Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor control swing and stance phase 
endoskeletal knee-shin system (L5856), fluid swing and stance phase control (L5828), a stance flexion feature 
(L5845), a fluid stance extension dampening feature (L5848), a programmable flexion/extension assist control 
(L5859), and a vertical shock reducing pylon feature (L5988). 
 
You asked the Plan to pre-approve a microprocessor control swing and stance phase endoskeletal knee-shin 
system, fluid swing and stance phase control, a stance flexion feature, a fluid stance extension dampening 
feature, a programmable flexion/extension assist control, and a vertical shock reducing pylon feature. You say 
that the enrollee needs these components. The Plan denied your request. The Plan says these components are 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that prosthetic components are covered when they are 
medically necessary as described in the rules section. 
 
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 microprocessor control swing and 
stance phase endoskeletal knee-shin system, fluid swing and stance phase control, a stance flexion feature, a 
fluid stance extension dampening feature, a programmable flexion/extension assist control , and a vertical 
shock reducing pylon feature. Our reviewer says that the requested components are not shows to be medically 
necessary. Our physician reviewer found the documentation does not include objective medical progress notes 
from the enrollee's physician supporting the need for the requested items. The documentation does not support 
that the enrollee participates in high impact activities that requires the vertical shock reducing pylon feature 
(L5988). The programmable flexion/extension assist control (L5859) is not medically necessary as the 
documentation does not support that lumbar spine pain requires the enrollee to have programmable 
flexion/extension assist control. There are no detailed medical progress notes documenting deficits in the lower 
extremities (i.e. impaired hip extension or quadriceps function) supporting the need for this item. The records indicate normal bilateral hip strength and range of motion. As the programmable flexion/extension assist 
control (L5859) is not medically necessary, the related components, the microprocessor control swing and 
stance phase endoskeletal knee-shin system (L5856), fluid swing and stance phase control (L5828), stance 
flexion feature (L5845), and fluid stance extension dampening feature (L5848), cannot be considered medically 
necessary. 
 
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 microprocessor control swing and stance phase endoskeletal knee-shin 
system, fluid swing and stance phase control, a stance flexion feature, a fluid stance extension dampening 
feature, a programmable flexion/extension assist control , and a vertical shock reducing pylon feature have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a microprocessor control swing and 
stance phase endoskeletal knee-shin system (L5856), fluid swing and stance phase control (L5828), a stance 
flexion feature (L5845), a fluid stance extension dampening feature (L5848), a programmable 
flexion/extension assist control (L5859), and a vertical shock reducing pylon feature (L5988).