Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (L5828), addition, endoskeletal, knee-shin system, stance flexion feature, 
adjustable (L5845), addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with 
or without adjustability (L5848), addition to lower extremity prosthesis, endoskeletal knee-shin system, 
microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856), 
addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968) and all 
lower extremity prostheses, flex-walk system or equal (L5981). 
 
 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary for you. The Plan 
denied your request. The Plan says that the request for a K3 prosthesis exceeds your need and does not meet 
Medicare criteria as reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The treating medical 
practitioner progress note documentation does not support that you are a K3 level. The documentation does not 
indicate that you are required to traverse most environmental barriers. You are not working and admit to not 
exercising. The documentation indicates you have numerous comorbidities including back pain with range of 
motion testing. The documentation states that you do normal activities of daily living around your house like 
dishes, laundry and walking at different cadence levels and the treating medical practitioner notes do not reveal 
a detailed neuromuscular evaluation supporting the need for a K3 prosthesis. Our physician reviewer found that 
your condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase 
control (L5828), addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), addition 
to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability 
(L5848), addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, 
swing and stance phase, includes electronic sensor(s), any type (L5856), addition to lower limb prosthesis, 
multiaxial ankle with swing phase active dorsiflexion feature (L5968) and all lower extremity prostheses, flex-
walk system or equal (L5981).