Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve MyoPro, Motion G Orthotic device (identified with code 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). 
 
You asked the Plan to pre-approve MyoPro, Motion G Orthotic device. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says that the requested item is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve MyoPro, Motion G Orthotic device. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee was diagnosed with right arm hemiparesis and aphasia related 
to a stroke from 2016. The enrollee is reported to have had significant gains from physical therapy, bracing, e-
stim, and Botox and is ambulating with a cane and right AFO, however, right arm strength remains low. failed 
traditional rehabilitation efforts. Based on the available evidence supporting powered myoelectric orthoses in 
the setting of permanent arm weakness such as with this enrollee who had already failed other first line 
treatment efforts, the MyoPro device appears to be appropriate and will likely provide significant 
improvements in independence and overall function as intended. Studies show that this technology is superior 
to conventional therapy and leads to cost savings over the long term, especially for enrollees that have a longer 
life expectancy such as this enrollee. The enrollee has an appropriate diagnosis for this device which meets 
Medicare criteria. The MyoPro would be considered the standard of care in this situation as it would be the 
most appropriate and most effective for the enrollee's specific condition. Therefore, the enrollee meets criteria 
for the requested item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro, Motion G Orthotic device have been met. Therefore, we decided that 
the Plan has to pre-approve MyoPro, Motion G Orthotic device (identified with code 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).  
 
 
 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.