Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has 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) and an addition to lower extremity prosthesis, endoskeletal knee-shin 
system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type 
(L5856). 
 
You asked the Plan to pre-approve prosthetics. You say that the requested items were incorrectly denied as not 
medically necessary. The enrollee has a very active lifestyle and is currently without a prosthesis. We need to 
expedite this appeal to promote the enrollee's wellbeing and prevent muscle atrophy and contractures from lack 
of activity. The Plan denied your request. The Plan says that Medicare Guidance says that a prosthesis that 
meets, but does not exceed, the enrollee's need can be provided. 
 
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 not only does the medical record satisfy Medicare policy in demonstrating this enrollee has a 
K3 functional level, but the Plan also attempts to create a more restrictive policy for defining K3 function than 
Medicare policy would allow, paradoxically while also tacitly accepting his K3 status by way of approving 
L5981. In contrast to these broad, inclusive K3-criteria that generally describe the average Medicare enrollee 
who lives independently at home and in the community, the Plans denial letter sets more stringent 
requirements than Medicare. In its own definition of the K3 level, the Plan seeks to create strict use-case 
criteria with a level of specificity that does not appear in the LCD, You must need to do more than simple 
walking. You must need to cross different barriers (such as walking long distances or walking on steep or 
slippery surfaces). The medical record in this case more than meets the standard for documenting the 
enrollees K3-status, and then goes above and beyond by describing the requested components particular uses 
for the enrollee. There is no doubt that original Medicare would cover the requested prosthesis for this K3- 
level enrollee. Therefore, the microprocessor knee is 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 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) 
and an addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, 
swing and stance phase, includes electronic sensor(s), any type (L5856).  
 
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.