Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve single axis, fluid swing and stance phase control 
(L5828) stance flexion feature, adjustable (L5845) fluid stance extension, dampening feature, with or without 
adjustability (L5848), microprocessor control feature, swing and stance phase, includes electronic sensor(s), 
any type (L5856) above knee or hip disarticulation, alignable system (L5920) multiaxial ankle with swing 
phase active dorsiflexion feature (L5968) flex-walk system or equal (L5981). 
 
You asked the Plan to pre-approve the alignable system, computerized knee and advanced foot. You say that 
the enrollee meets the definition of medical necessity for a below the knee amputee with the ability to function 
at a K3 level of ambulation. The Plan denied your request. The Plan says the requested alignable system, 
computerized knee and advanced foot exceed the enrollees 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 the alignable system, computerized 
knee and advanced foot. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the physician documentation does not 
support why the enrollee's needs cannot be effectively met with a mechanical knee. Furthermore the specific 
Orion 3 microprocessor knee ( https://www.blatchfordmobility.com/en-us/products/knees/orion3/) has features 
that exceed the enrollee's functional/medical need such as the cycling mode. The L5920 addition, endoskeletal 
system, above knee (AK) or hip disarticulation, alignable system exceeds the enrollee's medical need and is not 
medically necessary. The requested items exceed the enrollees medical need as the enrollee currently has an 
L5920 alignable system and there is no indication it cannot be used with the approved socket. The K3 foot, 
flex-walk system L5981 exceeds the enrollee's medical needs and is not medically necessary per Local 
Coverage Determination (LCD):  Limb Prostheses (L33787) and per Social Security Act, Section 1862 (a)1(A) 
and the 42 CFR 411.15(k). The treating medical physician provider documentation does not support that the 
enrollee is a K3 ambulator as the enrollee continues to use a cane for most ADLs. 
 
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 alignable system, computerized knee and advanced foot have not been met. 
Therefore, we decided that the Plan does not have to pre-approve single axis, fluid swing and stance phase 
control (L5828) stance flexion feature, adjustable (L5845) fluid stance extension, dampening feature, with or without adjustability (L5848), microprocessor control feature, swing and stance phase, includes electronic 
sensor(s), any type (L5856) above knee or hip disarticulation, alignable system (L5920) multiaxial ankle with 
swing phase active dorsiflexion feature (L5968) flex-walk system or equal (L5981).