Diagnosis: Congenital Elbow Anomaly

Treatment: Prosthetic Arm with Active Grasping Capability

The insurer denied coverage for a Prosthetic Arm with Active Grasping Capability. The denial was reversed.

This is a young male patient who was born with a right below-the-elbow congenital anomaly who has been receiving occupational physical therapy. It was reported by the mother that his current prosthesis no longer fits due to his increased growth, nor was he wearing it because of the pain it caused. It was recommended by the treating physical and occupational therapist that he be fitted for a new prosthesis; a body powered prosthesis was recommended.

According to the current literature, prosthetic interventions are guided by developmental stages. Components are chosen to anticipate growth and functional needs. Devices should fit comfortably and utility and satisfaction is the main focus of prosthesis fitting. Unwillingness to wear prosthesis often reflects poor fit, which seems to be the case for this patient who has outgrown his current device. Myoelectric and body-powered devices are durable and are prescribed early on as young as 1-2 years old. Prosthetic replacement for growth is indicated for children with amputations annually for the first 5 years of life, every 2 years from ages 5-12 years, and then every 5 years. Based on this reviewer's clinical experience, current literature, and the clinical information provided, this prosthesis would be medically necessary.

The carrier's denial of coverage for the prosthetic arm (pre-service) is reversed. The medical necessity is substantiated.