Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic sheath (L8410), socks (L8430, L8480), and shrinker (L8460); an ankle system addition with power assist (L5969); a microprocessor controlled ankle foot system (L5973); a microprocessor controlled knee (L5856) with a dampening feature (L5848), stance flexion (L5845) and fluid swing and stance phase control (L5828); a programmable endoskeletal knee-shin system (L5859); two socket inserts (L5673); a locking mechanism (L5671); an external frame (L5651); disarticulation sockets (L5650, L5649); test sockets (L5624); and a molded socket (L5321).

You asked the Plan to pre-approve a prosthetic sheath, socks, and shrinker; an ankle system addition with power assist; a microprocessor controlled ankle foot system); a microprocessor controlled knee with a dampening feature, stance flexion and fluid swing and stance phase control; a programmable endoskeletal knee-shin system; two socket inserts; a locking mechanism; an external frame; disarticulation sockets; test sockets; and a molded socket. You say that these items are medically necessary. The Plan denied your request. The Plan says the enrollee's functional status does not support these items.

The Plan follows Medicare rules. Medicare rules say that the requested prosthetic components are covered when medically necessary per the LCD criteria for beneficiaries whose functional level is 3 or above.

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 sheath, socks, and shrinker; an ankle system addition with power assist; a microprocessor controlled ankle foot system); a microprocessor controlled knee with a dampening feature, stance flexion and fluid swing and stance phase control; a programmable endoskeletal knee-shin system; two socket inserts; a locking mechanism; an external frame; disarticulation sockets; test sockets; and a molded socket. Our reviewer says that he documentation does not support that the patient's functional level is K3 or above; therefore, the requested items are not medically necessary Our physician reviewer found the documentation does not support that the patient can ambulate in the home with the current bilateral prosthesis or that she has vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.

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 sheath, socks, and shrinker; an ankle system addition with power assist; a microprocessor controlled ankle foot system); a microprocessor controlled knee with a dampening feature, stance flexion and fluid swing and stance phase control; a programmable endoskeletal knee-shin system; two socket inserts; a locking mechanism; an external frame; disarticulation sockets; test sockets; and a molded socket have not been met.

Therefore, we decided that the Plan does not have to pre-approve a prosthetic sheath (L8410), socks (L8430, L8480), and shrinker (L8460); an ankle system addition with power assist (L5969); a microprocessor controlled ankle foot system (L5973); a microprocessor controlled knee (L5856) with a dampening feature (L5848), stance flexion (L5845) and fluid swing and stance phase control (L5828); a programmable endoskeletal knee-shin system (L5859); two socket inserts (L5673); a locking mechanism (L5671); an external frame (L5651); disarticulation sockets (L5650, L5649); test sockets (L5624); and a molded socket (L5321).