CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices

This policy addresses myoelectric upper extremity prosthetic devices. Coverage is medically necessary when the person has an arm amputation or absence, a trained prosthetic clinician documents the ability to effectively operate myoelectric technology, a body-powered device is not usable or insufficient, and a myoelectric device is likely to better restore or maintain function than a standard body-powered prosthesis. Not covered if any criteria are unmet, for repairs/replacements when criteria are unmet, or for enhanced-dexterity myoelectric arms (e.g., LUKE arm) for any indication.

"Myoelectric upper extremity prosthetic devices are consideredmedically necessarywhen ALL of the criteria below have been met:"

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