Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approve above knee or hip disarticulation addition, addition to endoskeletal
knee-shin system, single axis addition, endoskeletal knee-shin system, stance flexion feature addition, and the
user adjustable heel height. We decided that the Plan does not have to pre-approve the user adjustable heel
height feature.
You asked the Plan to pre-approve above knee or hip disarticulation addition, addition to endoskeletal kneeshin
system, single axis addition, endoskeletal knee-shin system, stance flexion feature addition, and the user
adjustable heel height. You say that you would like the plan to reconsider their denial. The Plan says that the
requested items are not medically necessary.
We decided that the Plan has to pre-approve the above knee or hip disarticulation addition identified
with code L5920, addition to endoskeletal knee-shin system identified with code L5848, single axis
addition identified with code L5828, endoskeletal knee-shin system identified with code L5856, and the
stance flexion feature addition identified with code L5845.
The Plan follows Medicare rules. Medicare rules say that the records must document the enrollee's current
functional capabilities and his or her expected functional potential, including an explanation for the difference,
if that is the case. It is recognized, within the functional classification hierarchy, that bilateral amputees often
cannot be strictly bound by functional level classifications.
The rules say that coverage is extended only if there is sufficient clinical documentation of functional need for
the technologic or design feature of a given type of knee. This information must be retained in the treating
practitioner's or prosthetist's files
You can find these rules in the Local Coverage Determination (LCD) Lower Limb Prostheses, L33787.
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 above knee or hip disarticulation
addition, addition to endoskeletal knee-shin system, single axis addition, endoskeletal knee-shin system, stance
flexion feature addition, and the user adjustable heel height. Our reviewer says that the documentation does
support that the requested items (other than the user adjustable heel height feature) is medically reasonable and
necessary. Our physician reviewer found the records from the enrollee's prescribing provider document that the
enrollee is highly motivated to continue ambulating at a K3 level. The enrollee was previously using a
microprocessor knee and the enrollee needs a new microprocessor knee to continue ambulating on a high level
and on uneven surfaces. Therefore, the enrollee meets criteria for the requested items (other than the user
adjustable heel height feature).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of above knee or hip disarticulation addition, addition to endoskeletal knee-shin
system, single axis addition, endoskeletal knee-shin system, stance flexion feature addition, and the user
adjustable heel height have been met. Therefore, we decided that the Plan has to pre-approve the above knee or
hip disarticulation addition identified with code L5920, addition to endoskeletal knee-shin system identified
with code L5848, single axis addition identified with code L5828, endoskeletal knee-shin system identified
with code L5856, and the stance flexion feature addition identified with code L5845.
We also decided that the Plan does not have to pre-approve the user adjustable heel height identified
with code L5990.
The Plan follows Medicare rules. Medicare rules say that a user-adjustable heel height feature (L5990) will be
denied as not reasonable and necessary.
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 user adjustable heel height
identified with code L5990. Our reviewer says that the documentation does not support that the requested item
is medically reasonable or necessary. Our physician reviewer found the requested item is specifically noncovered.
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 user adjustable heel height identified with code L5990 have not been met.
Therefore, we decided that the Plan does not have to pre-approve the user adjustable heel height identified with
code L5990.