Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 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, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type 
(L5856), all lower extremity prostheses, flex-walk system or equal (L5981), an addition to lower limb 
prosthesis, vertical shock reducing pylon feature (L5988) and an addition to lower limb prosthesis, multiaxial 
ankle with swing phase active dorsiflexion feature (L5968). 
 
 You asked the Plan to pre-approve a prosthetic leg with an advanced foot-ankle feature and an electronic knee. 
You say that the enrollee requires a left transfemoral prosthesis which is medically necessary because not only 
does the enrollee present as a K-3 Level due to his pre-amputation function preceding LE pain and would care 
issues but his strong desire to ambulate and current presentation supports potential for full-time utilization and 
dependence upon a prosthesis for safety in mobility. He desires to return to his previous active lifestyle where 
he owned a lawn care business. The enrollee does meet the clinical indications as expressed by your 
practitioner. The Plan denied your request. The Plan says the request for a K3 knee and foot does not meet 
Medicare criteria as reasonable and necessary. Records do not support functional status is K3 ambulator, as 
enrollees PA does not corroborate prosthetist's (vendor's) claim that member is K3 ambulator. Notes from his 
practitioner are inconsistent with K3 ambulatory function. 
 
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 an advanced foot-
ankle feature and an electronic knee. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found provided records do not fully 
support that the enrollee is a K3 level ambulator to meet criteria for the requested knee and foot. Records 
document the enrollee is requiring the use of a walker and a motorized wheelchair is being ordered due to his 
mobility impairment, this is not consistent with K3 level mobility.  As stated in the Medicare rules, supplier-
produced records, even if signed by the treating practitioner, and attestation letters (e.g., letters of medical 
necessity) are deemed not to be part of a medical record for Medicare payment purposes. The information 
should include the enrollees diagnosis and other pertinent information including, but not limited to, duration of 
his condition, clinical course (worsening or improvement), prognosis, nature and extent of functional 
limitations, other therapeutic interventions and results, past experience with related items, etc. 
 
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 an advanced foot-ankle feature and an electronic knee have 
not been met. Therefore, we decided that the Plan does not have to pre-approve 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, microprocessor control feature, swing and stance phase, includes electronic 
sensor(s), any type (L5856), all lower extremity prostheses, flex-walk system or equal (L5981), an addition to 
lower limb prosthesis, vertical shock reducing pylon feature (L5988) and an addition to lower limb prosthesis, 
multiaxial ankle with swing phase active dorsiflexion feature (L5968).