Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal knee-shin system, single axis, fluid 
swing and stance phase control (L5828), endoskeletal, knee-shin system, stance flexion feature (L5845), 
endoskeletal knee-shin system, fluid stance extension, dampening feature (L5848), microprocessor control 
feature, swing and stance phase, includes electronic sensor(s) (L5856), alignable system (L5920), multiaxial 
ankle with swing phase active dorsiflexion feature (L5968), and flex-walk system (L5981). 
 
You asked the Plan to pre-approve a fluid swing and stance phase control, stance flexion feature, dampening 
feature, swing and stance phase, alignable system, multiaxial ankle with swing phase active dorsiflexion 
feature, and flex-walk system. You say that you are working and trying to maintain your household. You also 
say that you have found it to be difficult due to numerous falls and difficulty of movement. The Plan denied 
your request. The Plan says this request for a K3 knee and foot does not meet Medicare criteria as reasonable 
and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 a fluid swing and stance phase control, 
stance flexion feature, dampening feature, swing and stance phase, alignable system, multiaxial ankle with 
swing phase active dorsiflexion feature, and flex-walk system. Our reviewer says that the transtibial prosthesis 
components are not medically necessary. Our physician reviewer found the documentation provided does not 
support the use of the requested transtibial prosthesis with K3 components. The prosthetic note indicates that 
your amputee mobility predictor score is 42. However, there is no information provided in the clinical progress 
note that you have the cardiac and respiratory capacity to function as a K3 level ambulator. Our reviewer found 
that you are noted to have impaired oxygen saturation and an ejection fraction of 30%. There is no 
documentation indicating how you can tolerate the increased demands of operating a transfemoral prosthesis at 
a K3 level. You were noted to have significant oxygen desaturation, especially with exertion. Our physician 
reviewer also found that this would not support a K3 level of mobility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a fluid swing and stance phase control, stance flexion feature, dampening 
feature, swing and stance phase, alignable system, multiaxial ankle with swing phase active dorsiflexion 
feature, and flex-walk system have not been met. Therefore, we decided that the Plan does not have to pre-
approve an endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828), 
endoskeletal, knee-shin system, stance flexion feature (L5845), endoskeletal knee-shin system, fluid stance 
extension, dampening feature (L5848), microprocessor control feature, swing and stance phase, includes 
electronic sensor(s) (L5856), alignable system (L5920), multiaxial ankle with swing phase active dorsiflexion 
feature (L5968), and flex-walk system (L5981).