Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Powered Upper Extremity Range of Motion Device (Current Procedural Terminology (CPT) code L8702), for the enrollee.

You asked the Plan to pre-approve the device. You say that the enrollee has exhausted the other available therapies and has not regained meaningful use of their dominant right arm. You state without further intervention, the enrollee will labor indefinitely with this disability. The Plan denied your request. The Plan says that the device 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 the device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that The MyoPro orthosis (brace) is designed to enable individuals to support and assist movement of a weak or deformed hand and arm. Patients can self-initiate and control movement of a partially paretic upper limb using their own myoelectric signals. Similar to how a myoelectrically controlled prosthetic operates, the MyoPro orthosis utilizes surface EMG sensing technology to enable volitional motion of the impaired limb. When the user tries to move their extremity, sensors in the orthosis detect, process, and amplify the weak myoelectric signal, which activates motors to move the extremity in the desired direction. The user is in complete control of their own extremity; the orthosis assists with movement only once a signal is detected. According to the manufacturer website, the MyoPro is the only product on the market to help restore function for those who still have their arms and hands but are unable to use them. MyoPro is now covered by most Medicare Advantage plans (also known as Medicare Part C), the VA and most other insurance plans. The review indicates that the enrollee has exhausted the other available therapies and has not regained meaningful use of their dominant right arm. The review has determined that the requested Powered Upper Extremity Range of Motion Device (Current Procedural Terminology (CPT) code L8702), is medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have been met. Therefore, we decided that the Plan has to pre-approve Powered Upper Extremity Range of Motion Device (Current Procedural Terminology (CPT) code L8702), for the enrollee.

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.