Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve addition, endoskeletal, knee-shin system, stance flexion feature, 
adjustable (L5845) and addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion 
feature (L5968). 
 
You asked the Plan to pre-approve the prosthesis components. You say that the L5845 code is a knee feature 
that is medically necessary and the L5968 code is a hydraulic multiaxial ankle feature that is medically 
necessary. The Plan denied your request. The Plan says that a replacement/new prosthesis/components with 
mechanical knee and ankle - foot components does not meet Medicare criteria as reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 prosthesis components. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has a medical history of peripheral artery disease. A prosthetic note 
dated November 16, 2022, indicated that the enrollee underwent right sided transfemoral amputation on 
October 12, 2022. The enrollee is noted to be a K2 level ambulator and able to walk 100 feet in the parallel 
bars or with a walker and no prosthesis. Strength and range of motion was noted to be within normal limits 
except for below the left transfemoral amputation. 
 
The enrollee requires a transfemoral prosthesis for mobility and accomplishing daily activities. The enrollee is 
noted to have the ability to be a K2 level ambulator with a prosthesis. The stance flexion feature (L5845) for the prosthetic knee is required to stabilize the knee during ambulation is not integral to the prosthetic knee 
joint. Likewise, the hydraulic multiaxial ankle feature (L5968) is required for stabilization of the enrollees 
prosthetic foot/ankle during ambulation. They are appropriate and necessary for the enrollees condition and 
transfemoral prosthesis. Therefore, the stance flexion feature (L5845) for the prosthetic knee and hydraulic 
multiaxial ankle feature (L5968) are 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 the prosthesis components have been met. Therefore, we decided that the Plan 
has to pre-approve addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) and 
addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.