Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
You asked the Plan to pre-approve lower limb prosthetic components. You say that the enrollee needs this 
prosthesis to begin rehabilitation and return to daily life/activities. The Plan says that the denial of authorization 
for these components is correct, because a K2 knee and foot could meet the enrollee's needs and the record 
does not support the need for extra protection for the prosthesis. 
 
We decided that the Plan has to pre-approve the knee-shin flexion swing/stance phase control (L5828), 
knee-shin stance flexion feature (L5845), above-knee/hip disarticulation (L5925), multiaxial ankle 
(L5968), flex-walk system (L5981), and above-knee/hip disarticulation knee extension assist (L5850).  
 The Plan follows Medicare rules. Medicare rules state that coverage of lower limb prosthetic components is 
based on assessment of the enrollees functional level.  
 
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 lower limb prosthetic components. Our 
reviewer says that the enrollee meets the Medicare criteria for the requested lower limb prosthetic components. 
Our physician reviewer found clinical documentation shows that the enrollee is at a K3 functional level and 
would be expected to traverse difficult terrains with variable cadences.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower limb prosthetic components have been met. Therefore, we decided that 
the Plan has to pre-approve lower limb prosthetic components.  
 
We also decided that the Plan does not have to pre-approve flexible protective outer surface cover. 
 
The Plan follows Medicare rules. Medicare rules state that protective coverings may be covered under certain 
conditions.  
 
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 flexible protective outer surface 
covering. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested flexible 
protective outer surface covering. Our physician reviewer found there is nothing in the clinical documentation 
that would show why the prosthesis would be under such harsh or extreme conditions to require a flexible 
protective outer surface covering.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower limb prosthetic components have not been met. Therefore, we decided 
that the Plan does not have to pre-approve lower limb prosthetic components. 
 
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.