Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congenital Anomaly of the upper limb

Treatment: Elbow mold sock suspension (code L6110RT), elbow socket in use with lock (code L6694RT), and upper extremity prosthesis (code L7499RT),

The insurer denied coverage for elbow mold sock suspension (code L6110RT), elbow socket in use with lock (code L6694RT), and upper extremity prosthesis (code L7499RT)

The denial is overturned

Upon review of the literature submitted, the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations, I recommend reversing the insurer's decision to deny coverage of elbow mold socket suspension (code L4110RT), elbow socket in use with lock (code L6694RT), and upper extremity prosthesis (code L7499RT). The child has grown out of the old prosthesis due to natural pediatric growth and needs a replacement. Liners are also extremely worn and in need of replacement due to normal wear and tear, they are also causing skin irritation due to sweat and bacteria build up. 

She is dependent on the prosthesis to perform activities of daily living (ADL) such as cutting food with a fork and knife. Furthermore, she was having difficulty with the fit of the current prosthesis. It is not allowing for elbow flexion and motion to be translated to the prosthesis. Evaluation revealed that the patient's remaining bone is not being contained within the socket trim lines and is not allowing for elbow flexion and motion to be translated to the prosthesis. This results in motion of the prosthesis coming from soft tissue motion in the residual limb and only allowing about 30-40 degrees of elbow flexion. This limits the use of the prosthesis. She currently uses the prosthesis for play as well as school activities like writing, drawing, and art class. She occasionally uses it to carry a bag or other objects. 

It is medically necessary for the child to receive a new and improved prosthesis. This will provide the necessary function for her to independently manage her ADLs, such as cutting food with a fork and knife. It will improve her participation in sports and improve her ability to swing a bat. Lastly, it improves overall aesthetic appearance.

To achieve these goals, a better fitting prosthesis that gains better control of the remaining bony segment is necessary to allow better translation of elbow motion to the prosthesis. The goal is to allow elbow flexion through 90 degrees of motion. This will allow better ADL completion with all the terminal devices (TD). A baseball bat attachment TD will be used to allow better grasp of the bat. A passive functional hand and glove will be provided for a more aesthetic appearance and for passive grasp and holding of devices. This will be helpful for better social acceptance as well as drawing and writing tasks to hold paper still. It could also be used for two handed grasps and holding or carrying large objects. 

According to the documentation submitted, this is a female with a history of hemangioma of the skin and a congenital anomaly of the upper limb. She presented to the certified prosthetist's office for an evaluation for a prosthesis. She was having difficulty with the fit of the prosthesis. The prosthesis is not allowing for elbow flexion and motion to be translated to the prosthesis. The patient would like a new prosthesis to help with swinging a bat, cutting food with a fork and knife, and overall aesthetic appearance. The prosthetist requested a new prosthetic right forearm. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the elbow mold sock suspension (code L6110RT), elbow socket in use with lock (code L6694RT), and upper extremity prosthesis (code L7499RT), is overturned. Medical Necessity is substantiated.