Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an advanced foot. We decided that the Plan does not have to pre-
approve the protective covering.  
 
You asked the Plan to pre-approve an advanced foot. You say that the items are medically necessary. The Plan 
says that the items are not medically necessary. 
 
We decided that the Plan has to pre-approve an advanced foot.  
 
The Plan follows Medicare rules. Medicare rules say that a determination of the type of foot for the prosthesis 
will be made by the treating practitioner and/or the prosthetist based upon the functional needs of the 
beneficiary. Basic lower extremity prostheses include a SACH foot. Other prosthetic feet are considered for 
coverage based upon functional classification. 
 
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 an advanced foot. Our reviewer says 
that the advanced foot is medically necessary. Our physician reviewer found the documentation specifies 
advanced level of patient's mobility/functional status thus patient does meet the LCD coverage criteria for 
L5981.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an advanced foot have been met. Therefore, we decided that the Plan has to pre-
approve an advanced foot.  
 
We also decided that the Plan does not have to pre-approve the protective covering. 
 
The Plan follows Medicare rules. Medicare rules say that Protective outer surface covering systems (L5962, 
L5964, and L5966) are specialized covers intended to be worn over an existing prosthesis. They are used by a 
beneficiary who has special needs for protection against unusually harsh environmental situations where it is 
necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by L5704, L5705, 
L5706, and L5707. They are not for cosmetic or convenience reasons, or for everyday usage in a typical 
environment. Protective outer surface coverings are different from the covering that is already reimbursed as 
part of L5704, L5705, L5706, and L5707.  
 
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 protective covering. Our reviewer 
says that the protective covering is not medically necessary. Our physician reviewer found the clinical 
documentation states that the patient will be resuming typical activities of daily living and travel thus clinical 
documentation does not support  L5962 as 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 the protective covering have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the protective covering. 
 
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.