Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 microprocessor knee (L5828, L5845, L5848, 
L5850, L5856) and vertical shock reducing pylon (L5988). 
 
You asked the Plan to pre-approve the prosthetic equipment requested. You say that this equipment is 
medically necessary. The Plan denied your request. The Plan says medical necessity criteria have not been 
satisfied for the K3 microprocessor knee and vertical shock reducing pylon. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that a fluid, pneumatic, or electronic/microprocessor knee is 
covered for beneficiaries whose functional level is 3 or above.  
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 equipment requested. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the member is a 63-year-old male with a medical history including 
peripheral vascular disease with a previous right-sided above the knee amputation and a left-sided below the 
knee amputation who is requesting replacement parts for his prosthesis. The documentation indicates he 
intermittently uses a walker to assist him with mobility and has had dyspnea on exertion. A level 3 ambulator 
has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has 
the ability to traverse most environmental barriers and may have vocational, therapeutic or exercise activity 
that demands prosthetic utilization beyond simple locomotion. Medicare allows for replacement of a prosthesis 
or prosthetic component if there is a change in the physiological condition of the beneficiary, 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 replacement of the ill-fitting or broken 
prostheses. However, the documentation does not support that the member is a K3 level ambulator. The 
requested microprocessor knee is not medically necessary. 
 
Furthermore, it has not been sufficiently demonstrated that a vertical shock-reducing pylon is required for the 
enrollees activity level. In addition, there is insufficient evidence in the medical literature to support that a 
vertical shock-reducing pylon is effective in meaningfully attenuating transient impact forces to the lower limb 
of amputees upon loading. 
 
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 equipment requested have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a K3 microprocessor knee (L5828, L5845, L5848, L5850, L5856) 
and vertical shock reducing pylon (L5988).