Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an addition, endoskeletal system, below knee, flexible protective 
outer surface covering system (L5962). 
 
You asked the Plan to pre-approve a prosthetic. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says that the records provided do not indicate that the 
enrollee is exposed to harsh conditions or engages in extraordinary activities that require extra protection from 
a specialized prosthetic cover. 
 
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. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the governing Policy Article A52496 states, Protective outer surface covering systems (L5962, 
L5964, and L5966) are specialized covers intended to be worn over an existing prosthesis. They are used by an 
enrollee who has special needs for protection against unusually harsh environmental situations where it is 
necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by L5704, L5705, 
L5706, and L5707. They are not for cosmetic or convenience reasons, or for everyday usage in a typical 
environment. The chief product officers (CPOs) note from May in fact satisfies these criteria as he 
documents the enrollee being frequently outdoors in environments that are likely to expose her prosthesis to not 
just accidental water submersion but also to mud/dirt (which is ubiquitous in a ranch setting); those certainly 
count as unusually harsh environments compared to normal urban/suburban situations. Indeed, there is reason 
to suspect that Medicare previously covered her last flexible outer cover precisely because of these 
environmental exposures; particulate matter would otherwise be very damaging to a hydraulic foot if it got 
inside of its various moving joints or around its pistons, much more so than to a simple carbon fiber blade 
without these features. There is reason to suspect that the enrollees use of an L5962 type cover and its sealant 
effect over L5704 is the reason that her previous hydraulic foot lasted for over a decade despite the hard 
environmental exposures. Therefore, L5962 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 have been met. Therefore, we decided that the Plan has to pre-
approve an addition, endoskeletal system, below knee, flexible protective outer surface covering system 
(L5962).  
 
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.