Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 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 (L8702). 
 
You asked the Plan to pre-approve a powered upper extremity range of motion assist device. You say that the 
enrollee is in need of a custom, myoelectric elbow-wrist-hand-finger orthosis (the MyoPro Motion G) which is 
designed to provide functional restoration of strength and range of motion to a neurologically impaired upper 
extremity. The Plan denied your request. The Plan says the requested device does not meet the requirements for 
approval. 
 
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 a powered upper extremity range of 
motion assist device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found current clinical guidelines designate 
robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise 
therapies" with unproven benefit in the home environment. Although records from the device 
manufacturer/vendor argue medical necessity of the requested device, records from the enrollee's actual 
treating provider do not clarify why the requested device is the most appropriate treatment for the enrollee's 
condition. In addition, provided records report left upper extremity spasticity and left shoulder subluxation 
which may be a contraindication to use of the device. Medical information intended to demonstrate compliance 
with coverage criteria may be included on the prescription but must be corroborated by information contained 
in the medical record. The enrollee's medical record must contain sufficient documentation of the enrollee's 
medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency 
of use or replacement (if applicable). The information should include the enrollee's diagnosis and other 
pertinent information including, but not limited to, duration of her condition, clinical course (worsening or 
improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and 
results, past experience with related items, etc. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a powered upper extremity range of motion assist device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a 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 (L8702).