Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve custom shaped protective cover (L5704). We decided that the 
Plan does not have to pre-approve below knee flexible cover system (L5962).  
 
You asked the Plan to pre-approve procedure codes L5962, and L5704. You say that a lightweight prosthesis is 
medically necessary for the enrollee to participate in physical therapy and rehabilitation. You say that the 
enrollee needs this in order to ambulate, regain strength, improve balance, functional independence and prevent 
future falls. The Plan says that the requested protective covers are not medically necessary. 
 
We decided that the Plan has to pre-approve custom shaped protective cover (L5704).  
 
The Plan follows Medicare rules. Medicare rules say that lower limb prosthetic covers (L5704, L5705, L5706, 
and L5707) are complete products and afford shape, protection and waterproofing for normal daily usage of the 
prosthesis. They offer sufficient protection and weatherproofing for beneficiaries who require lower limb 
prosthetics. 
 
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 custom shaped protective cover. Our 
reviewer says that the requested below knee flexible cover system is not medically necessary. Our physician 
reviewer found the provided documentation indicates that the custom shaped protective cover L5704 is 
sufficient as protection of the prosthesis for normal daily use is reasonable and necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of custom shaped protective cover have been met. Therefore, we decided that the 
Plan has to pre-approve custom shaped protective cover (L5704).  
 
We also decided that the Plan does not have to pre-approve below knee flexible cover system (L5962). 
 
The Plan follows Medicare rules. Medicare rules say that protective outer surface covering systems (L5962, 
L5964, and L5966) are used by a beneficiary who has special needs for protection against unusually harsh 
environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of 
protection that is afforded by L5704, L5705, L5706, and L5707. 
 
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 below knee flexible cover system. Our 
reviewer says that the requested below knee flexible cover system is not medically necessary. Our physician 
reviewer found the provided medical records do not document that the enrollee will be exposed to such an 
unusually harsh and difficult environment that the standard prosthetic cover would be inadequate for the 
enrollee's needs. Therefore, the reviewer found that the requested below knee flexible cover system is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of below knee flexible cover system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve below knee flexible cover system (L5962). 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.