Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Left upper extremity hemiparesis.

Treatment: L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated.

The insurer denied coverage for L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated.

The denial is upheld.

This patient has a history of stroke and left upper extremity hemiparesis with spasticity. Prior treatments included physical/occupational therapy, medication management and Botox injections. Under review is a requested coverage for L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated.

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the requested device; powered L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated (aka MyoPro System-L8702) is best described for this patient as being of questionable benefit.  The medical literature cited was reviewed. The quality and quantity of data in the current peer-reviewed scientific medical literature is inadequate to conclude the clinical utility, safety and efficacy of the requested MyoPro System (L8702) for the treatment of this member's clinical condition. The studies are plagued by limited sample size, lack of control group and/or funded by the manufacturer. The device is not proven likely to be more beneficial than any available standard treatment for this particular patient.  

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, regarding the requested coverage for L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated: The scientific evidence in peer-reviewed literature support is insufficient to prove a result of improvement in health outcome. The L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated has final approval from the appropriate regulatory bodies for this diagnosis. This patient is a good candidate for L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated. The L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated is not proven to be the best available treatment for this patient at this time.
Adverse risks are not increased over standard treatment/services for the requested device.

In summary, the denial of  coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.