Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve addition, endoskeletal knee-shin system, single axis, fluid swing 
and stance phase control (L5828) addition, endoskeletal, knee-shin system, stance flexion feature, adjustable 
(L5845) addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without 
adjustability (L5848) addition to lower extremity prosthesis, knee-shin system, microprocessor control feature, 
swing and stance phase (L5856) addition, endoskeletal system, above knee or hip disarticulation, knee 
extension assist. (L5850) addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, 
manual lock (L5925) addition, endoskeletal system, above knee or hip disarticulation, alignable system 
(L5920). 
 
You asked the Plan to pre-approve microprocessor knee and advanced foot ankle system. You say that Please 
review medical record again as we have met all of the Medicare guidelines for the MPK prosthetic knee. The Plan denied your request. The Plan says that The requested computerized knee and alignable system exceeds 
the enrollee's need and is not reasonable and necessary per Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 to pre-approve microprocessor knee and advanced foot 
ankle system. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee is a K3 ambulator with a K2 system. The 
record is clear he has capacity and need to be an advanced ambulator on uneven terrain with multiple barriers. 
The physician and prosthetist records are in concordance and support the advanced ambulation system. The 
Plan states criteria are not met but does not provide specifics. In contrast medical record from physician 
evaluation clearly indicates criteria are met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of microprocessor knee and advanced foot ankle system have been met. Therefore, 
we decided that the Plan has to pre-approve addition, endoskeletal knee-shin system, single axis, fluid swing 
and stance phase control (L5828) addition, endoskeletal, knee-shin system, stance flexion feature, adjustable 
(L5845) addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without 
adjustability (L5848) addition to lower extremity prosthesis, knee-shin system, microprocessor control feature, 
swing and stance phase (L5856) addition, endoskeletal system, above knee or hip disarticulation, knee 
extension assist. (L5850) addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, 
manual lock (L5925) addition, endoskeletal system, above knee or hip disarticulation, alignable system 
(L5920).  
 
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.