Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the Nabtesco Symphony NK6 knee system. We decided that the 
Plan does not have to pre-approve the prosthesis and shank foot coded as L5590 and L5987.  
 
You asked the Plan to pre-approve the Nabtesco Symphony NK6 knee system. You say that these services are 
medically necessary and should be covered. The Plan says that there is a duplicate request for two prostheses 
which was made in error. In addition, L5987 cannot be used for the requested foot. You find that Nabtesco 
Symphony knee is also not coded correctly. 
 
We decided that the Plan has to-pre-approve the Nabtesco Symphony NK6 knee system.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
In this case, the Plan has decided that since there is no PDAC verification of the coding for the Nabtesco 
Symphony NK6 knee, it cannot be approved with the requested codes. However, no citations were provided to 
indicate that knee systems require PDAC verification in order to be covered. The medical necessity of the knee 
itself was not at issue. As such, we find that the question of how the requested knee should be coded is a matter 
for review after claim submission. The Plan must work with its network supplier to determine the proper 
coding for the requested item. Therefore, we decided that the Plan has to pre-approve the Nabtesco Symphony 
NK6 knee system.  
 
We also decided that the Plan does not have to pre-approve the prosthesis and shank foot coded as 
L5590 and L5987. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. The rules also specifically state that items coded as L5987 can only be covered when 
they have been reviewed and verified by the PDAC contractor.  
 
The file shows that the Plan has approved the prosthetic base unit under code L5321. There is no need for a 
second prosthetic base as the amputation is unilateral. This would be considered a back-up device not covered 
by Medicare.  
 
 
  The supplier has indicated that the requested foot is a Proteor Freedom Agilix foot system under code L5987. 
As there is a specific requirement that code L5987 only be used with devices approved by PDAC, and this type 
of foot has not been assigned L5987 after PDAC review, it cannot be used for the requested item. Therefore, 
we decided that the Plan does not have to pre-approve the prosthesis and shank foot coded as L5590 and 
L5987. 
 
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.