Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with advanced knee/foot features 
(L5828, L5845, L5848, L5856, L5981). 
 
You asked the Plan to pre-approve a prosthetic leg with advanced knee/foot features. You say that the enrollee 
requires replacement above knee prostheses due to irreparable damage, wear and tear, and anatomical change 
of the residuum (reduction in limb volume and shape change). His current sockets were fabricated over 6 years 
ago and the enrollee has lost 15Ibs, causing him to fall deep into the sockets due to inadequate suspension. His 
current microprocessor knees are malfunctioning, as the hydraulics are no longer functional, and his current 
feet are delaminating. The Plan denied your request. The Plan says a prosthesis that meets, but does not exceed, 
the enrollee's need can be provided. The requested prosthesis exceeds the enrollee's needs. 
 
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 a prosthetic leg with advanced 
knee/foot features. 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 current prostheses are over 6 years old, 
and the sockets are no longer fitting appropriately due to residual limb volume loss. The prosthetic components 
are also in disrepair and require replacement. The notes indicated that the enrollee was approved for a group 3 
power wheelchair with power tilt and recline 8/10/2022. He uses his power wheelchair for mobility 70% of the 
time. The letter of appeal from the prosthetist states that the enrollee has the capacity to be a K3 level 
ambulator. The documentation provided does not support the use of the replacement prostheses with 
microprocessor knees and advanced K3 feet. There is insufficient documentation regarding the enrollee's 
potential K level and current level of mobility and function. There is no documentation regarding the objective 
measurement of the enrollee's level of mobility. He is noted to currently use a group 3 power wheelchair with 
power tilt and recline, which would not support the patient being a K3 ambulator. He may require replacement 
prosthetic sockets and components, but there is insufficient objective documentation indicating that he requires 
microprocessor knees and K3 prosthetic feet given his use of a power wheelchair for mobility. Therefore, the 
replacement prostheses with microprocessor knees and advanced K3 feet 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 a prosthetic leg with advanced knee/foot features have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a prosthetic leg with advanced knee/foot features 
(L5828, L5845, L5848, L5856, L5981).