Upper Extremity Microprocessor Devices - DME.MU.204.A

Covered only when all listed criteria are met: myoelectric upper‑extremity prosthetic devices are medically necessary for traumatic or congenital limb absence and are not covered if any criterion is unmet. Key requirements are documented residual‑limb weight tolerance, objective EMG/microvolt testing meeting minimum thresholds, no interfering medical conditions (e.g., neuromuscular disease), documented trial/unsuitability of a body‑powered prosthesis, adequate cognitive function, and evidence of device training and related clinical assessments.

"Documentation that the residual limb is able to tolerate the weight of the myoelectric prosthetic device."

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