Prosthetics, Except Lower Limb Prosthetics
Durable Medical Equipment
© Blue Cross and Blue Shield of Montana
Current Effective Date:
February 15, 2014
Original Effective Date:
October 13, 2011
November 15, 2013
June 27, 2012; August 28, 2013; November 15, 2013
Prosthetics are artificial substitutes, which replace all or part of a body organ, or replace all or part of the function of a permanently inoperative, absent, or malfunctioning body part.
Artificial joint repair and reconstruction is most often performed for joints that are damaged by arthritis or trauma. Although hip and knee replacements are the most common, other joints may also be replaced, including shoulders, elbows, wrists and fingers.
An implantable artificial urethral sphincter is used to treat urinary incontinence caused by sphincter dysfunction or injury. It consists of three interconnected parts:
- A cuff implanted around the urethra,
- A pressure-regulating balloon reservoir implanted near the bladder, and
- A pump implanted in the scrotum or labia.
The cuff is inflated with saline, which closes the urethra. To urinate, the patient manually squeezes the pump to divert the fluid away from the cuff into the balloon reservoir, which allows the urethra to open. Usually, the cuff re-inflates on its own in a few minutes.
Upper Limb Prosthetics
Upper limb prostheses are used for amputations at any level from above the wrist to the shoulder. The primary goals of the upper limb prosthesis are to restore natural appearance and function. Achieving these goals also requires sufficient comfort and ease of use for continued acceptance by the wearer. The difficulty of achieving these diverse goals with an upper arm prosthesis increases as the level of amputation (i.e., hand, wrist, elbow and shoulder—and thus the complexity of joint movement) increases.
Upper limb prostheses are classified into three categories depending on the means of generating movement at the joints: passive, body-powered and electrically-powered movement. All three types of prostheses have been in use for over 30 years; each possesses unique advantages and disadvantages.
- The passive prosthesis is the lightest of the three types and is described as the most comfortable. Since the passive prosthesis must be repositioned manually, typically by moving it with the opposite arm, it cannot restore function.
- The body-powered prosthesis utilizes a body harness and cable system to provide functional manipulation of the elbow and hand. Voluntary movement of the shoulder and/or limb stump extends the cable and transmits the force to the terminal device. Prosthetic hand attachments, which may be claw-like devices that allow good grip strength and visual control of objects or latex-gloved devices that provide a more natural appearance at the expense of control, can be opened and closed by the cable system. Patient complaints with body-powered prostheses include harness discomfort, particularly the wear temperature, wire failure and the unattractive appearance.
- Myoelectric prostheses use muscle activity from the remaining limb for the control of joint movement. Electromyographic (EMG) signals from the limb stump are detected by surface electrodes, amplified, and then processed by a controller to drive battery-powered motors that move the hand, wrist, or elbow. Although upper arm movement may be slow and limited to one joint at a time, myoelectric control of movement may be considered the most physiologically natural. Patient dissatisfaction with myoelectric prostheses includes the increased cost, maintenance (particularly for the glove) and weight (batteries and motors may add considerable weight and require sufficient strength to wear.)
- Myoelectric hand attachments are similar in form to those offered with the body-powered prosthesis, but are battery-powered. An example of recently available technology is the Sensorhand™ by Otto Bock, which is described as having an AutoGrasp feature, an opening/closing speed of up to 300 mm/second, and advanced EMG signal processing. The iLIMB™ hand (Touch Bionics), sometimes referred to as the bionic hand, is the first commercially available myoelectric hand prosthesis with individually powered digits. ProDigits™, also from Touch Bionics, are prosthetic digits for one or more fingers in patients with amputation at a transmetacarpal level or higher. These may be covered by LIVINGSKIN™, a high-definition silicone prosthesis created to resemble a patient’s natural skin.
- A hybrid system, a combination of body-powered and myoelectric components, may be used for high level amputations (at or above the elbow). Hybrid systems allow control of two joints at once (i.e., one body-powered and one myoelectric) and are generally lighter and less expensive than a prosthesis composed entirely of myoelectric components.
Technology in this area is rapidly changing, driven by advances in biomedical engineering and by the U.S. Department of Defense Advanced Research Projects Agency (DARPA), which is funding a public and private collaborative effort on prosthetic research and development. Areas of development include the use of skin-like silicone elastomer gloves, “artificial muscles”, and sensory feedback. Smaller motors, microcontrollers, implantable myoelectric sensors and reinervation of remaining muscle fibers are being developed to allow fine movement control. Lighter batteries and newer materials are being incorporated into myoelectric prostheses to improve comfort.
Manufacturers must register prostheses with the U.S. Food and Drug Administration's (FDA) restorative devices branch and keep a record of any complaints, but do not have to undergo a full FDA review. Available myoelectric devices include ProDigits™ and i-LIMB™ (Touch Bionics), the Otto Bock myoelectric prosthesis (Otto Bock), the LTI Boston Digital Arm™ System (Liberating Technologies Inc.), and the Utah Arm Systems (Motion Control).
Additional Information and Terminology
Terminal devices are separated into four categories: passive hands, split hooks, mechanical hands, and specialized tools.
Passive hand: no gripping action, but does provide functional value to the unilateral amputee as a holding and positioning aid.
Split hook: the most popular terminal device because it provides gripping and precise manipulation at its tip.
Mechanical hands: more cosmetic than hooks, but provide little real functional benefit.
Special tools: can be designed for a variety of activities, such as sports, or allowing attachment of hand tools or kitchen utensils.
Electronic terminal devices: come in hook styles, but are usually requested as hands; these have two functions: fast clasping and firm gripping.
Exoskeletal: a hard shell built up into the shape of the limb with a hollow center.
