Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (L5828), an addition, endoskeletal knee-shin system, stance flexion 
feature (L5845), an addition to endoskeletal knee-shin system, fluid stance extension, dampening feature 
(L5848), an addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control 
feature, swing and stance phase, includes electronic sensor(s) (L5856), an addition to lower limb prosthesis, 
multiaxial ankle with swing phase active dorsiflexion feature (L5968), an all lower extremity prostheses, flex-
walk system or equal (L5981), an addition to lower limb prosthesis, vertical shock reducing pylon feature 
(L5988) and an addition, endoskeletal system, below knee (BK), alignable system (L5910). 
 
You asked the Plan to pre-approve prosthetics. You say that the requested prosthetics are medically necessary. 
The Plan denied your request. The Plan says the requested prosthetics do not meet criteria.  
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 there is no documentation that additional prosthetic features/accessories at issue in this case 
meet Medicare criteria. An addition, endoskeletal system, below knee (BK), alignable system is a below the 
knee system, records indicate the enrollee has an above the knee amputation. Provided records do not 
document a medical need for the remaining requests (a new K3 level knee and foot). Records indicate the 
enrollee was provided a K3 foot and knee in 2018 and no indication is provided in the records that these items 
have been lost, stolen or irreparably damaged. 
 
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 knee-shin system, single axis, fluid swing and stance phase 
control (L5828), an addition, endoskeletal knee-shin system, stance flexion feature (L5845), an addition to 
endoskeletal knee-shin system, fluid stance extension, dampening feature (L5848), an addition to lower 
extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, 
includes electronic sensor(s) (L5856), an addition to lower limb prosthesis, multiaxial ankle with swing phase 
active dorsiflexion feature (L5968), an all lower extremity prostheses, flex-walk system or equal (L5981), an 
addition to lower limb prosthesis, vertical shock reducing pylon feature (L5988) and an addition, endoskeletal 
system, below knee (BK), alignable system (L5910).