Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a replacement prosthetic (L5321, L5649, L5650, L5671, L5673, 
L5845, L5920, L5950, L8410, L8430, L8480) with a microprocessor knee (L5828, L5848, L5856) and flex-
walk system (L5981). We decided that the Plan does not have to pre-approve a test socket (L5624), acrylic 
socket (L5631) and flexible inner socket (L5651).  
 You asked the Plan to pre-approve a replacement prosthetic (L5321, L5649, L5650, L5671, L5673, L5845, 
L5920, L5950, L8410, L8430, L8480) with a microprocessor knee (L5828, L5848, L5856), flex-walk system 
(L5981), a test socket (L5624), acrylic socket (L5631) and flexible inner socket (L5651). You say that this is 
medically necessary. The Plan says that the records do not show that the enrollee's current prosthetic leg cannot 
be used. 
 
We decided that the Plan has to pre-approve a replacement prosthetic (L5321, L5649, L5650, L5671, 
L5673, L5845, L5920, L5950, L8410, L8430, L8480) with a microprocessor knee (L5828, L5848, L5856) 
and flex-walk system (L5981).  
 
The Plan follows Medicare rules. Medicare rules say that a lower limb prosthesis is covered when the 
beneficiary will reach or maintain a defined functional state within a reasonable period of time; and is 
motivated to ambulate. A fluid, pneumatic, or electronic/microprocessor knee (L5828, L5848, L5856) and flex-
walk system (L5981) are 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 a replacement prosthetic (L5321, 
L5649, L5650, L5671, L5673, L5845, L5920, L5950, L8410, L8430, L8480) with a microprocessor knee 
(L5828, L5848, L5856) and flex-walk system (L5981). Our reviewer says that the documentation provided 
does support the use of the requested transfemoral prosthesis with K3 components and a microprocessor knee.  
Our physician reviewer found the enrollee has a documented objective decrease in the size of her residual limb 
and her current prosthetic socket is no longer fitting appropriately despite modification and additional socks. It 
requires replacement. The prosthetic and clinical progress notes both indicate that the enrollee has the capacity 
to be a K3 level ambulator.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a replacement prosthetic (L5321, L5649, L5650, L5671, L5673, L5845, L5920, 
L5950, L8410, L8430, L8480) with a microprocessor knee (L5828, L5848, L5856) and flex-walk system 
(L5981) have been met. Therefore, we decided that the Plan has to pre-approve a replacement prosthetic 
(L5321, L5649, L5650, L5671, L5673, L5845, L5920, L5950, L8410, L8430, L8480) with a microprocessor 
knee (L5828, L5848, L5856) and flex-walk system (L5981).  
 
We also decided that the Plan does not have to pre-approve a test socket (L5624), acrylic socket (L5631) 
and flexible inner socket (L5651). 
 
The Plan follows Medicare rules. Medicare rules say that codes L5624, L5631 and L5651 will be denied as not 
reasonable and necessary 
 
We looked at the file and Medicare rules. The requested items are not considered reasonable and necessary 
under Medicare rules. Based on this information, we decided that Medicare rules for coverage of a test socket 
(L5624), acrylic socket (L5631) and flexible inner socket (L5651) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a test socket (L5624), acrylic socket (L5631) and flexible inner 
socket (L5651). 
 
 
 
 
 
 
 
 
 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.