Endoskeletal: component parts covered with an external soft foam covering.
Typical below-elbow prosthesis: usually includes the following components: voluntary opening split hook, friction wrist, double-walled plastic laminate socket, flexible elbow hinge, single-control cable system, biceps or triceps cuff, and figure-of-8 harness.
Typical above-elbow prosthesis: is similar, but substitutes an internal-locking elbow for the flexible elbow hinge, uses a dual control cable (instead of single control), and does not have a biceps or triceps cuff.
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.
A4280, A9282, L6000, L6010, L6020, L6025, L6050, L6055, L6100, L6110, L6120, L6130, L6200, L6205, L6250, L6300, L6310, L6320, L6350, L6360, L6370, L6380, L6382, L6384, L6386, L6388, L6400, L6450, L6500, L6550, L6570, L6580, L6582, L6584, L6586, L6588, L6590, L6600, L6605, L6610, L6611, L6615, L6616, L6620, L6621, L6623, L6624, L6625, L6628, L6629, L6630, L6632, L6635, L6637, L6638, L6640, L6641, L6642, L6645, L6646, L6647, L6648, L6650, L6655, L6660, L6665, L6670, L6672, L6675, L6676, L6677, L6680, L6682, L6684, L6686, L6687, L6688, L6689, L6690, L6691, L6692, L6693, L6694, L6695, L6696, L6697, L6698, L6703, L6704, L6706, L6707, L6708, L6709, L6711, L6712, L6713, L6714, L6715, L6721, L6722, L6805, L6810, L6880, L6881, L6882, L6883, L6884, L6885, L6890, L6895, L6900, L6905, L6910, L6915, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7260, L7261, L7360, L7362, L7364, L7366, L7367, L7368, L7400, L7401, L7402, L7403, L7404, L7405, L7499, L7510, L7520, L7600, L8000, L8001, L8002, L8010, L8015, L8020, L8030, L8031, L8032, L8035, L8039, L8040, L8041, L8042, L8043, L8044, L8045, L8046, L8047, L8048, L8049, L8500, L8501, L8505, L8507, L8509, L8510, L8511, L8512, L8513, L8514, L8515, L8600, L8630, L8631, L8641, L8642, L8658, L8659, L8692, L8699, L9900, S8270, V2623, V2624, V2625, V2626, V2628, V2629, V5011, V5014, V5020, V5030, V5040, V5050, V5060, V5070, V5080, V5090, V5100, V5110, V5120, V5130, V5140, V5150, V5160, V5170, V5180, V5190, V5200, V5210, V5220, V5230, V5240, V5241, V5242, V5243, V5244, V5245, V5246, V5247, V5248, V5249, V5250, V5251, V5252, V5253, V5254, V5255, V5256, V5257, V5258, V5259, V5260, V5261, V5262, V5263, V5264, V5265, V5266, V5267, V5268, V5269, V5270, V5271, V5272, V5273, V5274, V5275, V5281, V5282, V5283, V5284, V5285, V5286, V5287, V5288, V5289, V5290, V5298, V5299
- Kruger LM, Fishman S. Myoelectric and body-powered prostheses. J Pediatr Orthop 1993; 13(1):68-75.
- Edelstein JE, Berger N. Performance comparison among children fitted with myoelectric and bodypowered hands. Arch Phys Med Rehabil 1993; 74(4):376-80.
- Silcox DH 3rd, Rooks MD, Vogel RR et al. Myoelectric prostheses. A long-term follow-up and a study of the use of alternate prostheses. J Bone Joint Surg Am 1993; 75(12):1781-9.
- James MA, Bagley AM, Brasington K et al. Impact of prostheses on function and quality of life for children with unilateral congenital below-the-elbow deficiency. J Bone Joint Surg Am 2006; 88(11):2356-65.
- Biddiss EA, Chau TT. Upper limb prosthesis use and abandonment: a survey of the last 25 years. Prosthet Orthot Int 2007; 31(3):236-57.
- Biddiss E, Chau T. Upper-limb prosthetics: critical factors in device abandonment. Am J Phys Med Rehabil 2007; 86(12):977-87.
- Pylatiuk C, Schulz S, Döderlein L. Results of an Internet survey of myoelectric prosthetic hand users. Prosthet Orthot Int 2007; 31(4):362-70.
- Egermann M, Kasten P, Thomsen M. Myoelectric hand prostheses in very young children. Int Orthop 2009; 33(4):1101-5.
- Lindner HY, Linacre JM, Norling Hermansson LM. Assessment of capacity for myoelectric control: evaluation of construct and rating scale. J Rehabil Med 2009; 41(6):467-74.
- Inflatable artificial sphincter. Medline Plus Medical Encyclopedia. Accessed on 8/1/2005 at http://www.nlm.nih.gov .
- Egan, Thomas F. Efficacy and self esteem impact from a comprehensive nocturnal enuresis behavioral and educational management program. Accessed on 9/20/2005 at Pacific International, Ltd. http://www.stopwetting.com .
- Prosthetics. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (1997 January) Durable Medical Equipment 1.04.01-Archived.
- Myeolelectric Prosthesis for the Upper Limb. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (June 2013) Durable Medical Equipment 1.04.04.
||New Policy: Policy created with literature search; may be medically necessary under specified conditions|
||Policy updated with literature review through December 2011; reference 4 added; policy statement unchanged|
||Policy formatting and language revised. Added criteria for prosthetic appliances. Title changed from "Myoelectric Prosthesis for the Upper Limb" to "Prosthetics, Except Lower Limb Prosthetics".|
||Document updated with literature review. The following was added to the Coverage section: A prosthesis with individually powered digits, including but not limited to a partial hand prosthesis, is considered experimental, investigational and unproven.|