Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal knee-shin system, single axis, fluid 
swing and stance phase control (L5828), an endoskeletal, knee-shin system, stance flexion feature, (L5845), an 
addition to endoskeletal knee-shin system, fluid stance extension, dampening feature (L5848), an endoskeletal 
knee-shin system, microprocessor control feature (L5856), an endoskeletal system, above knee, knee 
disarticulation or hip disarticulation (L5925), an All lower extremity prostheses, flex-walk system (L5981), a 
multi-axial rotation unit (L5986), a lower extremity prosthesis, not otherwise specified (L5999) and an 
endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit (K1022). 
 
 
 You asked the Plan to pre-approve leg, foot and knee prosthetics. You say that all codes should be approved, 
and an addendum has been attached for an overturn on the decision. The Plan denied your request. The Plan 
says the documentation does not support the need for a microprocessor knee instead of a mechanical knee 
based on documented activity needs and need for stability when ambulating. The enrollee's activity needs can 
be met with a mechanical knee. The enrollee is not functioning at a K3 level and the foot with ankle can be met 
with lower functional level components. HiFi socket system is included in the base code for an above knee 
prosthesis. 
 
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 leg, foot and knee prosthetics. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee's activities and functional needs can safely and effectively be 
met with a mechanical knee. The documentation does not support the need for a K3 microprocessor knee. The 
enrollee uses an assistive device for ambulation. The enrollee has not had a change in activities that would 
require a microprocessor knee at this time. The enrollee does not require a K3 level foot and ankle (L5981 and 
L5968) for his activity levels. His activities can be met with a lower-level ankle and foot. The physician 
document also does not reveal a detailed gait analysis including observing gait in swing and stance. His knee 
stability can safely and effectively be met with a mechanical knee. His hobbies and activity level does not 
require a K3 level foot or microprocessor knee. The lower extremity prosthesis and the positional rotation unit 
are not medically necessary as the physician documentation does not support the need for these items. The 
enrollee was approved for a socket and the request for separate items are already included in this socket and 
these items would be duplicates and exceed the enrollee's medical need. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of leg, foot and knee prosthetics have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an endoskeletal knee-shin system, single axis, fluid swing and stance phase 
control (L5828), an endoskeletal, knee-shin system, stance flexion feature, (L5845), an addition to endoskeletal 
knee-shin system, fluid stance extension, dampening feature (L5848), an endoskeletal knee-shin system, 
microprocessor control feature (L5856), an endoskeletal system, above knee, knee disarticulation or hip 
disarticulation (L5925), an All lower extremity prostheses, flex-walk system (L5981), a multi-axial rotation 
unit (L5986), a lower extremity prosthesis, not otherwise specified (L5999) and an endoskeletal, knee 
disarticulation, above knee, hip disarticulation, positional rotation unit (K1022).