Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Orthopedic/Musculoskeletal/Other/Acquired absence of left leg above knee.
Treatment: Prosthetics/Prosthetic Leg.
The health plan denied the requested prosthetic leg as not medically necessary. 
The health plan's determination is upheld.

The patient is a female who underwent left above the knee amputation surgery. The treating physician recommended an above the knee molded socket with single axis microprocessor knee and advanced foot.
At issue is the medical necessity for the requested computerized knee and advanced foot.

The health plan's determination of medical necessity is upheld, in whole.

No. The requested health service/treatment of a computerized knee and advanced foot is not medically necessary for this patient.
More than 100 different prosthetic ankle-foot and knee designs are currently available. The choice of the most appropriate design may depend on the patient's underlying activity level. For example, the requirements of a prosthetic knee in an elderly, largely homebound individual will differ from those of a younger, active person. Key elements of a prosthetic knee design involve providing stability during both the stance and swing phase of the gait. Prosthetic knees vary in their ability to alter the cadence of the gait, or the ability to walk on rough or uneven surfaces. In contrast to more simple prostheses, which are designed to function optimally at one walking cadence, fluid and hydraulic-controlled devices are designed to allow amputees to vary their walking speed by matching the movement of the shin portion of the prosthesis to the movement of the upper leg. For example, the rate at which the knee flexes after "toe-off" and then extends before heel strike depends in part on the mechanical characteristics of the prosthetic knee joint. If the resistance to flexion and extension of the joint does not vary with gait speed, the prosthetic knee extends too quickly or too slowly relative to the heel strike if the cadence is altered. When properly controlled, hydraulic or pneumatic swing-phase controls allow the prosthetist to set a pace adjusted to the individual amputee, from very slow to a race-walking pace. Hydraulic prostheses are heavier than other options and require gait training; for these reasons, these prostheses are prescribed for athletic or fit individuals. Other design features include multiple centers of rotation, referred to as "polycentric knees." The mechanical complexity of these devices allows engineers to optimize selected stance and swing-phase features. Microprocessor-controlled prostheses use feedback from sensors to adjust joint movement on a real-time as-needed basis. Active joint control is intended to improve safety and function, particularly for individuals who can maneuver on uneven terrain and with variable gait. A trial period may be indicated to evaluate the tolerability and efficacy of the prosthesis in a real-life setting. Decisions about the potential benefits of microprocessor-knees involve multiple factors including activity levels, as well as the patient's physical and cognitive ability. A patient's need for daily ambulation of at least 400 continuous yards, daily and frequent ambulation at variable cadence or on uneven terrain (e.g., gravel, grass, curbs), and daily and frequent use of ramps and/or stairs (especially stair descent) should be considered as part of the decision. Typically, daily and frequent need of 2 or more of these activities would be needed to show benefit.
However, in this case, the records do not provide a thorough explanation as to why this patient cannot first be fitted with a standard prosthesis to determine their level of function before using a more advanced prosthesis.