Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower extremity prosthesis, endoskeletal 
knee-shin system, microprocessor control feature, swing and stance phase (L5856), an addition, endoskeletal, 
knee-shin system, stance flexion feature, adjustable (L5845), an addition to endoskeletal knee-shin system, 
fluid stance extension, dampening feature (L5848), an addition, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (L5828), an addition, endoskeletal knee-shin system, single axis, fluid 
swing phase control (L5824), an addition to lower extremity, above knee or knee disarticulation, acrylic socket 
(L5631), an addition to lower extremity, ischial containment/narrow m-l socket (L5649), an addition to lower 
extremity, below knee / above knee suspension locking mechanism (L5671), an addition, endoskeletal system, 
below knee, ultra-light material (L5940), a lower extremity prosthesis, not otherwise specified (L5999), a 
replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model 
(L5701) and an addition to lower extremity, below knee/above knee, custom fabricated from existing mold or 
prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism (L5673x2). 
 
You asked the Plan to pre-approve orthotic and accessories. You say that you disagree with the denial. The 
Plan denied your request. The Plan says based on Medicare guidelines and the information they have about 
your condition; you do not meet the requirements. 
 
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 orthotic and accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found according to Medicare additional features or components to a prosthesis may be 
necessary depending on your potential functional abilities. Potential functional ability is based on the 
reasonable expectations of the prosthetist, and treating practitioner, considering multiple factors. These factors 
include your history, current condition including the status of the residual limb and the nature of the other 
medical problems and your desire to ambulate. A level 3 ambulator has the ability or potential for ambulation 
with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental 
barriers and may have vocational, therapeutic or exercise activity that demands prosthetic utilization beyond 
simple locomotion. In this case, the documentation does not support you are a K3 ambulator and therefore the 
requested prosthesis with upgraded components is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of orthotic and accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an addition to lower extremity prosthesis, endoskeletal knee-shin system, 
microprocessor control feature, swing and stance phase (L5856), an addition, endoskeletal, knee-shin system, 
stance flexion feature, adjustable (L5845), an addition to endoskeletal knee-shin system, fluid stance extension, 
dampening feature (L5848), an addition, endoskeletal knee-shin system, single axis, fluid swing and stance 
phase control (L5828), an addition, endoskeletal knee-shin system, single axis, fluid swing phase control 
(L5824), an addition to lower extremity, above knee or knee disarticulation, acrylic socket (L5631), an addition 
to lower extremity, ischial containment/narrow m-l socket (L5649), an addition to lower extremity, below knee 
/ above knee suspension locking mechanism (L5671), an addition, endoskeletal system, below knee, ultra-light 
material (L5940), a lower extremity prosthesis, not otherwise specified (L5999), a replacement, socket, above 
knee/knee disarticulation, including attachment plate, molded to patient model (L5701) and an addition to 
lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, 
silicone gel, elastomeric or equal, for use with locking mechanism (L5673x2).