP-C174286 — OR-PR.00005 Upper Extremity Myoelectric Orthoses
BCBSIL-DME104.001 — Myoelectric Prosthetic and Orthotic Components for the Upper Limb
BCBSMT-DME104.001 — Myoelectric Prosthetic and Orthotic Components for the Upper Limb
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