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), an addition, endoskeletal system, above knee or hip disarticulation, knee 
extension assist (L5850), an addition to lower extremity prosthesis, endoskeletal knee-shin system, 
microprocessor control feature, swing and stance phase (L5856), an all lower extremity prostheses, flex-walk 
system (L5981) and an all lower extremity prostheses, multi-axial rotation unit (L5986). 
 
You asked the Plan to pre-approve prosthetics. You say that you use your leg to walk on uneven terrain and to 
walk up and down ramps and steps and also slippery services. You do more than simple walking. You would 
like to get your independence back. The Plan denied your request. The Plan says that the requested 
prosthesis/prosthetic parts exceed your needs and cannot be approved. 
 
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 you have a left transfemoral amputation since 2007 in the setting of diabetic vasculopathy. You 
live alone and have become a successful prosthetic ambulator, living independently at home and going out in 
the community to do your shopping. Your existing prosthesis (2018) includes a microprocessor knee and other 
K3 components, but the prosthesis overall is ill fitting, malfunctioning, and off-warranty/beyond repair. Not 
only does the medical record satisfy Medicare policy in demonstrating you have a K3 functional level, but the 
Plan also attempts to create a more restrictive policy for defining K3 function than Medicare policy would 
allow. 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 
prescribers notes from April of this year more than satisfy Medicare requirements for documenting your K3 
functional potential and need for a new prosthesis. Meanwhile, the notes offered by the Plan regarding the 
power mobility scooter are 3 years old, are inconsistent with your contemporary functional potential (there is 
no documentation of any physically limiting issues at present given that you are medically well managed), and 
frankly this line of evidence is irrelevant to this request since some use of a power mobility device is not, on its 
own, disqualifying of a K3 status. Moreover, LCD L33787 states A fluid, pneumatic, or 
electronic/microprocessor knee is covered for beneficiaries whose functional level is 3 or above, and it also 
states flex foot system (L5981) 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 and flex-walk feet are part of the basic 
standard of care for all community above knee amputee ambulators given that the evidence of their benefits and 
superiority to less sophisticated alternatives are so well proven and long standing. There is no doubt that 
original Medicare would cover the requested prosthesis for you. Therefore, the requested microprocessor knee 
(L5828, L5845, L5848, L5850, L5856) and foot (L5981, L5986) 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 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), an addition, endoskeletal system, above knee or hip disarticulation, knee extension assist (L5850), an 
addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing 
and stance phase (L5856), an all lower extremity prostheses, flex-walk system (L5981) and an all lower 
extremity prostheses, multi-axial rotation unit (L5986).  
 
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.