Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Absence of upper extremity. 

Treatment: Durable medical equipment, L6680 x 2, L6686, L6687, L6881, L6882 x 2, L6890 x 4, L6935, L7007, L7009, L7367, and L7368 (externally powered left upper extremity artificial limb). 

The insurer denied coverage for durable medical equipment, L6680 x 2, L6686, L6687, L6881, L6882 x 2, L6890 x 4, L6935, L7007, L7009, L7367, and L7368 - externally powered left upper extremity artificial limb. 

The denial is upheld. 

This is a male with a history of upper extremity amputations and a left trans femoral amputation due to a motor vehicle accident (MVA). He presented to the Internal Medicine physician's office for follow up care after a recent hospital admission. He had wound contractures and poor healing. He needed a home care referral and script for an arm prosthetic. The physician recommended continuing pain medications as needed (PRN). She ordered durable medical equipment, L6680 x 2, L6686, L6687, L6881, L6882 x 2, L6890 x 4, L6935, L7007, L7009, L7367, and L7368 - externally powered left upper extremity artificial limb. 

Regarding an externally powered prosthesis, https://www.ncbi.nlm.nih.gov/books/NBK453290/ states: "Whereas a body-powered system's power comes from the user's movements, an externally powered prosthesis is powered by batteries contained within the system. The device can be controlled with various inputs, including electromyographic (EMG) signals, force-sensing resistors, pull switches, and push switches (Esquenazi). Physical switches are a good complement to EMG signals for high-level amputees when multiple motors must be controlled or when the EMG signal is insufficient. Given that the most prevalent type of externally powered device is a myoelectric prosthesis, the following description focuses on those devices. 

A typical myoelectric control scheme, direct control, uses EMG signals from two antagonist muscle contractions to operate two directions of movement. With a simple two-site direct control system, for example, wrist extensor EMG signals control opening of the hand, while wrist flexor EMG signals control closing of the hand. Thresholds are set for each muscle to allow some contraction without the occurrence of inadvertent movement. Most modern systems provide proportional control, in which the magnitude of the signal above the threshold is proportional to the speed of device movement and the generated grip force. 

There is insufficient information to substantiate necessity for the powered device. There are several factors which need to be taken into consideration. These include the size of the extremity, status of skin, social situation, defining who will be responsible for placing the device, charging and maintaining the unit. An external powered device is complex and prone to breakdown. Frustration leads it to be simply discarded. 

At the very least, the patient would require a multidisciplinary evaluation with the appropriate specialist. Specialties may include Physical Medicine and Rehab (PMR), Prosthetist, Orthopedic Surgeon. All aspects of his clinical case should be assessed prior to use of the prosthesis. Clear indications and goal should be established. It may be of benefit to utilize a simply passive device to the effected extremity taking into consideration his limited shoulder motion. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for durable medical equipment, L6680 x 2, L6686, L6687, L6881, L6882 x 2, L6890 x 4, L6935, L7007, L7009, L7367, and L7368 - externally powered left upper extremity artificial limb is upheld. Medical Necessity is not substantiated.