Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Traumatic amputation at level between knee and ankle, right lower leg

Treatment: Healthcare Common Procedure Coding System (HCPCS) code L5781 (additional to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system)- modifier RT (right side)

The insurer denied coverage for Healthcare Common Procedure Coding System (HCPCS) code L5781 (additional to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system)- modifier RT (right side)

The denial is overturned

This case involves a patient with a history of a right below the knee amputation (BKA) during childhood.  He described the incident in Peru as a forklift injury at a young age when a vehicle backed onto his leg.  He does report he has been active with a below the knee prosthesis since his childhood without issue.  His current socket was greater than 10 years of age and was worn and torn.  Recently his socket was cracked beyond repair while riding a bicycle.  The foot and ankle unit was also worn and he had been utilizing a spare while his main unit was in disrepair.  He does exercise regularly with walking and biking.  He is a K3 (ability/ability to ambulate) ambulator and has the ability or potential for ambulation with variable cadence.  The physical examination revealed the patient was a modified independent ambulator using a right below the knee prosthesis.  The socket did fit poorly, and the plan was for a custom molded right below the knee socket with liners and appropriate suspension as well as a K3 foot and ankle unit that will need his activity demands for daily ambulation on uneven terrain allowing negotiation of all environmental barriers.

The patient has a history of right  BKA and is noted to be a K3 ambulator. According to the medical literature and guidelines, the request for custom molded right below the knee socket with liners and appropriate suspension as well as a K3 foot and ankle is appropriate and has been shown to improve health outcomes in this specific patient population, in addition to improving mobility, performance of ADLs, and overall quality of life.

The above request is a common and appropriate treatment option for R BKA and current K3 ambulator level. Therefore, the request does not require final approval from a regulatory body.

The patient is noted to be a K3 ambulator. According to the medical literature and guidelines, the request for custom molded right below the knee socket with liners and appropriate suspension as well as a K3 foot and ankle is appropriate for the patient's functional deficits. 

The patient has a history of R BKA and is noted to be a K3 ambulator. According to the medical literature and guidelines, the request for custom molded right below the knee socket with liners and appropriate suspension as well as a K3 foot and ankle is appropriate for their functional deficits and K3 ambulator level.

According to the medical literature and guidelines, the request for custom molded right below the knee socket with liners and appropriate suspension as well as a K3 foot and ankle is a common and appropriate treatment option for the claimant's R BKA and current K3 ambulator level. Based on the patient's functional ambulatory level, the request will improve health outcomes, in addition to improving mobility, performance of activities of daily living (ADL), and overall quality of life. The risks are not increased and the requested item is likely to be more beneficial than any other standard item.

The insurer's denial of coverage for Healthcare Common Procedure Coding System (HCPCS) code L5781 (additional to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system)- modifier RT (right side) is overturned.