A notable change was the addition of coverage criteria for “Myoelectric upper-limb whole prosthetic hands with independent articulating digits” and “Orthosis for upper limb,” shown below.

  1. Myoelectric upper-limb whole prosthetic hands with independent articulating digits (L6880) may be considered for coverage when ALL the following conditions are met: a. Member meets the above criteria for a myoelectric upper limb prosthetic b. Member has an amputation or missing limb at the wrist or above (forearm, elbow, etc.) c. Member has used a standard myoelectric prosthesis for one year or more and found insufficient to meet the functional needs of the Member in performing activities of daily living
  2. Orthosis for upper limb: a. An upper extremity orthotic device (HCPCS codes L3650-L3999) (non-myoelectric, nonpower enhanced) is covered for HAP/AHL Members who require stabilization or support of the upper limb when the use of the orthotic device is expected to have improved function such as but not limited to the following uses: i. Used to substitute for weak muscles (such as following cervical spine injury, brachial plexus injury, peripheral nerve injury [e.g., median, ulnar or radial nerves], sprain, strain) ii. Used to support or immobilize a structure (e.g., rheumatoid arthritis, osteoarthritis, overuse syndromes[such as lateral epicondylitis, cubital tunnel syndrome, carpal tunnel syndrome, de Quervain tenosynovitis, trigger finger], trauma, following surgical repairs, fractures [such as acromioclavicular dislocation, clavicle fracture]) iii. Used prevent contracture or deformity from neurological injury (such as brain injury, stroke, spinal cord injury, brachial plexus injury, peripheral nerve injury) iv. Used to correct joint contractures resulting from disease or immobilization (such as post fracture, burns) v. When device is necessary to carry out ADLs (e.g., spinal cord injured individuals)

Health Alliance Plan of Michigan policy update published on 7-21-17, which included the following changes:

Reviewed with changes to criteria, limitations, exclusions and coding. 
Updated criteria for “An upper limb myoelectric prosthetic device”:
Reworded criterion regarding absence of upper limb. 
Added criterion: Absence of a comorbidity that might interfere with maintaining the function of the prosthesis (e.g., neuromuscular disease).

Added limitations pertaining to the following scenarios:

  • Device is not in a serviceable condition due to neglect.
  • Device is no longer under warranty.
  • The cost of repair is not greater than replacement costs.

Added exclusions:

  • Myoelectric upper-limb prosthetic components are not covered for indications other than those addressed under coverage criteria as the effectiveness in other situations has not been established.
  • A prosthesis with individual y powered digits, including but not limited to a partial hand prosthesis, is considered experimental and investigational and is not covered.
  • Transcranial direct current stimulation for enhancing the performance of myoelectric prosthesis is not covered because it is considered experimental and investigational due to a lack of evidence of effectiveness.
  • Implantable myoelectric sensors for upper limb prostheses and hand prosthesis are not covered as they are considered experimental and investigational as the effectiveness has not been established.