202203-147061
2022
Capital District Physicians' Health Plan Inc.
HMO
Central Nervous System/ Neuromuscular Disorder
Durable Medical Equipment (DME) (including Wearable Defibrilllators)
Experimental/Investigational
Overturned
Case Summary
Diagnosis: Central Nervous System/Neuromuscular Disorder/Paralysis/Right Arm
Treatment: Durable Medical Equipment(DME)
The health plan denied the requested MyoPro motion device as experimental/investigational.
The health plan's determination is upheld.
The patient is a male with complete paralysis of the right arm due to severe complete brachial plexus root avulsion injury following a motor vehicle accident. The brachial plexus injury was so severe that it resulted in the nerve roots being avulsed, which means that all the nerves to the right upper extremity were disconnected from the spinal cord and brain. He was left with a completely paralyzed right upper extremity with no function of any muscle groups in the right upper extremity. Treatment has included physical therapy, occupational therapy, nerve repair surgeries, and (cervical-thoracic) C4-T1 laminoplasty with right sided DREZ (dorsal root entry zone) procedure (to treat pain). The nerve repair surgeries were not successful.
At issue is whether the proposed health service or treatment of the MyoPro Motion Device is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
I uphold, in whole, the health plan's determination regarding the proposed health service or treatment.
The proposed health service or treatment of the MyoPro Motion Device is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The MyoPro is a custom fabricated myoelectric upper extremity orthosis for use in patients with partial paralysis. The patient has complete paralysis, which makes this device unlikely to be beneficial.
The medical records indicate that there has been no recovery from the nerve repair surgeries and that the patient has complete paralysis of the right upper extremity. The brachial plexus nerve root avulsion injury means that all of the nerves to the right upper extremity have been completely disconnected from the brain and spinal cord. The nerves and muscles of the right upper extremity cannot work without a connection to the brain and spinal cord. The MyoPro Motion Device is considered experimental/investigational and there are no well-designed well conducted studies published in peer-reviewed journals to support this device, demonstrate that this device affects health outcomes, or show that this device is equally or more effective than conventional therapies. There are many standard treatments for the diagnosis of complete paralysis of the right arm due to severe complete brachial plexus root avulsion injury, including surgery, physical therapy, occupational therapy, and medications. The use of the MyoPro Motion Device is not considered medically necessary, not supported by the peer-reviewed medical literature is not considered the standard of care in United States at this time.