Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvea prosthetic leg with a special cushion, advanced foot, ankle feature, and other parts.You asked the Plan to pre-approvea prosthetic leg with a special cushion, advanced foot, ankle feature, and other parts. You say that the documentation provided supports criteria for the requested items.The Plan denied your request. The Plan says that the notes do not show why the requested foot is needed. The Plan also says that the gel liners have extra padding at the end of the liner, and the additional distal end padding is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a prosthetic leg with a special cushion, advanced foot, ankle feature, and other parts. Our reviewer says that the documentation provided supports criteria for the requested items. Our physician reviewer found in this case, the enrollee is a below-knee amputee with the current request for a prosthesis.  The request was denied with the rationale that the provider's records do not include any objective clinical information or physical exam findings to support that the member is a K3 ambulator.  The provider's notes indicate under the exam findings "left transtibial amputation; his superficial wounds are now essentiallyall healed.  He is still fairly swollen but maintains a good cylindrical shape."  The Medicare LCD states that "the records must document the beneficiary's current functional capabilities and his/her expected functional potential, including an explanationfor the difference, if that is the case."  The original request from 11/05/2020 indicates that during daily activities the enrollee will be covering indoor and outdoor services to include grass, gravel, and other uneven terrains.  The provider clearly outlined the enrollee's functional potential and needs that fall within the K-3 level.  With respect to the clinical findings, the enrollee was ready to begin the use of a prosthesis in addition to an active exercise program.  Therefore, the requested prosthesis meets the requirements from the Medicare coverage database, local coverage determination: lower limb prosthesis (L33787). The requested prosthesis with a special cushion, advanced foot, ankle feature, and other parts is reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a prosthetic leg with a special cushion, advanced foot, ankle feature, and other parts have been met.Therefore, we decided that the Plan has to pre-approvea prosthetic leg with a special cushion, advanced foot, ankle feature, and other parts.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter