Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a right partial hand prosthesis. 
 
You asked the Plan to pre-approve the requested services. You say that the requested device will improve 
bipedal function. The Plan denied your request. The Plan says that the requested device exceeds the enrollee's 
needs.  
 
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 requested services. Our physician 
reviewer found that the enrollee has a right partial hand amputation since 2019 in the setting of an infected 
wound/sepsis. Specifically, the enrollee is missing his right thumb through the metacarpophalangeal joint, 
while digits 3-5 have severe contractures such that they are non-functional, leaving only digit 2 (index finger) 
with any functional range of motion. It is notable that the enrollee is also missing his left index finger. This 
request appears to be a Point Designs brand mechanical thumb (L7499, described as "addition to upper 
extremity partial hand prosthesis, single digit, heavy duty, full finger with manual ratchet/lock") to restore the 
enrollees right hand grasping through thumb opposition with the index finger and palm. This was prescribed 
by the enrollees physician, who also documented that the requested finger design, which can be repositioned 
in various angles/attitudes, is necessary to allow the enrollee to change the shape of right-handed grasp patterns 
to suit different objects and activities of daily living. 
 
 
 The Plan asserts vaguely that simpler devices could meet this enrollees needs but it is not at all clear what 
devices the Plan could be referring to. Passive devices (e.g., L6905) do not confer the functional grip patterns 
that this enrollee needs to make meaningful use of his right hand. Other established L-codes for traditional 
body-powered devices apply to devices that actually open/close fingers by proximal body-powered movements.  
The requested device in both form and function is unique among prosthetic components. It is not characterized 
by other established codes, nor has it been addressed by the Pricing, Data Analysis and Coding (PDAC). Code 
L7499 exists for precisely this kind of situation, and the treating team has explicitly justified their treatment 
plan. Therefore, L7499 as requested/described in this case, is medically reasonable and 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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve a right partial hand prosthesis.  
 
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.