Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Congenital absence of right upper extremity, Carpal tunnel syndrome

Treatment: Myoelectric upper limb and hand prostheses with associated service codes:  L7499-RT x 2, L7403-RT, L7400-RT, L6935-RT, and L6882-RT

The insurer denied coverage for myoelectric upper limb and hand prostheses with associated service codes: L7499-RT x 2, L7403-RT, L7400-RT, L6935-RT, and L6882-RT.

The denial is overturned.

This is a female patient diagnosed with right below elbow congenital deficiency and left wrist repetitive strain injury. According to a clinical note, the patient presented with a right congenital transradial deficiency at the short forearm level. There were reports of complaints of overuse of the left wrist and hand. The patient is a dancer which required extensive usage of the left wrist and hand. The patient reported that she was unable to do upper body workouts to improve the strength of the left upper extremity. Her reported pain was rated 7 to 8 out of 10, in severity. On examination, the patient was left-hand dominant. Her residual limb presented as a short length below the elbow; it was non-tender to touch and exhibited 5/5 motor strength. The patient's range of motion was full in the right shoulder, and her range of motion of the right elbow on flexion was 130 degrees with extension was full; sensation was intact. The patient was recommended for a powered prosthesis.

There were reports that the patient experienced symptoms related to overuse of her sound limb and was recommended for a myoelectric design. Her activities and desired activities involved using the prosthesis in multiple planes to achieve overall body symmetry and strengthening. The recommended operating system was recommended to provide intuitive pattern recognition and improve the patient's ability to adapt to two-handed function more quickly and naturally. The patient demonstrated cognitive ability to use and maintain the recommended prosthesis.

According to current peer-reviewed medical literature, the upper limb myoelectric orthosis has been proposed as an assist device to enable individuals to control movements of a partially paralyzed or weakened arm and to regain the ability to perform activities of daily living. Sensors built into the custom, wearable device detect the electrical activity of muscles at rest in the affected arm in the bicep/triceps and the forearm flexor/extensor muscle groups. The signals are amplified when the wearer initiates movement, driving small motors which allow the wearer to extend/flex their elbow and open/close their thumb and fingers. There is evidence to support this technology. The use of myoelectric upper limb orthosis has been proven safe and effective. The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome, and this patient is considered a good candidate for this device and its associated service codes: L7499-RT x 2, L7403-RT, L7400-RT, L6935-RT, and L6882-RT.

The requested service is likely to be more beneficial than any of the standard treatments/ procedures for this patient.

The carrier's denial of myoelectric upper limb and hand prostheses with associated service codes: L7499-RT x 2, L7403-RT, L7400-RT, L6935-RT, and L6882-RT should be overturned.