Diagnoses: Orthopedic/ Musculoskeletal
Treatment: Prosthetics
The insurer denied proposed service of prosthetic arm.
The health plan's determination is overturned in whole. The proposed service of prosthetic arm is medically necessary for this patient.
This patient per the provider on has lost all fingers "down to the palm on dominant right side and down to the first knuckle on nondominant left side." While a body powered upper extremity prosthesis is typically standard of care for a single upper extremity amputee this is not the case for bilateral upper extremity amputees. This patient does not have the benefit of retraining her non-dominant hand and does not have a sound hand to perform most activities. Instead, as the provider noted, the patient requires assistance with all care including peri care following a bowel movement. Therefore, this prosthesis is not an assistive device but, instead, an essential device. The patient does not even have the ability to form a pincer grip on the non-dominant hand as the provider noted that amputation on non-dominant hand is "down to the first knuckle." A body powered prosthesis requires a harness which in and of itself will be difficult for this patient to don independently while a myoelectric prosthesis will allow for independent donning and doffing. In addition, a myoelectric prosthesis will allow this patient to have unrestricted range of motion of the shoulder and elbow. A myoelectric prosthesis will also allow for increased grip strength and does not require sustained input requiring the user to concentrate on the mechanical use and not the functional task. For all these reasons, a myoelectric upper extremity prosthesis is not only medically necessary but also standard of care for this patient.