Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal system, above knee or hip 
disarticulation, alignable system (L5920), an addition, endoskeletal knee-shin system, single axis, friction 
swing and stance phase control (L5812), an addition, endoskeletal, knee-shin system, stance flexion feature 
(L5845), an all-lower extremity prosthesis, foot, flexible keel (L5972), an all lower extremity prostheses, multi-
axial rotation unit (L5986) and an addition, endoskeletal system, above knee or hip disarticulation, knee 
extension assist (L5850). 
 
You asked the Plan to pre-approve prosthetics. You say that the request for replacement of L AKA px- 
definitive px for residual limb volume changes and appears to meet criteria for socket replacement. This 
request also includes K2 component replacements for higher function that are only 6 months old-may not meet 
criteria at this time. Taking into consideration that the enrollee has been a completely independent high level 
K3 ambulator, as a BK amputee, before his revision. The definitive components, along with a properly fitting 
socket, will not only facilitate him becoming a K3 ambulator again, but will also provide additional safety 
during this phase of his rehab. The Plan denied your request. The Plan says the alignable system is not 
reasonable and necessary for the approved prosthesis. Medicare does not cover replacements for an item under 
manufacturer's warranty. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Medicare allows for replacement of a prosthesis or prosthetic component if there is a change in 
the physiological condition of the enrollee, there is irreparable wear of the device or a part of the device or if 
the condition of the device, or part of the device, requires repairs and the cost of such repairs would be more 
than 60% of the cost of a replacement device, or the part being replaced. In this case, the health plan has 
authorized a replacement prosthesis, but the documentation does not support the need for a replacement 
alignable system or an upgraded knee or foot. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition, endoskeletal system, above knee or hip disarticulation, alignable system 
(L5920), an addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control 
(L5812), an addition, endoskeletal, knee-shin system, stance flexion feature (L5845), an all-lower extremity 
prosthesis, foot, flexible keel (L5972), an all lower extremity prostheses, multi-axial rotation unit (L5986) and 
an addition, endoskeletal system, above knee or hip disarticulation, knee extension assist (L5850).