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 with a past medical history of right elbow congenital deficiency who underwent a prosthetic evaluation. She presented to the physician's office with left wrist pain and complaints of overuse of her left wrist and hand. The patient's discomfort in her left wrist was exacerbated by the extensive typing she needed to do at her job. She was also a dancer, which required extensive usage of her left wrist and hand. The patient was unable to do upper body workouts to improve the strength in her left upper extremity. In the sound limb, the patient reported constant pain rated 7 to 8 out of 10, in intensity. Her residual limb presented as a short length below the elbow. The patient's right shoulder range of motion was full. The patient's right elbow range of motion was full, with flexion of 130 degrees and full extension. The patient's light touch and pinprick sensations were intact in the upper extremity dermatomes.  It was documented that the patient was in need of an externally powered prosthesis. For her lifetime, she had experienced a complete loss of function of her right upper limb at the forearm level. This decreased function had caused asymptomatic use of her upper extremity limbs, gross body positioning and repositioning for specific tasks and it promoted poor ergonomics. The patient had developed overuse syndrome in her left upper extremity which was impairing her ability to perform her self-care activities, her job, and participated in recreational activities she enjoyed such as dancing. She currently experienced fatigue and overuse in her intact upper limb as well as back and neck pain. The provider noted the patient would benefit from the prosthetic technology to mitigate any of these problems.

According to literature review, 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 prostheses excel in cosmesis, decreased phantom-limb pain, and fine manipulation adjustments and are more accepted for light intensity work.   

In this case, the patient would benefit from the requested myoelectric prosthesis. She meets the insurer's criteria for medical necessity. She has the cognitive and neurologic ability to utilize a myoelectric device. The patient's remaining musculature of the arms contains the minimum microvolt threshold to allow operation of a myoelectric prosthetic device. Given the left carpal tunnel and over-use syndromes, the myoelectric is the better prosthetic option over the body-powered prosthesis. There is no evidence of a comorbidity that would interfere with maintaining function of the prosthesis. There is sufficient musculature to use this device. This device would provide easier use and greater dexterity to provide a more beneficial outcome with function. The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome with this myoelectric prosthesis, and the patient is considered a good candidate for 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 associated codes: L7499-RT x 2, L7403-RT, L7400-RT, L6935-RT, and L6882-RT should be overturned.