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, above knee (AK) or knee disarticulation, acrylic socket, endoskeletal knee-shin 
system, fluid stance extension, dampening feature, with or without adjustability, flex-walk system or equal, 
multiaxial rotation unit, stance flexion feature, and endoskeletal knee-shin system, microprocessor control 
feature, swing and stance phase, includes electronic sensor(s). 
 
You asked the Plan to pre-approve an endoskeletal knee-shin system, single axis, fluid swing and stance phase 
control, above knee (AK) or knee disarticulation, acrylic socket, endoskeletal knee-shin system, fluid stance 
extension, dampening feature, with or without adjustability, flex-walk system or equal, multiaxial rotation unit, 
stance flexion feature, and endoskeletal knee-shin system, microprocessor control feature, swing and stance 
phase, includes electronic sensor(s). You say that the services are necessary. The Plan denied your request. The 
Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific 
criteria are met. 
 
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 an endoskeletal knee-shin system, 
single axis, fluid swing and stance phase control, above knee (AK) or knee disarticulation, acrylic socket, 
endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability, flex-
walk system or equal, multiaxial rotation unit, stance flexion feature, and endoskeletal knee-shin system, 
microprocessor control feature, swing and stance phase, includes electronic sensor(s). Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have been a K2 ambulator and uses 
an assistive device which is not consistent with a K3 level of ambulation. The requested items exceed your 
medical need. The physician documentation does not support that you require a microprocessor knee over a 
mechanical knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an endoskeletal knee-shin system, single axis, fluid swing and stance phase 
control, above knee (AK) or knee disarticulation, acrylic socket, endoskeletal knee-shin system, fluid stance 
extension, dampening feature, with or without adjustability, flex-walk system or equal, multiaxial rotation unit, 
stance flexion feature, and endoskeletal knee-shin system, microprocessor control feature, swing and stance 
phase, includes electronic sensor(s) 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, above knee 
(AK) or knee disarticulation, acrylic socket, endoskeletal knee-shin system, fluid stance extension, dampening 
feature, with or without adjustability, flex-walk system or equal, multiaxial rotation unit, stance flexion feature, and endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic 
sensor(s).