Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic arm weakness
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 upheld

This case involves an adult male seeking authorization for L8702 prostetic. The patient had a history of hypertension and stroke. The patient was seen for a stroke follow-up at the physical medicine and rehabilitation clinic. There was a goal for the patient to return to work. The patient continued to have spasticity in the left hand. The patient was participating in range of motion exercises and splinting. The patient continued to be symptomatic without sufficient benefit to restore functional use of the left upper extremity. The provider recommended custom myoelectric orthosis.  

The request for custom myoelectric orthosis was denied. The treatment was not eligible for coverage as it was considered experimental or investigational under the patient's health plan.

The provider requested reconsideration of the patient's custom myoelectric orthosis. The provider felt that the request was appropriate for the treatment of the patient's chronic arm weakness. It would provide daily restoration of arm function and range of motion in the home. The provider cited clinical studies and case reports that demonstrated the safety of the requested prostetic for the patient's clinical presentation. The provider noted that the device was Food and Drug Administration approved, and thus, was not experimental. There were clinically meaningful and statistically significant improvements for patients with chronic arm weakness or paralysis after stroke with use of the device. The patient had engaged in traditional rehabilitation strategies including occupational therapy, physical therapy with modalities of static bracing and electrical stimulation, and Botox injections.

Per the cited literature, myoelectric prosthesis may be indicated when there is unilateral transhumeral or transradial deficiency and no underlying neuromuscular disease. The documentation should identify that standard body powered prosthesis cannot be used or has insufficient functionality to assist the patient with performance of activities of daily living. In this case, the patient has sustained a stroke. The patient continued to have spasticity in the left hand. The patient had been treated with traditional rehabilitation strategies including occupational therapy, physical therapy with modalities of static bracing, and electrical stimulation as well as Botox injections. The provider recommended 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. However, the documentation did not detail that standard body powered prosthesis could not be used or had insufficient functionality to assist the patient with performance of activities of daily living. The documentation did not support that the device would be safer or more effective than standard treatments for the patient's condition.  

In summary, the denial of  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 should be upheld. This treatment is not 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.