I. Introduction

In 2024 Medi-Cal added assistive robotic arms to the Medi-Cal Durable Medical Equipment (DME) manual. This is an extremely exciting development for people with significant disabilities who receive Medi-Cal. Assistive robotic arms attach to a power wheelchair and operate like a human arm and hand, enabling people to perform many activities of daily living more independently. Currently, the Kinova 2 Jaco Robotic Arm1 (Jaco arm) is the only assistive robotic arm registered by the Food and Drug Administration (FDA)2 and available in the U.S. This publication is intended to inform you about the Jaco arm, help you determine whether this type of DME is appropriate for you, and explain how to get Medi-Cal coverage for these devices.

II. What is Medi-Cal?

Medicaid, known as “Medi-Cal” in California, is a state and federally funded program. It pays for medically necessary treatment and services, medicines, durable medical equipment, and medical supplies. You can visit the California Department of Health Care Services (DHCS) website for more information about Medi-Cal and how to apply, at: https://www.dhcs.ca.gov/services/medi-cal/Pages/ApplyforMedi-Cal.aspx.

Most Medi-Cal members are in managed care plans (MCPs), but some people have fee-for-service Medi-Cal through the Department of Health Care Services (DHCS).

III. What is the Jaco Robotic Arm?

The Jaco is a robotic arm that attaches to a power wheelchair and operates like a human arm and hand. It is designed to help people be more independent in their daily lives.

The Jaco arm is manufactured by a company called Kinova, Inc.3 and distributed by a company called Partners in Medicine.4 The Jaco arm is made of lightweight carbon fiber materials and can be controlled by the same controller currently used to drive a wheelchair (joystick, head array, sip-and-puff, or any other compatible controller). It can be used to perform a range of activities of daily living, including grooming, eating, drinking, opening doors, picking up dropped items, taking medications, adjusting limbs, retrieving items from shelves or cabinets, self-suctioning, and more.

The Jaco arm is appropriate for people with severe upper limb mobility limitations including, but not limited to, people living with muscular dystrophy, spinal muscular atrophy, quadriplegia, spinal cord injury, ALS, cerebral palsy, upper limb amputation, stroke, and more.

To learn more about the Jaco arm, you can visit the Kinova website, at: https://assistive.kinovarobotics.com/product/jaco-robotic-arm and the Partners in Medicine website, at: https://partnersinmed.com/assistive-devices/jaco-robotic-arm/.

IV. Medi-Cal Coverage Criteria for Assistive Robotic Arms

As of September 1, 2024, assistive robotic arms are officially a covered Medi-Cal benefit. This means that Medi-Cal and Medi-Cal MCPs must cover an assistive robotic arm when medically necessary, and when prescribed by a qualified, licensed health care practitioner. A specialty evaluation and treatment goals are also required.5

a. Medical Necessity

Medi-Cal will pay for DME only if it is “medically necessary.” “Medically necessary” DME must be “reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.”6 This includes coverage for conditions that “cause suffering, endanger life, result in illness or infirmity, interfere with capacity for normal activity including employment, or for conditions which may develop into some significant handicap.”7

Authorization for DME is limited to the lowest cost item that meets your needs.8

In addition to this general standard, Medi-Cal has special medical necessity standards for people under age 21. Under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, individuals under age 21 are entitled to necessary health care if it corrects or ameliorates defects and physical and mental illnesses and conditions discovered through screening.9 For more information about EPSDT, visit: https://www.medicaid.gov/medicaid/benefits/early-and-periodic-screening-diagnostic-and-treatment/index.html.10

An assistive arm is considered medically necessary when all the following are met:

