Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the axial rotation unit (L5984) and residual volume management 
system (L5781). We decided that the Plan does not have to pre-approve the vertical shock reduction pylon 
(L5988).  
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan says that there 
is no objective clinical documentation from the physician to corroborate the vendor's claim that these items are 
required. 
 
We decided that the Plan has to pre-approve the axial rotation unit (L5984) and residual volume 
management system (L5781).  
 
The Plan follows Medicare rules. Medicare rules say that services are covered when they are medically 
necessary. 
 
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 for an axial rotation unit and residual volume 
management system. Our reviewer says that the patients prosthesis requires an axial rotation unit and residual 
volume management system. Patients with a transtibial amputation do not typically require a volume 
management system given that the size and volume of their residual limb volume does not fluctuate 
significantly. However, this patient requires dialysis and therefore she experiences frequent volume fluctuation 
that can impact the fit of her prosthetic socket. The volume management system will allow for better 
management of volume changes of her residual limb and therefore a better fit. The patient is noted to have a K3 
level and therefore axial rotation unit can be used to allow for better ambulation when walking on uneven 
surfaces. 
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 been met. Therefore, we decided that the Plan has to pre-approve 
the axial rotation unit (L5984) and residual volume management system (L5781).  
 
We also decided that the Plan does not have to pre-approve the vertical shock reduction pylon (L5988). 
 
The Plan follows Medicare rules. Medicare rules say that services are covered when they are medically 
necessary. 
 
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 for the vertical shock reduction pylon. Our reviewer 
says that the patients prosthesis does not require a vertical shock reduction pylon feature. For a K3 level 
ambulator with the requested foot ankle system and axial rotation unit, the patient should be able to achieve 
satisfactory alignment and gait. 
 
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 vertical shock reduction pylon (L5988) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the vertical shock reduction pylon (L5988). 
 
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.