Medical policy: Upper Limb Prostheses

Policy number: MP 6.052

Effective date: 4/1/2026

Policy

Preparatory prosthesis

A preparatory prosthesis may be considered medically necessary after surgery to prevent edema of the residual limb. Additions are investigational for preparatory prosthesis since these have all initial components.

All other uses of preparatory prosthesis are considered investigational as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

Passive functional

Passive functional prosthesis does not include any mechanical working parts. The passive prosthesis relies on manual positioning, typically using the opposite arm, and cannot restore function. A passive functional prosthesis may be considered medically necessary only when there is clear documentation that the requested prosthesis is required to perform activities of daily living (ADLs).

All other uses of passive functional prostheses are considered investigational as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

Body-powered prostheses

A body-powered prosthesis will consist of a socket or interface, suspension system, harness, wrist unit, terminal device (such as a hook or hand), and possibly a triceps cuff (below elbow), hinges (below elbow), elbow (above elbow) and a shoulder (if a shoulder disarticulation or higher).

Body-powered upper extremity prostheses may be considered medically necessary when ALL the following are met:

• The member has history of upper limb amputation or absence of upper limb(s);
• A certified prosthetist determines a body-powered upper extremity prosthesis is appropriate to meet the member’s functional needs.

Sockets and suspension systems

No more than two test (diagnostic) sockets may be considered medically necessary for an individual prosthesis without additional documentation of medical necessity. No more than one of the same socket inserts are allowed at the same time. Socket and socket insert replacements may be considered medically necessary if there is documentation of functional and/or physiological need. Explanation to include but is not limited to:

• Changes in residual limb
• Functional need changes
• Irreparable damage due to wear and tear
• Wear and tear due to excessive weight
• Prosthetic demands of a very active amputee

Terminal devices (above and below elbow, shoulder, hand)

Terminal devices may be considered medically necessary for work and when essential to ADLs. Terminal devices are considered investigational when used solely for activities related to sports or recreation.

All other uses of body-powered prostheses are considered investigational as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

Electric/myoelectric prostheses

Electric and myoelectric upper limb prosthetic components may be considered medically necessary when the following conditions are met:

• The individual has an amputation or missing limb at the wrist or above (forearm, elbow, etc.);
• Standard body-powered prosthetic devices cannot be used or are insufficient to meet the functional needs of the individual in performing ADLs; and
• The remaining musculature of the arm(s) contains the minimum microvolt threshold to allow operation of a myoelectric prosthetic device; and
• The individual has demonstrated neurological and cognitive function to operate the prosthesis effectively; and
• The individual is free of comorbidities that could interfere with function of the prosthesis (neuromuscular disease, etc.); and
• Functional evaluation indicates that with training, use of a myoelectric prosthesis is likely to meet the functional needs of the individual (e.g., gripping, releasing, holding, and coordinating movement of the prosthesis) when performing ADLs. This evaluation should consider the individual needs for control, durability (maintenance), function (speed, work capability), and usability.

A prosthesis with individually powered digits, including but not limited to a partial hand prosthesis, is considered investigational. There is insufficient evidence to support a general conclusion concerning the health outcomes or benefits associated with these item(s).

Myoelectric upper limb prosthetic components are considered investigational under all other conditions, as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

Additions and accessories

Accessories such as sheaths, socks, hinges, switches, extensions, adaptors, cables for residual limbs, etc. may be considered medically necessary when these appliances aid in or are essential to the effective use of the prosthetic limb. Additions should be billed on the same claim as the base procedure when supplied at the same time as the base procedure.

Adjustments

Adjustments and/or modifications to the prosthesis required by wear and tear or due to a change in individual’s condition (such as growth in a child) or to improve the function may be considered medically necessary.

Repairs

Repairs necessary to make the prosthetic functional may be considered medically necessary. The expense for repairs may not exceed the estimated expense of purchasing another prosthesis.

Replacement

The life of a prosthesis is approximately 5-years. A replacement prosthesis may be considered medically necessary only if the previous prosthesis is no longer functional. Requests for upgrades/newer technology will be reviewed for medical necessity.

Cross-reference

• MP 6.042 Lower Limb Prostheses

Product variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

FEP PPO - Refer to FEP Medical Policy Manual.

Description/background

Upper-limb amputation

The need for a prosthesis can occur for a number of reasons, including trauma, surgery, or congenital anomalies.

