Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an addition to lower extremity, above knee or knee disarticulation, 
silesian bandage (L5698), an addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase 
control (L5828), an addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), an 
addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without 
adjustability (L5848), an addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor 
control feature, swing and stance phase (L5856) and an endoskeletal ankle foot system, microprocessor 
controlled feature, dorsiflexion and/or plantar flexion control, includes power source (L5973). 
 
You asked the Plan to pre-approve a prosthetic leg. You say that the enrollee was referred for evaluation of his 
current right transfemoral prosthesis, ambulating independently using temporary crutches due to 
discomfort/instability. The enrollees current prosthesis was provided 6 years ago by another provider. He 
expresses dissatisfaction with the fit and functionality of the prosthesis. He has lost 10 pounds over the past 
year resulting in a poorly fitting socket and continued discomfort from the callosity on the distal end of his 
residual limb necessitating use of crutches to offload the residual limb in his socket. He also reported multiple 
falls and one instance of a visit to the emergency room for treatment following fall. The Plan denied your 
request. The Plan says that the request of two suspension systems for a single prosthesis is a duplicate service 
that exceeds the enrollee's functional need and does not meet the criteria of reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 a prosthetic leg. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is currently not a K3 ambulator secondary to wound on residual leg. The enrollee 
has a 5-degree contracture of the hip. He has a history of falls. The enrollee is a K3 ambulator per cumulative 
evidence in the record. His contracture is consistent with function; does not inhibit function. The request is a 
replacement of a microprocessor knee plus ankle. The request is consistent with the enrollee's functional 
capacity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a prosthetic leg have been met. Therefore, we decided that the Plan has to pre-
approve an addition to lower extremity, above knee or knee disarticulation, silesian bandage (L5698), an 
addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828), an addition, 
endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), an addition to endoskeletal knee-
shin system, fluid stance extension, dampening feature, with or without adjustability (L5848), an addition to 
lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance 
phase (L5856) and an endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or 
plantar flexion control, includes power source (L5973).  
 
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.