Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multi-axial rotation unit (L5986) endoskeletal knee-shin 
system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856) 
addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without 
adjustability (L5848) addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control 
(L5828) addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) and flex-walk 
system (L5981). 
 
You asked the Plan to pre-approve the advanced foot and computerized knee. You say that the enrollee 
requests reconsideration of the decision to deny the advanced components of the microprocessor knee and 
replacement foot to allow her to continue being active without limitation. The Plan denied your request. The 
Plan says the records do not support the need for microprocessor knee instead of mechanical knee. 
 
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 the advanced foot and computerized 
knee. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested C-leg 4 microprocessor knee is not 
medically necessary. The documentation indicates that the requested item has features that exceed the 
enrollees medical need and also the documentation is conflicting that the enrollee requires the C-leg 4. The 
enrollees activities appear to be able to be met through a mechanical K3 knee and there are no extenuating 
factors on the medical progress notes that require a microprocessor knee. Furthermore, the requested knee has 
features such as a cycle mode per the certified prosthetist/orthotist (CPO) documentation. The documentation 
does not support that the enrollee participates in cycling activities. The document notes in a review of systems 
notes the enrollee is not exercising, has difficulty walking, climbing stairs, and doing errands alone. 
Furthermore, the May 23, 2022 family nurse practitioner documentation states that the requested knee is 
waterproof for increased ability in the shower and for other water activities. The CPO note states the enrollee 
will be able to wear the prosthesis at all times even around water activities. A review of the website for the C 
leg 4 (https://www.ottobock.com/en-us/product/3C88-3~23C98-3) states, "Although the C-Leg is weatherproof 
and well suited for contact with water in various everyday situations, such as rain showers or light splashes, it 
is not fully waterproof. You should not wear it in the shower or for activities like swimming."   
 
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 advanced foot and computerized knee have not been met. Therefore, we 
decided that the Plan does not have to pre-approve multi-axial rotation unit (L5986) endoskeletal knee-shin 
system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856) 
addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without 
adjustability (L5848) addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control 
(L5828) addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) and flex-walk 
system (L5981).