Treatment

The primary goals of upper-limb prostheses are to restore function and natural appearance. 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 any upper-limb prosthesis increases with the level of amputation (digits, hand, wrist, elbow, shoulder), and thus the complexity of joint movement increases.

Upper-limb prostheses are classified into 3 categories depending on the means of generating movement at the joints: passive, body-powered, and electrically powered movement. All 3 types of prostheses have been in use for more than 30 years; each possesses unique advantages and disadvantages.

Passive prostheses

The passive prostheses rely on manual repositioning, typically using the opposite arm, and cannot restore function. This unit is the lightest of the 3 prosthetic types and is thus generally the most comfortable.

Body-powered prostheses

The body-powered prostheses use 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

Myoelectric prostheses are powered by electric motors with an external power source. The joint movement of an upper limb prosthesis (e.g., hand, wrist, and/or elbow) is driven by microchip-processed electrical activity in the muscles of the remaining limb stump.

• 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 may act at the hand, wrist, or elbow. Although upper arm movement may be slow and limited to 1 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.
• Myoelectric hand attachments are similar in form to those offered with the body-powered prosthesis but are battery-powered. Commercially available examples are listed in the Regulatory Status section.
• 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. As of development include the use of skin-like silicone elastomer gloves, “artificial muscles,” and sensory feedback. Smaller motors, microcontrollers, implantable myoelectric sensors, and reinnervation 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.

The LUKE Arm (previously known as the DEKA Arm System) was developed in a joint effort between DEKA Research and Development and U.S. DARPA, which is funding a public and private collaborative effort on prosthetic research and development. It is the first commercially available myoelectric upper limb that can perform complex tasks with multiple simultaneous powered movements (e.g., movement of the elbow, wrist, and hand at the same time). In addition to the electromyographic electrodes, the LUKE Arm contains a combination of mechanisms, including switches, moment sensors, and force sensors. The primary control resides within inertial measurement sensors on top of the feet. The prosthesis includes vibration pressure and grip sensors.

Rationale

Summary of evidence

For individuals who have a missing limb at the wrist or above who receive myoelectric upper limb prosthesis components at the wrist or proximal to the wrist, the evidence includes a systematic review and comparative studies. Relevant outcomes are functional outcomes and quality of life. The goals of upper-limb prostheses relate to restoration of both appearance and function while maintaining sufficient comfort for continued use. The identified literature focuses primarily on patient acceptance and rejection; data are limited or lacking in the areas of function and functional status. The limited evidence suggests that, compared with body-powered prostheses, myoelectric possess the similar capability to perform light work; however, myoelectric components could also suffer a reduction in performance when operating under heavy working conditions. The literature also indicates that the percentage of amputees who accept use of a myoelectric prosthesis is approximately the same as those who prefer to use a body-powered prosthesis, and that self-selected use depends at least in part on the individual’s activities of daily living. Appearance is most frequently cited as an advantage of myoelectric prostheses, and for patients who desire a restorative appearance, the myoelectric prosthesis can provide greater function than a passive prosthesis, with equivalent function to a body-powered prosthesis for light work. Because of the differing advantages and disadvantages of currently available prostheses, myoelectric components for persons with an amputation at the wrist or above may be considered when passive or body-powered prostheses cannot be used or are insufficient to meet the functional needs of the patient in activities of daily living. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have a missing limb at the wrist or higher who receive sensor and myoelectric controlled upper-limb prosthetic components, the evidence includes a series of publications from a 12-week home study. Relevant outcomes are functional outcomes and quality of life. The prototypes for the advanced prosthesis were evaluated by the U.S. military and Veterans Administration. Demonstration of improvement in function has been mixed. After several months of home use, activity speed was shown to be similar to the conventional prosthesis, and there were improvements in the performance of some activities, but not all. There were no differences between the prototype and the participants’ prostheses for outcomes of dexterity, prosthetic skill, spontaneity, pain, community integration, or quality of life. Study of the current generation of the sensor and myoelectric controlled prosthesis is needed to determine whether newer models of this advanced prosthesis lead to consistent improvements in function and quality of life. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

No peer-reviewed publications were identified for individuals who have a missing limb distal to the wrist who receive a myoelectric prosthesis with individually powered digits. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals with upper-extremity weakness or paresis who receive a myoelectric powered upper-limb orthosis, the evidence includes a small within-subject study. Relevant outcomes are functional outcomes and quality of life. The largest study (N=18) identified tested participants with and without the orthosis but did not provide any training with the device. Performance on the tests was inconsistent. Studies are needed that show consistent improvements in relevant outcome measures. Results should also be replicated in a larger number of patients. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Definitions

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Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as permitted by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These policies are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the members’ benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

Covered when medically necessary

Investigational; there is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with these item(s).

