All PlansCoverageMedium impact
Myoelectric and Microprocessor Prosthetic and Orthotic Components for the Upper Limb
Regence BlueShield·Orthopedics, PM&R (Physical Medicine & Rehab), Plastic Surgery·Coding
Effective date
Apr 1, 2026
We identified it
Jun 16, 2026
Summary
New policy DME80 establishes coverage criteria for myoelectric and microprocessor prosthetic/orthotic components for upper limbs, requiring specific documentation and functional evaluations. The policy designates upper-limb prosthetics with both sensor and myoelectric control, as well as myoelectric or microprocessor controlled upper-limb orthoses, as investigational (non-covered).
Action Required
Before April 1, 2026: Billing team must create prior authorization workflow for myoelectric upper limb prosthetics requiring comprehensive documentation including amputation records, functional testing results, cognitive assessment, comorbidity evaluation, and prosthetist evaluation. Update system to flag upper-limb prosthetics with sensor/myoelectric control and microprocessor controlled orthoses as investigational (non-covered). Train staff on six-point medical necessity criteria and required documentation checklist.