Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the flex walk system (L5981) and vertical shock reducing pylon feature (L5988).

You asked the Plan to provide coverage for this prosthetic equipment. You say that this prosthetic equipment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for the flex walk system (L5981) and vertical shock reducing pylon feature (L5988). The Maximus Physician Reviewer determined that the items are medically necessary. The Plan requested a reopen and argues that you have been a below the knee amputee since 2004 and has been and is currently using a K2 foot since 2005. There was a request for a replacement of the foot in 2019 which was denied as you were not a K3 ambulator. Your primary care physician agreed that you were "more aligned as a K2 ambulator that a K3 ambulator." The Plan further notes that you have a body mass index of 34.5, underlying cardiac history, and a partial amputation of the contralateral foot which is not consistent with a K3 ambulator.
The medical records show you are a 67-year-old man with multiple medical problems, including coronary artery disease with a history of heart disease, diabetes, hypertension, hyperlipidemia, obesity, and right great toe amputation. You underwent a left below the knee amputation in 2004 due to gangrene. The provider note dated March 14, 2022 documents that you are using a left leg prosthesis that it is too heavy for you causing back pain. You were referred for a new prosthesis evaluation. The note by the certified prosthetist and orthotist/licensed prosthetist-orthotist, who is the president of the orthotics & prosthetics service company, states that the enrollee "walks in using a cane today." It is noted that the enrollee takes care of a household, does all the shopping, does yardwork on uneven ground, and frequently goes for walks.   

Our Medical Director has concluded that the plan is correct in this case. The documentation in the case file is most supportive of you being a K2 ambulator, with the ability or potential for ambulation on low level environmental barriers such as curbs, stairs, or uneven surfaces. This is typical of the limited community ambulator. The flex- walk system is only covered for enrollees whose functional level is 3 or above.
Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of foot. This information must be retained in the treating practitioner's or prosthetist's files. Bases on the records provided, these criteria are not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this request have not been met. Therefore, we decided that the Plan does not have to provide coverage for the flex walk system (L5981) and vertical shock reducing pylon feature (L5988).