BCBS ArizonaAll Plans · Coverage · Medical Policy · AZ · Physical Therapy, Occupational TherapyMedium impact
Myoelectric Prosthetic and Orthotic Components
Effective date
Not stated in the notice
Identified
Jun 16, 2026
Summary
Myoelectric upper limb prosthetic components are medically necessary, when benefit coverage for biomechanical or myoelectric devices is available, with documentation of ALL six criteria: an amputation or missing limb at the wrist or above, standard body-powered prosthetic devices cannot be used or are insufficient for activities of daily living, the remaining arm musculature contains the minimum microvolt threshold, sufficient neurologic and cognitive function to operate the prosthesis, no comorbidities that could interfere with function, and a functional evaluation by an independent qualified professional indicating that with training a myoelectric prosthesis is likely to meet functional needs. Myoelectric upper limb prosthetic components for other indications, advanced prostheses with both sensor and myoelectric control (such as the LUKE Arm), prostheses with individually powered digits including partial hand prostheses, and myoelectric controlled upper-limb orthoses are considered experimental or investigational when any one or more of five listed criteria are met, including lack of final approval from the FDA.
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01REQUIREMENTS: Billing team: Before billing myoelectric upper limb prosthetic components, verify the member's benefit plan booklet, because coverage for biomechanical or myoelectric devices depends on benefit plan language.
02Billing team: For myoelectric upper limb prosthetic components, document ALL six criteria: amputation or missing limb at the wrist or above, body-powered devices cannot be used or are insufficient for activities of daily living, the minimum microvolt threshold in the remaining musculature, sufficient neurologic and cognitive function, no interfering comorbidities, and a functional evaluation by an independent qualified professional.
03Billing team: Advanced sensor and myoelectric prostheses, prostheses with individually powered digits including partial hand prostheses, and myoelectric controlled upper-limb orthoses are experimental or investigational when any one or more of the listed criteria are met.
04Providers: When requesting any exception to these guidelines, provide BCBSAZ complete medical rationale.
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