Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve all lower extremity prostheses, flex-walk system or 
equal identified with code L5981 and addition to lower limb prosthesis, multiaxial ankle with swing phase 
active dorsiflexion feature identified with code L5968. 
 
You asked the Plan to pre-approve all lower extremity prostheses, flex-walk system or equal identified with 
code L5981 and addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion 
feature identified with code L5968. You say that you would like the plan to reconsider their denial. The Plan 
denied your request. The Plan says the requested items are not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that prosthetics and prosthetic accessories are only 
covered for certain indications. 
 
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 all lower extremity prostheses, flex-
walk system or equal identified with code L5981 and addition to lower limb prosthesis, multiaxial ankle with 
swing phase active dorsiflexion feature identified with code L5968. Our reviewer says that the documentation 
does not support that the requested items are medically reasonable or necessary. Our physician reviewer found 
you have a medical history of a right transtibial amputation. A clinical progress note dated March 21, 2022 
indicated that you are a K3 level ambulator but ambulate with a walker due to chronic back pain that 
necessitated the implantation of a spinal cord simulator. You currently require a new prosthetic foot and ankle. 
A prosthetic clinical summary dated April 19, 2022 indicated that the enrollee's K3 odyssey foot requires 
replacement given that the hydraulic unit is broken and cannot be repaired. The evaluation indicates that you 
can walk with variable cadence and uneven terrain. Per the policy, coverage is extended only if there is 
sufficient clinical documentation of functional need for the technologic or design feature of a given type of 
foot. There is insufficient clinical documentation indicating that you require a multi axial ankle with swing 
phase active dorsiflexion control such as the Echelon ER and why a less sophisticated prosthetic foot and ankle 
would not suffice for mobility needs. Therefore, you do not meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of all lower extremity prostheses, flex-walk system or equal identified with code 
L5981 and addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature 
identified with code L5968 have not been met. Therefore, we decided that the Plan does not have to pre-
approve all lower extremity prostheses, flex-walk system or equal identified with code L5981 and addition to 
lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature identified with code 
L5968.