Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve addition, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (CPT code L5828), addition, endoskeletal, knee-shin system, stance 
flexion feature, adjustable (CPT code L5845), addition to endoskeletal knee-shin system, fluid stance 
extension, dampening feature, with or without adjustability  (CPT code L5848), addition to lower extremity 
prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes 
electronic sensor(s), any type (CPT code L5856), all lower extremity prostheses, flex-walk system or equal 
(CPT code L5981), for the enrollee. 
 
You asked the Plan to pre-approve the prosthetic. You say that the items are necessary. The Plan denied your 
request. The Plan says the records they have do not show why the requested computerized prosthetic knee and 
advanced foot are needed. The Plan states there are other prosthetic knees and feet that can meet the enrollee's 
needs and that is why the requested prosthetic parts are still denied. 
 
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 the prosthetic. Our physician reviewer 
found the review indicates that the enrollee with right transfemoral amputation from July 19, 2016. Uses a 
walker mostly around the house. The enrollee notes their prosthesis is heavy, rotates when they are walking. Knee 
buckles unexpectedly when walking and the socket brim cuts into their groin. The enrollee reports pain and 
pressure points in the socket when walking. Current prosthesis is from 2017 and is not fitting well. Rush 81 
foot, size 26, category 3, Tight in size 9 shoes. 1-1.5 inch above the end of the socket, ischial containment 
system with lanyard. Comorbidities include: Obesity BMI 31.15. The enrollee is stated to be K3 Ambulator, 
yet uses wheelchair at home. Prosthetic when going out, shopping. Uses walker within home and independent 
with self-care. The reviewed documentation does not support the need for microprocessor knee instead of 
mechanical knee based on documented activity needs and need for stability when ambulating. Enrollee's 
activity needs can be met with mechanical knee. Enrollee uses assistive devices: wheelchair and walker. 
Documentation from enrollee's physician do not show why mechanical knee will not meet enrollee's needs. 
The enrollee states that they do not use current mechanical knee at home, as it is too bulky. Microprocessor 
knee has greater weight than mechanical knee, so request for mechanical knee is not consistent with desire to 
use prosthesis more consistently. Further, the enrollee requires use of walker and wheelchair, which is not 
consistent with K3 ambulation. Notes do not support the need for microprocessor knee instead of mechanical 
knee based on documented activity needs. The enrollee's activity needs can be met with mechanical knee, 
especially given that this is enrollee's initial prosthesis. Documentation submitted does not support medical 
need for K3 prosthesis with microprocessor knee and K3 foot, given need for walker and wheelchair, even at 
home, despite having been an amputee since 2016. The review has determined that the medical records 
provided do not meet the requirements listed in the LCD/LCA for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the prosthetic have not been met. Therefore, we decided that the Plan does not 
have to pre-approve addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control 
(CPT code L5828), addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (CPT code 
L5845), addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without 
adjustability  (CPT code L5848), addition to lower extremity prosthesis, endoskeletal knee-shin system, 
microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (CPT code 
L5856), all lower extremity prostheses, flex-walk system or equal (CPT code L5981), for the enrollee.