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

Physician 1: The patient is a 24-year-old female who is status post right trans-femoral amputation following a motor vehicle accident in 2001. Her physician states the patient has used a wheelchair since the accident due to the fact that her limb is too short for a prosthesis. Her physician also indicates the patient underwent revision of the residual limb in October 2004 and has recovered well enough to allow her to use a prosthesis. The patients physician has recommended the patient receive an Otto-Bock C-leg prosthesis.There are no case-controlled, randomized studies demonstrating the superiority or improved functional outcomes of the Otto-Bock C-leg prosthesis compared to standard prosthetics. There are small studies, which indicate the Otto-Bock prosthesis may have decreased energy expenditure at certain walking speeds, but a standard prosthesis is not significantly different at customary walking speeds. Furthermore, the longevity/safety of the device with long-term use is not known. The Otto-Bock prosthesis relies on electrodes, which may move, affecting function. The knee has to be programmed periodically. Some preliminary indications suggest the lifespan of this device may be only two to five years. Furthermore, it is not clear this patient can use the requested prosthesis, as it is noted she had a short trans-formal amputation in 2001.Based upon the information set forth above, I have determined that the requested prosthesis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheldPhysician 2:The patient is a 24-year-old female who has been non-ambulatory since a proximal trans-femoral amputation due to an accident in 2001. She has not used a prosthesis and her functional level is not described. The patient has requested authorization and coverage for an Otto-Bock C-Leg prosthesis. The Health Plan has denied this request indicating the efficacy of the requested prosthesis has not been established.The efficacy of the Otto-Bock C-Leg remains unproven at this time. Most studies are either descriptive studies, opinion studies or performed with very small populations. In any case, the patient is not yet a prosthetic user and has not been trained with any prosthetics. The patient does not meet medical criteria for prescription of this device. Therefore, I have determined that the requested prosthesis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 24-year-old female who is status post right trans-femoral amputation following a motor vehicle accident in 2001. Her limb was originally too short to accommodate a prosthesis and the patient underwent revisional surgery in October 2004. The patients provider indicates the patient is now able to use a prosthesis. She is requesting the Otto-Bock C-Leg prosthesis. The Health Plan has denied this request stating the efficacy of the requested prosthesis is not proven in peer-reviewed literature.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 this patients age and expected functional status, the Otto-Bock C-Leg prosthesis is medically appropriate and likely to be more beneficial than standard prosthetic devices or having this patient remain wheelchair dependent. Therefore, I have determined that the requested prosthesis is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.