Myoelectric upper-limb prosthetic components may be considered medically necessary when the following conditions are met:
The patient has an amputation or missing limb at the wrist or above (eg, forearm, elbow); and
Standard body-powered prosthetic devices cannot be used or are insufficient to meet the functional needs of the individual in performing activities of daily living; and
The remaining musculature of the arm(s) contains the minimum microvolt threshold to allow operation of a myoelectric prosthetic device; and
The patient has demonstrated sufficient neurologic and cognitive function to operate the prosthesis effectively; and
The patient is free of comorbidities that could interfere with function of the prosthesis (eg, neuromuscular disease); and
Functional evaluation indicates that with training, use of a myoelectric prosthesis is likely to meet the functional needs of the individual (eg, gripping, releasing, holding, coordinating movement of the prosthesis) when performing activities of daily living. This evaluation should consider the patient’s needs for control, durability (maintenance), function (speed, work capability), and usability.
Advanced upper-limb prosthetic components with both sensor and myoelectric control (e.g., LUKE Arm) are considered investigational.
A prosthesis with individually powered digits, including but not limited to a partial hand prosthesis, is considered investigational.
Myoelectric controlled upper-limb orthoses are considered investigational.
Myoelectric upper-limb prosthetic components are considered investigationalunder all other conditions.
