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Myoelectric and Microprocessor Prosthetic and Orthotic Components for the Upper Limb
Effective date
Oct 1, 2026
Identified
Jun 16, 2026
Summary
Medical policy DME80 sets the criteria for myoelectric upper limb prostheses and for replacement of an existing myoelectric upper limb prosthesis. Myoelectric upper limb prostheses may be medically necessary for an amputation or missing limb at the wrist or above when the listed criteria are met, including that standard body-powered prosthetic devices cannot be used or are insufficient to meet the functional needs of the individual. Upper-limb prosthetic components with both sensor and myoelectric control, and myoelectric or microprocessor controlled upper-limb orthoses, are considered investigational.
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What to do
Action · 2 steps
01Already effective October 1, 2026: The billing team must submit the following for review of myoelectric upper limb prostheses: history and physical or chart notes; documentation of amputation or missing limb at the wrist or above; documentation that standard body-powered devices cannot be used or are not efficient, including the ADLs and/or physical activities that cannot be accomplished currently; documentation that the remaining musculature in the limb contains the minimum microvolt threshold, including a functional test using a physical or computer model prosthesis; documentation that the individual is cognitively and neurologically able to operate the prosthetic; documentation that the individual does not have comorbidities that might interfere with the use of the prosthetic; an evaluation by a qualified professional such as a prosthetist showing the individual will be able to use the prosthetic for ADLs, including the ability to control, maintain, function, and use the prosthetic and why it is necessary for ADLs, job functions, and/or physical activities; and documentation that the prosthetic is not being requested to replace a functioning prosthetic.
02If any of these items are not submitted, it could impact the review and decision outcome.
Codes mentioned
A8005A8006E1399L6026L6693L6700L6715L6880L6881L6882L6925L6935L6945L6955L6965L6975L7007L7008L7009L7045L7180L7181L7190L7191L7259L7499L8701L8702
Original notice
Myoelectric and Microprocessor Prosthetic and Orthotic Components for the Upper Limb
beonbrand.getbynder.com · Always check the source before changing claims.
Related changes
See all Regence BlueShield changes →Definitive Lower Limb ProsthesesMediumEffective Nov 1, 2026 · CodingGeneral Medical Necessity Guidance for Durable Medical Equipment, Prosthetic, Orthotics and Supplies (DMEPOS)MediumEffective Jan 1, 2026 · Medical PolicyMyoelectric and Microprocessor Prosthetic and Orthotic Components for the Upper LimbMediumEffective Oct 1, 2026 · Prior AuthorizationMyoelectric and Microprocessor Prosthetic and Orthotic Components for the Upper LimbMediumEffective Jul 1, 2026 · Prior AuthorizationBrowse every Regence BlueShield change in the policy list
Related policy hubs
Regence BlueShield policiesOrthopedicsPM&R (Physical Medicine & Rehab)Occupational TherapyCode A8005Code A8006Code E1399Code L6026Code L6693Code L6700Code L6715Code L6880Code L6881Code L6882Code L6925Code L6935Code L6945Code L6955Code L6965Code L6975Code L7007Code L7008Code L7009Code L7045Code L7180Code L7181Code L7190Code L7191Code L7259Code L7499Code L8701Code L8702