• The beneficiary also meets criteria for a powered wheelchair,
• The beneficiary’s power wheelchair accommodates the assistive arm,
• The beneficiary has an upper extremity mobility functional limitation that significantly impairs their ability to meet daily functional needs, including performing activities of daily living (ADLs) or instrumental activities of daily living (IADLs).
  • ADLs include dressing, bathing, eating, drinking, toileting, hygiene, and similar activities.11
  • IADLs include shopping, housekeeping, accounting, food preparation, taking medication, opening doors, accessing public transportation, and other activities.12
• The beneficiary’s upper extremity mobility functional limitation cannot be equally or effectively addressed using an arm support or other less costly equipment,
• Use of an assistive arm will improve the beneficiary’s ability to meet daily functional needs, including performing ADLs and IADLs, and the beneficiary will use it daily,
• Other, less costly treatment options have failed or would be futile, as determined and explained by a qualified health care practitioner,
• The beneficiary has expressed a willingness to use the assistive arm, and,
• The beneficiary has sufficient function and other physical and mental capabilities needed to operate the assistive arm during a typical day.13

b. Authorization of a Robotic Arm

To determine if an assistive arm is medically necessary, your doctor must submit a Treatment Authorization Request (TAR) or Service Authorization Request (SAR) with supporting documentation to DHCS if you have fee-for-service Medi-Cal or to your Medi-Cal MCP if you have managed care. The TAR/SAR from your doctor must include: 1) an in-person or telehealth assessment and evaluation, 2) documentation from your doctor about your medical diagnoses and record of significant medical history, including all of the information listed in the “medical necessity” criteria above, 3) a specialty evaluation, 4) any information that affects the beneficiary’s ability to safely use an assistive arm, and, 5) an explanation of why the assistive arm is the most effective and least costly DME available for the beneficiary.14

The required specialty evaluation must be performed by a licensed, qualified health care practitioner like a physical therapist or occupational therapist as well as a qualified professional who is certified by a manufacturer of assistive arms.15 Your doctor can refer you to the appropriate department within your health plan and you can also reach out to Partners in Medicine at: https://partnersinmed.com/about-us/assistive-services/.

V. Assistive Robotic Arm if you have Medicare and Medi-Cal

If you have both Medi-Cal and Medicare, you are considered a “dual eligible” member or “Medi-Medi.” If you are dual eligible and trying to get an assistive robotic arm, it is important to understand your rights and we recommend reviewing our publication: https://www.disabilityrightsca.org/publications/durable-medical-equipment-medi-cal-medicare-and-dual-eligible-individuals. This provides detailed information about how Medi-Cal and Medicare work together, as well as the requirement that Medi-Cal provide DME to dual eligibles and then bill Medicare, rather than making a dual eligible wait for a Medicare determination before Medi-Cal coverage.

Typically, Medicare is the primary payer for dual eligible individuals, and generally always pays before Medi-Cal.16 Medicare currently does not have a policy covering robotic arms.

VI. California Children’s Services (CCS)

Children who receive CCS can get DME for the purpose of improving mobility and self-care activities, when limited by the child’s CCS eligible medical condition.17 This can include coverage of a robotic arm. The DME must be medically necessary to treat a CCS eligible condition. Medical necessity is defined as a “limitation of a mobility or a self-care skill related to a CCS eligible medical condition which is verified by physical findings and which justifies authorizing DME.”18 Keep in mind that for CCS beneficiaries who have Medi-Cal, the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) medical necessity standard must apply. Under EPSDT, benefits and services necessary to “correct or ameliorate defects and physical and mental illnesses and conditions” are required to be covered.19 For more detailed information about CCS and DME see, https://healthconsumer.org/wp/wp-content/uploads/2021/08/2021-CCS-DME-Issue-Brief_8.6.2021-updated.pdf.

VII. Medi-Cal Denials, Appeals, and Grievances

What are my options if Medi-Cal denies a robotic arm?

a. Common reasons for denying the Jaco Arm

Health plans will often deny the Jaco arm for several different reasons. Below is a list of common denials and how to rebut them. If your plan denies for any of the reasons below, we recommend providing a copy of the Medi-Cal Provider Bulletin, “Durable Medical Equipment and Medical Supplies Bulletin 587” at No. 3: Durable Medical Equipment and Medical Supplies Bulletin.

i. “Not a covered benefit.”

Health plans may try and claim that the Jaco arm is not a covered Medi-Cal benefit. This is incorrect: Medi-Cal covers assistive robotic arms when medically necessary.

Additionally, Title XIX of the Medicaid Act provides that states like California that cover “home health care services” must also provide benefits for “durable medical equipment.”20 Federal law also says that “States are prohibited from having absolute exclusions of coverage on medical equipment, supplies, or appliances” and “must use reasonable and specific criteria to assess items for coverage.”21

ii. “Not medically necessary.”