References

1. Biddiss EA, Chau TT. Upper limb prosthesis use and abandonment: a survey of the last 25 years. Prosthet Orthot Int. Sep 2007; 31(3): 236-257. PMID 17979100
2. Kruger LM, Fishman S. Myoelectric and body-powered prostheses. J Pediatr Orthop. Jan-Feb 1993; 13(1): 68-75. PMID 8416338
3. 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. Dec 1993; 75(12): 1781-1789. PMID 8258548
4. McFarland LV, Hubbard Winkler SL, Heinemann AW, et al. Unilateral upper-limb loss: satisfaction and prosthetic-device use in veterans and servicemembers from Vietnam and OIF/OEF conflicts. J Rehabil Res Dev. Aug 2010; 47(4): 299-316. PMID 20803400
5. Sjoberg L, Linder H, Hermansson L. Long-term results of early myoelectric prosthesis fittings: A prospective case-control study. Prosthet Orthot Int. Sep 2017; 41(5): 309-316. PMID 28905686
6. Eggermann M, Kasten P, Thomsen M. Myoelectric hand prostheses in very young children. Int Orthop. Aug 2009; 33(4): 1101-1105. PMID 18636257
7. Resnik LJ, Borgia ML, Aluche F. Perceptions of satisfaction, usability and desirability of the DEKA Arm before and after a trial of home use. PLoS One. Jun 2017; 12(6): e0178640. PMID 28575025
8. Resnik L, Cancio J, Klinger S, et al. Predictors of retention and attrition in a study of an advanced upper limb prosthesis: implications for adoption of the DEKA Arm. Disabil Rehabil Assist Technol. Feb 2018; 13(2): 206-210. PMID 28375687
9. Resnik L, Klinger S. Attrition and retention in upper limb prosthetics research: experience of the VA home study of the DEKA arm. Disabil Rehabil Assist Technol. Nov 2017; 12(8): 816-821. PMID 28098513
10. Resnik LJ, Borgia ML, Alucihe F, et al. How do the outcomes of the DEKA Arm compare to conventional prostheses? PLoS One. Jan 2018; 13(1): e0191326. PMID 29342217
11. Resnik LJ, Alucihe F, Lieberman Klinger S, et al. Does the DEKA Arm substitute for or supplement conventional prostheses? Prosthet Orthot Int. Sep 2017; 41(5): 309-316. PMID 28905665
12. Resnik L, Alucihe F, Borgia M. The DEKA hand: A multifunction prosthetic terminal device—patterns of usage at home. Prosthet Orthot Int. Sep 2017; 41(5): 435-445. PMID 28965483
13. Peters HT, Page SJ, Persch A. Giving them a hand: wearing a myoelectric elbow-wrist-hand orthosis reduces upper extremity impairment in chronic stroke. Ann Rehabil Med. Sep 2017; 39(4): 321-328. PMID 28103304
14. Chung K, Yoneda H. Upper extremity amputation. In: UpToDate. Post TW (Ed), UpToDate, Waltham, MA. Updated March 06, 2024. Literature current through May 2025.
15. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services. Committee on the Use of Selected Assistive Products and Technologies in Eliminating or Reducing the Effects of Impairments; Flaubert JL, Spicer CM, Jette AM, editors. The Promise of Assistive Technology to Enhance Activity and Work Participation. Washington (DC): National Academies Press (US); 2017 May 9. 4. Upper Extremity Prostheses.
16. Maat B, Smiet P, Plettenburg D, Breedveld P. Passive prosthetic hands and tools: A literature review. Prosthet Orthot Int. 2018; 42(1): 66-74. doi:10.1177/0309364617691622
17. Walsh AR, Lu J, Rodriguez E, Diamond S, Sultan SM. The Current State of Targeted Muscle Reinnervation: A Systematic Review. J Reconstr Microsurg. 2023; 39(3): 238-244. doi:10.1055/s-0042-1755262
18. Engdahl SM, Meehan SK, Gates DH. Differential experiences of embodiment between body-powered and myoelectric prosthesis users. Sci Rep. 2020; 10(1): 15471. Published 2020 Sep 22. doi:10.1038/s41598-020-72470-0