Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Weakness.
Treatment:  Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), included microprocessor, sensors, all components and accessories, custom fabricated.
The insurer denied Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), included microprocessor, sensors, all components and accessories, custom fabricated.
The determination is upheld.

This is a male patient with left upper extremity weakness following a stroke. The patient was previously treated with physical therapy and occupational therapy. Other diagnoses include diabetes, hypertension, aortic valve stenosis status post aortic valve replacement, status post right total hip replacement, status post left total hip replacement, status post cervical spine surgery with hardware implantation, hyperlipidemia, obstructive sleep apnea, ankylosing spondylitis, chronic back pain, and psoriatic arthritis. He is unable to dress/undress himself, open jars, or wash dishes. He requires assistance from his wife with these activities.
The patient's nurse practitioner (NP) stated that he had a contracture of the left hand. He was alert and oriented to person, place, and time. His mood, behavior, thought content, and judgement were normal. He had a history of a cerebrovascular accident (CVA) with residual left arm flaccidity and contracture. The NP stated that he had decreased range of motion of the neck, left shoulder and left elbow. He had a contracture of the left hand. Surface electromyography (EMG) was performed. Nerve conduction studies and needle EMG which are the components of an adequate EMG study were not performed. The report conclusion did not diagnose any neurological and musculoskeletal conditions based on the EMG findings. The report stated that there was none to mild flexor/extensor tone in the wrist and fingers, which is inconsistent with the reports by the NP indicating that the patient had a left-hand contracture. At issue is whether the MyoPro EWHFO orthosis (elbow-wrist-hand-finger orthosis): powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), included microprocessor, myoelectric sensors, all components and accessories, custom fabricated is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment of MyoPro EWHFO orthosis (elbow-wrist-hand-finger orthosis): powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), included microprocessor, myoelectric sensors, all components and accessories, custom fabricated is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has left upper extremity weakness following a stroke. The patient was previously treated with physical therapy and occupational therapy. He is unable to dress/undress himself, open jars, or wash dishes. He requires assistance from his wife with these activities. The patient has a permanent left-hand contracture due to severe left-hand spasticity caused by his chronic stroke. A contracture is a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints and soft tissues to shorten, preventing movement of the joints of the left hand and fingers. Due to the contracture, the MyoPro would be ineffective.
Studies that demonstrate that a MyoPro type device would work exclude patients with contractures for this reason. 
The MyoPro requires at least minimal range of motion and arm musculature that will allow proper function. His left-hand contracture does not meet the minimal range of motion criteria. There must be reasonable expectation of predicted improved functional state within a reasonable period of time, and there is not, due to the left-hand contracture. The patient is not being treated in a clinically controlled research setting using specific research protocols meeting National Institute of Health (NIH) standards and there are no well-designed studies showing that use of this device results in significantly improved medical outcome or super clinical outcome in stroke patients with hand contracture, such as this patient.