Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Left upper extremity hemiparesis.

Treatment: L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated.

The insurer denied coverage for L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated.

The denial is overturned.

The patient is an adult who suffered a stroke and a seizure, which resulted in left upper extremity partial paralysis. The patient previously tried and failed physical therapy, Occupational Therapy, and Botox injections, none of which provided significant improvement in the patient's condition. The treating physician recommended the patient utilize the L8702 Powered upper extremity range of motion assist device given that the patient was suffering from partial paralysis and the MyoPro demise has demonstrated safety and efficacy through multiple clinical studies and case reports and was cleared for sale by the Food and Drug Administration (FDA). The requesting physician is stating that the device was cleared by the FDA, and there is sufficient scientific evidence documenting the clinically meaningful and statistically significant improvements for patients with chronic arm weakness or paralysis following stroke.  In addition to the treating physician, multiple peers submitted letters indicating the benefit of the device as it pertains to improving the patient's functionality in the left upper extremity that has not been obtained through traditional means. The issue at hand pertains to the denial of coverage for L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated.  

There are scientific evidence and peer-reviewed medical literature that supports a result of improvement in health outcomes for patients such as the one in question.

The L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated has received final approval from the appropriate regulatory bodies for this diagnosis.

The patient is a good candidate for the L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated.

Based upon medical literature, the L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated as one of the best available treatments for this patient at this time.

The adverse risks are not increased over standard treatment/services.

The requested service is likely to be as beneficial as other standard treatment/procedures for this patient.

In summary, the denial of  coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.