Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s) (CPT code L6880), automatic grasp feature, addition to upper limb electric prosthetic terminal device (L6881) and microprocessor control feature, addition to upper limb prosthetic terminal device (L6882), for the enrollee.  You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your request. The Plan says the requested prosthetic hands exceed the enrollee's need and there are other computerized hands that can be used for the enrollee's condition.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   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 items. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the member has history of chronic lower back pain (LBP) with transfemoral and bilateral transradial amputations due to wet gangrene with Osteomyelitis. Modified independent for bed mobility, treatment, wheelchair mobility. Be able to use bilateral upper limbs for self-care and functional fine motor coordination tasks. Request denied on prior review as myoelectric control prosthesis not reasonable and necessary. The enrollee has used a body powered prostheses, but the enrollee found the body powered prosthesis insufficient for activities of daily living (ADLs). Given that the enrollee has failed use of body-powered prosthesis, the request for a myoelectric prosthesis appears reasonable and necessary. The requested myoelectric prosthesis is approved except for L6880 - Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s) L6881 - Automatic grasp feature, addition to upper limb electric prosthetic terminal device, L6882 - Microprocessor control feature, addition to upper limb prosthetic terminal device. The request for upper limb myoelectric prosthesis with independently articulating digits exceeds the enrollee's need and does not meet the Medicare criteria of reasonable and necessary. The review has determined that the items/services at issue in this case are not 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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s) (CPT code L6880), automatic grasp feature, addition to upper limb electric prosthetic terminal device (L6881) and microprocessor control feature, addition to upper limb prosthetic terminal device (L6882), for the enrollee.