Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a prosthetic leg with an electronic knee feature (L5828, L5845, 
L5848, L5850, L5856).  
 
You asked the Plan to pre-approve a prosthetic leg with an electronic knee. You say that the prosthetics are 
medically necessary. The Plan denied your request. The Plan says that the request for a microprocessor knee 
does 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 a prosthetic leg with an electronic knee. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found you have a right transfemoral amputation since July 2022, in the setting of 
trauma. Your previous prosthesis was provided with K1 level componentry, including a purely mechanical 
knee. You have managed to resume independent living at home alone, maintain your yard, and go out in the 
community to do your shopping. Your socket is now ill-fitting, and you have had multiple falls recently using 
this leg. The medical record more than satisfies Medicare coverage policy for this component, first and 
foremost in demonstrating that you have a K3 functional level, which the Plan has tacitly already accepted by 
way of approving L5981.  
 
LCD L33787 states simply A fluid, pneumatic, or electronic/microprocessor knee is covered for beneficiaries 
whose functional level is 3 or above. No further specific documentation is required in the LCD, the Policy 
Article, or any of the relevant Medicare manuals because Medicares policy recognizes that microprocessor 
knees are the basic standard of care for all community above knee amputee ambulators given that the evidence 
of their benefits and superiority to alternatives are so well proven and long standing. Less sophisticated 
technology would amount to sub-standard care and would not meet your needs, as evidenced by your frequent 
falls using a less safe mechanical knee as just a single example. There is no doubt that original Medicare would 
cover the requested prosthesis for your K3- level. Therefore, the requested microprocessor knee (L5828, 
L5845, L5848, L5850, L5856) 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 a prosthetic leg with an electronic knee have been met. Therefore, we decided 
that the Plan has to pre-approve a prosthetic leg with an electronic knee feature (L5828, L5845, L5848, L5850, 
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.