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 overturned.

The patient is a male. He underwent Right Transfemoral Amputation.
Consult Notes noted the patient was seen following amputation. He was noted to be
in good spirits. The right residual limb was wrapped with an ace bandage. Follow up
next week to ensure he is comfortable and on the right track for his prosthesis.
Consult Notes noted the patient was seen for an initial pre-amputation consultation.
He is a young male with a right paralysis and flexion contracture at the knee. He
presents with a rolling walker, extreme discomfort and pain in his right limb, and the
inability to stretch it out. He has been to several surgeons, and the recommendation
has been amputation above the knee. He is obviously not happy with the decision,
however he has come to the realization that his quality of life is so poor that this will
enable him to return to a semi-functional lifestyle. He will be having surgery in two
weeks. Will follow up post-surgery to ensure he is directed in the right place for
rehabilitation. Hoping to get him in to the best rehabilitation center in the immediate
area. He will be an excellent candidate for a prosthesis.

Prosthetics and Orthotics Consultation Note noted that the patient was seen at the
bedside and just underwent removal of his staples today in the right transfemoral
stump. He had an amputation. He reports he continues to have some neuropathic
pain, phantom pain. He took off the shrinker today. His residual limb shrunk down.
On exam, he is in bed, he has Steristrips in place in the distal right transfemoral
stump. He has 1+ edema. He has some mild hypersensitivity in the medial stump.
The distal stump measures 19 inches in circumference distally. It is down from 20.5
inches last week. He was assessed with right transforaminal amputation, in the
setting of right knee and ankle flexion contractures, post-traumatic stress disorder
and bipolar disorder. A gel liner will be acquired. This will also help with shaping of
the residual limb. Will follow up with the patient following discharge. He is an
excellent candidate to get the prosthesis coming along shortly. He will be very high level.

Prosthetics and Orthotics Consultation Note noted that the patient was seen in an
outpatient clinic as it relates to his right transfemoral amputation. He had been
discharged to home. He reports overall he is doing well. He reports that prior to
when he initially developed painful spasm and was later diagnosed with complex
regional pain syndrome, he was active playing baseball, basketball and football. He
was dispensed a gel liner a couple days ago. His swelling has come down. He is
wearing the stump shrinker. He reports he was diagnosed with ADHD (attention
deficit hyperactivity disorder), bipolar, anxiety and depression
and PTSD (post-traumatic stress disorder) as an adolescent following witnessing of a fatal stabbing. He is holding off on outpatient PT (physical therapy) until he gets his
prosthetics, as he is pretty functional using a walker as he had used a walker prior
to the amputation. He reports his father is his conservator, and he did not have his
complete list of medications with him. He reports he is looking for another treatment
provider to prescribe the Suboxone. He reports his doctor will no longer prescribe it.
He remains on Lyrica 300mg (milligrams) 2x daily for the neuropathic pain. He
reports the oxcarbazepine and Lexapro as well as Seroquel are all prescribed by
his psychiatric provider. He no longer takes melatonin. He reports he is sleeping
well.

The C-Leg 4 provides enhanced stumble recovery. This feature is essential for
keeping the patient and his colleagues and customers safe. It also has
programmable stance resistance, which is critical for providing support for sitting,
kneeling, and would allow for the ability to have hands-free descent from standing
transferring into a chair or into a kneeling position. During his work duties he will likely need to take steps backward and/or back up. The C-Leg will not buckle while
backing up. While working in tight spaces, such as when working as a waiter,
walking backward can be part of the job.

Yes, the requested therapy likely to be more beneficial for the enrollee than any
available standard therapy.
The patient has had right paralysis and flexion contracture at the knee. He was
having an extreme discomfort and pain in his right limb and the inability to stretch it
out. He had an amputation. He reported he continued to have some neuropathic
pain and phantom pain. His residual limb shrunk down. On exam, he has 1+
edema. He has some mild hypersensitivity in the medial stump. The distal stump
measures 19 inches in circumference distally. It is down from 20.5 inches. A C-Leg
microprocessor knee was recommended and ordered

The patient requires a prosthetic foot that will allow him to navigate environmental
barriers, allow him to change pace, walk backward as well as climb stairs, all while
minimizing energy expenditure. The Ottobock Taleo Vertical Shock Foot was
prescribed, which relieves residual limb pressure and enhances comfort. It helps
support the natural way legs rotate as they function and reduces stress and strain
on the residual limb due to torsion.

Given the patient's extremely high activity level and neuropathic pain associated
with complex regional pain syndrome, torsion and vertical shock features will help
reduce discomfort in the residual limb. It is more beneficial as studies have shown
that C-Legs have provided additional health benefits and are likely to be effective in
transfemoral amputee compared with NMPKs (non-microprocessor-controlled
prosthetic knees). It has provided meaningful improvements in gait performance,
safety, and participant-reported measures.

Yes, the health plan should cover the proposed treatment.
The patient has had right paralysis and flexion contracture at the knee. He was
having an extreme discomfort and pain in his right limb and the inability to stretch it
out. He will be an excellent candidate for a prosthesis. He had an amputation. He
reported he continued to have some neuropathic pain and phantom pain. His
residual limb shrunk down. On exam, he has 1+ edema. He has some mild
hypersensitivity in the medial stump. The distal stump measures 19 inches in
circumference distally. It is down from 20.5 inches last week. He reported he was
sleeping well. A C-Leg microprocessor knee was recommended and ordered.