Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve codes L5828, L5848, L5850, L5856, L5920, L5984, and L5987. 
We decided that the Plan does not have to pre-approve code L5845. 
 
You asked the Plan to pre-approve a prosthetic limb and its components represented by codes L5828, L5845, 
L5848, L5850, L5856, L5920, L5984, and L5987. You say that the requested prosthesis is medically necessary 
in order for you to continue ambulating and in order to continue your life in the same way you have been for 
the last 20 years. You say that the medical records provided support this medical need. The Plan says that the 
criteria for coverage of a new prosthetic leg have not been met, but that you may meet criteria for a 
replacement of the prosthetic socket. 
 
We decided that the Plan has to pre-approve codes L5828, L5848, L5850, L5856, L5920, L5984, and 
L5987. 
 
The Plan follows Medicare rules. Medicare rules say that the replacement of a prosthetic device is covered for 
certain medical indications. Medicare rules say that prosthetic devices and components are covered when 
medically reasonable and necessary. Medicare rules also say that health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
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 codes L5828, L5848, L5850, L5856, 
L5920, L5984, and L5987. Our reviewer says that the criteria for coverage of these items has been met. Our 
physician reviewer found that the request is to replace a prosthetic limb for you, who has an above knee 
amputation. The appeal states the limb is causing chafing of the residual leg and the leg is malfunctioning and 
out of warranty. The Plan agrees the socket needs replacement but states the prosthetic leg and its multiple 
components do not need replacement because it is not malfunctioning. The prosthesis is out of warranty, 
malfunctioning and cannot be repaired per the appellant. The Plan has provided no evidence to the contrary. 
The criteria for coverage of the knee and ankle prosthesis and the requested components have been met, as the 
enrollee is functioning at a K3 level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes L5828, L5848, L5850, L5856, L5920, L5984, and L5987 have been met. 
Therefore, we decided that the Plan has to pre-approve codes L5828, L5848, L5850, L5856, L5920, L5984, 
and L5987. 
 
We also decided that the Plan does not have to pre-approve code L5845. 
 
The Plan follows 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 L5845.  Our reviewer says that the criteria for coverage of this item have not been met. Our physician reviewer found 
that the sound limb is functioning and there are no spinal issues. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code L5845 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the knee-shin system with a stance flexion system represented by code L5845. 
 
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.