Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a total contact knee disarticulation socket (L5650), a knee-shin 
system, stance flexion feature (L5845), a knee-shin system, single axis, friction swing and stance phase control 
(L5812), and a above knee or hip disarticulation, knee extension assist (L5850). 
 
You asked the Plan to pre-approve a total contact knee disarticulation socket (L5650), a knee-shin system, 
stance flexion feature (L5845), a knee-shin system, single axis, friction swing and stance phase control 
(L5812), and a above knee or hip disarticulation, knee extension assist (L5850). You say that the requested 
total contact knee disarticulation socket (L5650), the knee-shin system, stance flexion feature (L5845), the 
knee-shin system, single axis, friction swing and stance phase control (L5812), and the above knee or hip 
disarticulation, knee extension assist (L5850) are medically necessary. The Plan denied your request. The Plan 
says that they were unable to make a determination within the allotted time frame. 
 
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 a total contact knee disarticulation 
socket (L5650), a knee-shin system, stance flexion feature (L5845), a knee-shin system, single axis, friction 
swing and stance phase control (L5812), and a above knee or hip disarticulation, knee extension assist (L5850). 
Our reviewer says that the requested total contact knee disarticulation socket (L5650), the knee-shin system, 
stance flexion feature (L5845), the knee-shin system, single axis, friction swing and stance phase control 
(L5812), and the above knee or hip disarticulation, knee extension assist (L5850) are medically necessary. Our 
physician reviewer found the clinical documentation states that the enrollee will meet K3 level of ambulation 
within a reasonable time frame, traversing variable surfaces and cadences thus total contact knee disarticulation 
socket (L5650), the knee-shin system, stance flexion feature (L5845), the knee-shin system, single axis, friction 
swing and stance phase control (L5812), and the above knee or hip disarticulation, knee extension assist 
(L5850) are medically appropriate and meet criteria. 
 
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 total contact knee disarticulation socket (L5650), a knee-shin system, stance 
flexion feature (L5845), a knee-shin system, single axis, friction swing and stance phase control (L5812), and a 
above knee or hip disarticulation, knee extension assist (L5850) have been met. Therefore, we decided that the 
Plan has to pre-approve a total contact knee disarticulation socket (L5650), a knee-shin system, stance flexion 
feature (L5845), a knee-shin system, single axis, friction swing and stance phase control (L5812), and a above 
knee or hip disarticulation, knee extension assist (L5850).  
 
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.