Myoelectric Prosthetic and Orthotic Components for the Upper Limb

This policy covers medically necessary myoelectric upper‑limb prosthetic components and related orthotic/prosthetic services for individuals with upper‑limb amputations (wrist or above) from trauma, surgery, or congenital conditions, and includes certain Arkansas HCSC mandates for prostheses (e.g., athletic, bathing, and post‑mastectomy prostheses). Coverage requires documented medical necessity — including inadequate function with body‑powered devices, sufficient residual muscle EMG signals and cognitive ability, and a functional evaluation or trial showing the device will meet ADLs — and is subject to plan/mandate limits (not applicable to ASO groups), excludes experimental devices (e.g., advanced sensor‑myoelectric systems like the LUKE Arm or individually powered digits), and generally limits replacement to once every three years unless medically necessary.

"Coverage required for an orthotic device or orthotic service for HCSC members residing in Arkansas under AR § 23-99-417."