Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom myoelectric elbow-wrist-hand-finger orthosis (MyoPro 2 Motion G). There is a lack of evidence in current medical literature supporting the use of the requested device in assisting a patient with weakness of an upper limb due to a cerebral event, such as a brain tumor, in regaining neurological or muscular strength or function, such as the innate ability to use the arm for functional tasks when the orthosis is removed. The requested device takes time and effort to don and doff, with assistance from others, and is not proven to help a user become more independent. It is not proven to be well-adapted to everyday usage in the community setting, and there are high rates of abandonment due to its poor efficiency. The available medical literature regarding the potential of the device is limited and does not establish proven health outcomes, such as reduction in the incidence of overuse injury of the sound, unaffected limb. Recent and current literature regarding the potential of the device to improve strength or function is limited to anecdotal literature and small trials, including industry-supported trials, with larger trials either in progress or planned. Arya and colleagues note that rehabilitation efforts should aim to support and suspend the shoulder and arm weight. Due to its weight, the requested device may cause the shoulder to sublux and result in greater instability for a patient with hemiparetic gait by displacing the center of gravity. In this clinical setting, the weight of the requested device would make it difficult for the patient to position her upper extremity for purposeful use of the device. The requested device is not proven to enhance or replace the role of conventional orthoses and is not expected to provide clinically or functionally significant marginal benefits over conventional orthotic therapy. Therefore, a custom myoelectric elbow-wrist-hand-finger orthosis (MyoPro 2 Motion G) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested custom myoelectric elbow-wrist-hand-finger orthosis (MyoPro 2 Motion G) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in physical medicine and rehabilitation and are actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.