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, with 
or without adjustability (L5848), an addition to lower extremity prosthesis, endoskeletal knee-shin system, 
microprocessor control feature, swing and stance phase (L5856) and an all lower extremity prostheses, flex-
walk system or equal (L5981). 
 
You asked the Plan to pre-approve prosthetics. You say that the enrollee is in need of a prosthetic called a 
micro-processor knee (electronic knee). The enrollee is 6 foot 5 inches and weighs about 260 LBS and has a 
size 16 foot and needs the most knee stability in order to walk and the microprocessor knee has a stance control 
to prevent buckling. The Plan denied your request. The Plan says the request for an initial prosthesis with MPK 
K3 functional level knee components and a K3 mechanical foot does not meet Medicare criteria as reasonable 
and necessary. 
 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 according to Medicare, additional features or components to a prosthesis may be necessary 
depending on the enrollees potential functional abilities. Potential functional ability is based on the reasonable 
expectations of the prosthetist, and treating practitioner, considering multiple factors. These factors include the 
enrollees past history, current condition including the status of the residual limb and the nature of the other 
medical problems and the enrollees desire to ambulate. 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. In this case, the documentation provided does not support that the 
enrollee is able to ambulate at a K3 level. The requested advanced foot and knee are not medically necessary. 
 
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, with or without adjustability 
(L5848), an addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control 
feature, swing and stance phase (L5856) and an all lower extremity prostheses, flex-walk system or equal 
(L5981).