Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endoskeletal knee-shin system, single axis, fluid swing and stance phase control (CPT code L5828), endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability (L5848), endoskeletal system, above knee or hip disarticulation, knee extension assist (L5850), addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856), endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock (L5925), and extremity prostheses, flex-walk system or equal (L5981), 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 requested prosthesis is medically necessary for the enrollee, except for the advanced foot and computerized knee. The Plan states the computerized knee and advanced foot exceed the enrollee's medical need and these cannot be covered. The Plan states there are other knees and feet that can meet the enrollee's needs and the remaining items are approved. The Plan states to please talk to the enrollee's doctor about this and a request for a knee and foot that meet the enrollee's needs and Medicare rules 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 the items are not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k), as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The
requested items exceed the patient's medical need as the physician documentation does not support that this patient is a level K3 ambulator given the documentation that the enrollee will use an assistive device after the enrollee receives their prosthesis. The enrollee has a right heel ulcer, currently lives in assistive living, will use an assistive device and has a significant history of PVD and peripheral neuropathy which do not support that the enrollee requires a K3 level heavy microprocessor knee or a K3 level foot. This is the enrollees first knee and there is no evidence that the enrollee is unable to use a mechanical knee. 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 endoskeletal knee-shin system, single axis, fluid swing and stance phase control (CPT code L5828), endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability (L5848), endoskeletal system, above knee or hip disarticulation, knee extension assist (L5850), addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856), endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock (L5925), and extremity prostheses, flex-walk system or equal (L5981), for the enrollee.