Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Right Transfemoral Amputation
Treatment: Treatment: Lower Limb Prosthesis With A Microprocessor Knee
The insurer denied the Treatment: Lower Limb Prosthesis With A Microprocessor Knee 
The denial is upheld.

The records report that the patient is a male with a history of attention deficit
hyperactivity disorder, bipolar disorder, depression and anxiety. He witnessed a fatal stabbing and was diagnosed with post-traumatic stress disorder.

The patient developed painful spasms, not further described. He was given a
diagnosis of complex regional pain syndrome affecting the right lower extremity.

The patient underwent an elective right transfemoral amputation in the setting of
extreme discomfort and pain in the right lower limb, as well as a right knee flexion
and ankle contractures.

No, the health plan should not cover the requested lower limb prosthesis with a
microprocessor knee, shank foot system with vertical loading pylon, and other
requested components and accessories.

The patient's amputation is still recent. His residual limb is still maturing with
respect to shape and size. There are no indications that his residual limb has been
exposed to the mechanical stresses of weight bearing and ambulation in a
preliminary prosthesis, which will incite further changes to the residual limb. There
are no indications that the patient is ready for a definitive prosthesis at this time.

A lack of a microprocessor-controlled prosthetic knee is not a barrier to
accomplishing activities of daily living and community level mobility. The patient
would remain at risk for adverse effects such as falls, because he is a new user of a
prosthesis, with or without the proposed microprocessor-aided prosthetic knee.
Prosthetic gait for a person with a unilateral transfemoral amputation, overall,
without or without a microprocessor knee, is challenging and less efficient than
ambulation with two intact lower limbs. Notably, falls even occur in unilateral
transtibial (below knee) amputees who still have an intact, anatomical knee, i.e., the
knee they were born with.

The patient's amputation is still recent. His residual limb is still maturing with
respect to shape and size. There are no indications that his residual limb has been
exposed to the mechanical stresses of weight bearing and ambulation in a
preliminary prosthesis, which will incite further changes to the residual limb. There
are no indications that the patient is ready for a definitive prosthesis at this time.
The proposed definitive prosthesis is, therefore, not medically appropriate. All of
the listed components and accessories in question are also not medically
appropriate, because the underlying prosthesis for which these components and
accessories are designed to be mounted on and/or used with is not medically
appropriate.

A microprocessor-controlled prosthetic knee, moreover, is not necessary for
activities such as work or sports, which can be performed as well, if not better,
using prostheses without microprocessor-aided knees, especially at higher levels of
sport.

The patient was seen in prosthetics clinic. He was noted to have been active
playing baseball, basketball and football prior to his diagnosis of complex regional
pain syndrome. He was noted to have been a waiter as well, i.e. He was noted to
currently be functional with a walker. He was on Suboxone, Lyrica and medications
for his psychiatric conditions. He was noted to want to return to some type of
gainful employment, possibly detailing cars. A prosthesis with a microprocessoraided knee (an Ottobock C-Leg 4), Ottobock Taleo vertical shock foot, and other
components and accessories were recommended.