Medi-Cal plans must also provide coverage for medically necessary equipment to its beneficiaries. As stated above, DME is medically necessary when “it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.”22

To prove that the Jaco arm is medically necessary for you, you must work with your doctor and health care team to submit all the required documentation and detailed information listed in Section IV, above. In our experience, treating physician support, including detailed letters and information provides the best chance for Medi-Cal to approve the Jaco arm.

iii. “Experimental/Investigational.”

Health plans may also try and claim that the Jaco arm is not a covered device because it is “experimental” or investigational.” However, as of September 1, 2024, DHCS added Medi-Cal coverage for assistive robotic arms when medically necessary, meaning it is not an experimental or investigational device.

iv. “Must first seek coverage through Medicare.”

If you are a dual eligible individual, or have both Medi-Cal and Medicare, Medi-Cal MCPs may wrongfully claim that you must first seek coverage for an assistive arm through Medicare. For more information, please see Section V, above. If your health plan says this, we recommend providing them a copy of the Medi-Cal Manual Sections, Durable Medical Equipment (DME): Bill for DME at pages 23-25 and Durable Medical Equipment (DME): An Overview at page 11 regarding Charpentier billing requirements.

For more information on Medi-Cal Appeals and Grievances, please see DRC’s Publication: “Medi-Cal Managed Care: Appeals and Grievances,” at: https://www.disabilityrightsca.org/publications/medi-cal-managed-care-appeals-and-grievances.

VIII. Jaco Repairs and Replacements

If your Jaco arm needs repair or maintenance, Kinova provides a two-year warranty from the date of delivery.23 Medi-Cal will only reimburse for one month of rental while the assistive arm is being repaired. After the warranty has expired, Medi-Cal will only pay for repair or maintenance if it is less costly than to replace the assistive arm. For more information on assistive arm repairs or replacements, see Durable Medical Equipment (DME): An Overview at page 10.24

If you have questions or concerns about your legal rights, please call DRC’s intake line at: 1-800-776-5746.

• 1. https://assistive.kinovarobotics.com/product/jaco-robotic-arm
• 2. Device Class 1, Regulation Number 890.342, Product Code IQZ.
• 3. https://www.kinovarobotics.com/
• 4. https://partnersinmed.com/assistive-devices/jaco-robotic-arm/
• 5. DHCS DME and Medical Supplies Bulletin, "Assistive Robotic Arm Device Now a Medi-Cal Benefit," August 16, 2024; Medi-Cal Provider Manual, Durable Medical Equipment, "Assistive Robotic Arm Device" at pp. 10-16.
• 6. Welf. & Inst. Code, § 14059.5.
• 7. Welf. & Inst. Code, § 14059.
• 8. 22 C.C.R. § 51321(g).
• 9. Title XIX of the Social Security Act, § 1905(r)(5); Welf. & Inst. Code, § 14059.5(b)(1).
• 10. See also, Medi-Cal Provider Manual, EPSDT.
• 11. Medi-Cal Provider Manual, Durable Medical Equipment, "Assistive Robotic Arm Device" at p.10.
• 12. Id.
• 13. Id. at p. 11.
• 14. Id. at pp. 11-12.
• 15. Id. at pp. 11-12.
• 16. 42 U.S.C.A § 1396a(a)(25).
• 17. See CCS Numbered Letter 09-0703, Revised CCS Guidelines for Recommendation and Authorization of Rental or Purchase of Durable Medical Equipment-Rehabilitation (Aug. 8, 2003)
• 18. Id.
• 19. 42 USC § 1396d(r)(5); Cal. Welf. & Inst. Code § 14059.5(b)(1)
• 20. Blue v. Bonta, 99 Cal.App.4th 980, 988 (2002) (citing 42 U.S.C. §§ 1396d(a)(7); 42 U.S.C. § 1395x(m)(5)).
• 21. 42 C.F.R. 440.70(b)(3)(v).
• 22. Welf. & Inst. Code, § 14059.5.
• 23. https://assistive.kinovarobotics.com/product/jaco-robotic-arm.
• 24. Medi-Cal Provider Manual, Durable Medical Equipment, "Assistive Robotic Arm Device" at p.14.