Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (CPT code L5828), all lower extremity prostheses, flex-walk system or 
equal (CPT code L5981), addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (CPT 
code L5845), addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or 
without adjustability (CPT code L5848), addition to lower extremity prosthesis, endoskeletal knee-shin system, 
microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (CPT code 
L5856), for the enrollee. 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the records we have do not show why the requested computerized prosthetic knee and 
advanced foot are needed. The Plan states there are other prosthetic knees and feet that can meet the enrollee's 
needs. The Plan states this is why the requested prosthetic parts are still denied. The Plan states a request for a 
prosthetic knee and foot that meet the enrollee's needs and Medicare guidelines can be reviewed if submitted. 
 
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 items. Our physician reviewer 
found documentation from enrollee's nurse practitioner (NP) do not show why mechanical knee will not meet 
the enrollee's needs. NP states that enrollee's "daily activities and lifestyle include outdoor activities and require ambulating on uneven terrain and at varying cadences." The described activity needs can be met with 
mechanical knee. MPK is requested for safety concerns, which contradicts enrollee's ability to ambulate at K3 
level, especially given that enrollee scored within K2 range on AMPnoPRO. Notes do not support the need for 
microprocessor knee instead of mechanical knee based on documented activity needs. The enrollee's activity 
needs can be met with mechanical knee, especially given that this is enrollee's initial AKA prosthesis. 
Documentation submitted does not support medical need for K3 prosthesis with microprocessor knee and K3 
foot. The described activity needs can be met with mechanical knee. MPK is requested for safety concerns, 
which contradicts enrollee's ability to ambulate at K3 level, especially given that the enrollee scored within K2 
range on AMPnoPRO. The review has determined that the medical records provided do not meet the 
requirements listed in the LCD for Medicare coverage. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control (CPT 
code L5828), all lower extremity prostheses, flex-walk system or equal (CPT code L5981), addition, 
endoskeletal, knee-shin system, stance flexion feature, adjustable (CPT code L5845), addition to endoskeletal 
knee-shin system, fluid stance extension, dampening feature, with or without adjustability (CPT code L5848), 
addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing 
and stance phase, includes electronic sensor(s), any type (CPT code L5856), for the enrollee.