Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral above elbow (trans-humeral) amputations 
Treatment: L6955RT x 1Right Above Elbow Myoelectronic Control upper arm prosthetic, L7180RT x 1 Electronic Microprocessor Elbow, L6693RT x 1 Locking Elbow Forearm Counterbalance, L7259RT x 1 Electronic Wrist Rotator, L6621 RT x 1 Flexion/Extension Wrist with or without Friction, L6882RT x 1 Microprocessor Control Feature, L6881RT x 1 Automatic Grasp Feature, L7499 x 1TASKA Electric Hand, Myoelectric Control Independent Articulating Digits, and L7499 x 1 Nudge Switch Kit 

The insurer denied coverage for L6955RT x 1Right Above Elbow Myoelectronic Control upper arm prosthetic, L7180RT x 1 Electronic Microprocessor Elbow, L6693RT x 1 Locking Elbow Forearm Counterbalance, L7259RT x 1 Electronic Wrist Rotator, L6621 RT x 1 Flexion/Extension Wrist with or without Friction, L6882RT x 1 Microprocessor Control Feature, L6881RT x 1 Automatic Grasp Feature, L7499 x 1TASKA Electric Hand, Myoelectric Control Independent Articulating Digits, and L7499 x 1 Nudge Switch Kit. The denial is upheld. 

This patient is a male who sustained bilateral above elbow (trans-humeral) amputations as a result of an electrical accident. The patient currently had bilateral upper extremity body powered prostheses that were reportedly poorly fitting. Currently under review is the medical necessity of the requested bilateral microprocessor upper extremity prostheses. 

From a physical medicine & rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, based on the clinical information available for review, the requested bilateral microprocessor upper extremity prostheses are not medically necessary for this patient at this time. 

Each type of prosthesis has its own advantages and disadvantages. For example, body-powered prostheses excel in durability, training time, and frequency of adjustment, maintenance, and feedback. Myoelectric excel in cosmesis, decreased phantom-limb pain, fine manipulation adjustments and are more accepted for light intensity work. 

In this case, the patient has only had the body powered prostheses for approximately 6 months, prior to being evaluated for myoelectric prostheses. Upper extremity prosthesis training (particularly bilateral) and fitting can be extensive; independent of the power source; body powered or myoelectric. There is no clinical evidence to support that extensive training and fitting adjustments have been provided for the patient prior to consideration of transitioning to myoelectric prosthesis. Thus, the requested bilateral microprocessor upper extremity prostheses are considered not medically necessary for this patient at this time. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

Based on the above, the medical necessity for L6955RT x 1Right Above Elbow Myoelectronic Control upper arm prosthetic, L7180RT x 1 Electronic Microprocessor Elbow, L6693RT x 1 Locking Elbow Forearm Counterbalance, L7259RT x 1 Electronic Wrist Rotator, L6621 RT x 1 Flexion/Extension Wrist with or without Friction, L6882RT x 1 Microprocessor Control Feature, L6881RT x 1 Automatic Grasp Feature, L7499 x 1TASKA Electric Hand, Myoelectric Control Independent Articulating Digits, and L7499 x 1 Nudge Switch Kit is not substantiated. The insurer's denial should be upheld.