Diagnosis: Left, Congenital below-elbow amputee (trans radial).
Treatment: Hand Prosthesis (high definition silicone prosthesis).

The insurer denied the hand prosthesis (high definition silicone prosthesis).
The health plan's determination is overturned.

The patient is a male with a congenital left trans-radial amputation for whom a high-definition silicone hand prosthesis was requested and denied. The medical records indicate that the patient suffers from anxiety and depression complicated by his feelings of his appearance due to his congenital left upper extremity amputation.
He also has impaired function due to his congenital amputation. The rationale with requesting a high-definition silicone prothesis as noted by the prosthetist and physician are for functional assist to improve the patient's overall quality of life functionally, socially and emotionally.

At issue is the medical necessity for the hand prosthesis.

The requested service and treatment of a hand prosthesis is medically necessary for the patient as detailed above. It will provide the patient with a medically necessary prosthetic to improve the functional use of his upper extremity.
It is well documented in the literature that custom silicone prosthesis provide for functional use as a prosthetic, but also an improvement quality of life.
It is well documented in the patient's medical record that he is suffering socially, emotionally and functionally in a large part due to his congenital limb amputation. The requested high-definition silicone prosthesis will provide him with medically necessary function for upper extremity amputees.