Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1The patient is a 19-year-old male who had a right hip disarticulation, which makes for a difficult gait that requires high-energy demand. The patient reports he is limited in activities of daily living with his current prosthesis. The patient has requested authorization and coverage for an Otto Bock C-leg to allow the patient to function at a higher level of activity. The Health Plan has denied the request on the basis that the requested equipment is considered investigational.Unfortunately, the patients gait will always be impacted and walking will take a great deal of energy due to the high level of amputation. The efficacy and safety of the Otto Bock C-leg remains unproven. The reliability of this prosthesis must be further investigated with regard to slippage of electrodes, etc. Furthermore, no medical documentation has been provided, which demonstrates that the patient will be better able to lift the Otto Bock C-leg or to climb stairs any better than with his current prosthesis. Therefore, I have determined that the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard equipment. The Health Plans denial should be upheld.Physician 2The patient is a 19-year-old male athlete of high-level status post bone cancer treatment and surgery. The patient is also status post hip disarticulation. He is currently not at an optimal or desired level of functioning. A request has been made for authorization and coverage for an Otto Bock C-leg prosthesis. The Health Plan has denied the request on the basis that the requested equipment is considered investigational.Review of the medical literature indicates there is growing support for the Otto Bock C-leg prosthesis. In addition, anecdotal data and experiences suggest the patient is likely to benefit from this technology. Given the patients age and pre-surgical level of function including superior balance, strength, dexterity, and coordination, he is an excellent candidate for the Otto Bock C-leg. Furthermore, the patients stability and level of function is likely to be superior with the Otto Bock C-leg than with a standard prosthesis. Therefore, I have determined that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard equipment. The Health Plans denial should be overturned.Physician 3The patient is a 19-year-old status post amputation for cancer. He is doing well post osteosarcoma treatment. He was a highly active young man prior to the amputation and wishes to remain active in sports and life. He has requested authorization and coverage for an Otto Bock C-leg. The Health Plan has denied the request on the basis that the requested equipment is considered investigational.The patient is an excellent candidate for an Otto Bock C-leg. In fact, he represents the ideal candidate for this prosthetic product. There is no other prosthesis that is likely to be as safe and effective for this highly active patient. The requested equipment will allow the patient to achieve maximum stability while maintaining function at a high level of activity. Therefore, I have determined that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard equipment. As such, the Health Plans denial should be overturned.