Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower extremity prosthesis, endoskeletal, 
knee disarticulation, above knee, hip disarticulation, positional rotation unit (K1022), an addition, endoskeletal 
knee-shin system, single axis, fluid swing and stance phase control (L5828), an addition, endoskeletal, knee-
shin system, stance flexion feature, adjustable (L5845), an addition to endoskeletal knee-shin system, fluid 
stance extension, dampening feature, with or without adjustability (L5848), an addition to lower extremity 
prosthesis, endoskeletal knee-shin system (L5856) and an endoskeletal ankle foot system, microprocessor 
controlled feature, dorsiflexion and/or plantar flexion control, includes power source (L5973). 
 
You asked the Plan to pre-approve a prosthetic leg with knee and foot features. You say that the enrollee needs 
a prosthetic leg to walk. The Plan denied your request. The Plan says the request for an integrated 
microprocessor knee and foot system does not meet Medicare criteria as reasonable and necessary. The rotation 
unit exceeds the enrollee's needs. 
 
The Plan must follow 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 a prosthetic leg with knee and foot 
features. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested Linx knee and foot are a single integrated 
item. The physician documentation does not support the need for the enrollee to have a microprocessor 
foot/ankle over a mechanical foot/ankle which the enrollee has been using. Furthermore, the enrollee uses 
assistive devices for ambulation and the requested K3 integrated components exceed the enrollee's medical 
need per policy article A52496 and Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), as 
Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or 
treatment of illness or injury or to improve the functioning of a malformed body member. 
 
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 prosthetic leg with knee and foot features have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an addition to lower extremity prosthesis, endoskeletal, knee 
disarticulation, above knee, hip disarticulation, positional rotation unit (K1022), an addition, endoskeletal knee-
shin system, single axis, fluid swing and stance phase control (L5828), an addition, endoskeletal, knee-shin 
system, stance flexion feature, adjustable (L5845), an addition to endoskeletal knee-shin system, fluid stance 
extension, dampening feature, with or without adjustability (L5848), an addition to lower extremity prosthesis, 
endoskeletal knee-shin system (L5856) and an endoskeletal ankle foot system, microprocessor controlled 
feature, dorsiflexion and/or plantar flexion control, includes power source (L5973).