Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an all-lower extremity prostheses, flex-walk system (L5981), an 
all endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability (L5984) and an 
addition to lower limb prosthesis, vertical shock reducing pylon feature (L5988). 
 
You asked the Plan to pre-approve prosthetics. You say that the enrollee ambulates greater than 400 yards per 
day and would greatly benefit from a prosthetic foot that provides energy in return. The Plan denied your 
request. The Plan says that the request for feet and ankle prosthetics do not meet Medicare criteria as 
reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 prosthetics. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has bilateral transtibial amputations since November 2022, in the setting of 
thromboemboli. On one hand, the Plan is attempting to create a more restrictive policy for defining K3 function 
than Medicare policy would allow, and on the other hand this enrollee (as a bilateral amputee) is not strictly 
bound by K-levels. This enrollee credibly has K3 potential, per not only the certified prosthetist/orthotists 
(CPOs) clinic note and appeal letter but also the primary care physicians (PCPs) clinic note. Medicare 
enrollees with documented K3 level are explicitly entitled to this class of componentry as part of the standard 
of care laid out in the feet section of LCD 33787. But, beyond that, the LCD suggests that this case does not 
even necessarily revolve around documentation of the enrollees K-level, when it says, It is recognized, within 
the functional classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level 
classifications. Indeed, the enrollees medical needs are closely tied to functional ambulation. The Plan has 
already agreed in principle that the enrollee needs a new prosthesis, and the CPO and prescriber are unified on 
the reasonableness and necessity of the specific feet requested. There is simply no doubt that original Medicare 
would cover the requested prostheses for this enrollee regardless of K-level. Therefore, L5981, L5984, and 
L5988, each x2, are hereby approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have been met. Therefore, we decided that the Plan has to pre-
approve an all-lower extremity prostheses, flex-walk system (L5981), an all endoskeletal lower extremity 
prosthesis, axial rotation unit, with or without adjustability (L5984) and an addition to lower limb prosthesis, 
vertical shock reducing pylon feature (L5988).  
 
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.