Does L8701 require prior authorization?

Yes, L8701 requires prior authorization (high confidence). Code explicitly requires prior authorization.

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`L8701`, Powered upper extremity range of motion assist device, elbow, wrist, hand with

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Documentation Required

No specific documentation requirements are stated in the provided text segment.
For provision of myoelectric elbow orthoses (MEO/MyoPro/MEWHO): documentation of detectable volitional EMG signals from paretic muscles (explicit requirement in studies providing MEO to BPI patients with detectable EMG).
Baseline and follow-up clinical assessments as used in cited studies (examples that may be required/expected in clinical documentation): Fugl-Meyer Assessment — Upper Limb (FM-UL), Disabilities of the Arm, Shoulder and Hand (DASH), Wolf Motor Function Test–Orthopedic version (WMFT-O), Modified Ashworth Scale (MAS), Box and Block (BB) test, range of motion (goniometer), muscle strength testing, visual analog pain scale (VAS).

Key Coverage Criteria

None — Aetna considers robotic-assisted rehabilitation of the upper limb and lower limb experimental and investigational because of insufficient evidence of its effectiveness.
Upper-limb robot-assisted therapy (UL-RAT) / exoskeleton-assisted rehabilitation (e.g., ArmeoPower) for motor recovery after subacute stroke, aimed at improving activities of daily living (ADL), arm and hand function, and muscle strength (study: multicenter RCT protocol in subacute stroke).
Upper-limb home-based robotic rehabilitation (e.g., iCONE device) for chronic stroke patients to improve robot-evaluated indices (e.g., Independence, Size for Circle Drawing, Movement Duration for Point-to-Point) and to reduce spasticity (MAS) — pilot, no control group.
Home-based overground robotic-assisted gait training (O-RAGT) in combination with usual care physiotherapy for individuals with chronic stroke (3 months to 5 years post-stroke) to improve vascular health measures (reduction in carotid-femoral pulse wave velocity, cfPWV) and increase physical activity.
Assistive robotic training added to conventional occupational and physical therapy for patients after proximal humeral fracture (PHF) early after surgical treatment to potentially improve shoulder/upper-arm functional outcomes (primary outcome: DASH; secondary: WMFT-O) — randomized trial protocol.
Portable myoelectric elbow-wrist-hand orthosis (MEWHO) as an assistive and/or therapeutic device for chronic, stable, moderately impaired stroke survivors to reduce upper-extremity (UE) impairment (Fugl-Meyer) and improve functional task performance and gross manual dexterity.

9 Active Policies

ANTHEM-MP-C174286, OR-PR.00005 Upper Extremity Myoelectric Orthoses

EVICORE-HPLAN-CIGNA_MEDICARE-268F28B96146, Cigna Medicare Advantage Durable Medical Equipment Code List - Effective 01/01/2025

AETNA-CPB-0778, Robotic-assisted Rehabilitation of the Extremities

AMBETTER-CP.MP.107, Durable Medical Equipment and Orthotics and Prosthetics Guidelines

BCBSIL-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb

BCBSMT-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb

BCBSNM-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb

BCBSOK-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb

REGENCE-DME80, Myoelectric and Microprocessor Prosthetic and Orthotic Components for the Upper Limb

`L8701`, Powered upper extremity range of motion assist device, elbow, wrist, hand with

Prior Authorization

Documentation Required

Key Coverage Criteria

9 Active Policies

Related Codes

Have a follow-up question?

L8701, Powered upper extremity range of motion assist device, elbow, wrist, hand with

Prior Authorization

Documentation Required

Key Coverage Criteria

9 Active Policies

Related Codes

Have a follow-up question?

`L8701`, Powered upper extremity range of motion assist device, elbow, wrist, hand with