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) and an addition to lower extremity prosthesis, endoskeletal knee-shin system, 
microprocessor control feature, swing and stance phase (L5856). 
 
You asked the Plan to pre-approve prosthetic leg parts. You say that a Quatro Knee is a standard K3 
microprocessor knee that is payable for K3 enrollees. The Plan denied your request. The Plan says that the 
requested prosthetic parts exceed the enrollee's need. The notes do not show why the parts of the enrollee's 
prosthesis are needed. 
 
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 prosthetic leg parts. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has right transtibial amputation since 2017 in the setting of thrombosis. He has 
become a successful unlimited community prosthetic ambulator, is very active and intends to start work as a 
fitness instructor. His existing prosthesis includes componentry from 2018 which is no longer keeping up with 
his much-increased physical activity and is off warranty. The medical records as submitted establishes the 
enrollee's K3-level, his need for new components, and the particular benefits of those requested components for 
him. This is established both by the CPO and the prescribing MD. It is notable that the Plan does not actually 
dispute the enrollee's K3 status, having already approved a K3-level foot. Indeed, LCD L33787 states A fluid, 
pneumatic, or electronic/microprocessor knee is covered for enrollees whose functional level is 3 or above, 
and it also states, shank foot system with vertical loading pylon (L5987) is covered for enrollees 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 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. A non-
microprocessor knee, particularly for an athletic, frankly K4 potential, enrollee like this one is clinically 
inappropriate and inadequate for numerous reasons that are beyond the scope of this review. But in any event, 
it does not fall to the Plan to second guess the treatment decisions of the locally treating team when they 
already more than met their documentary burden by establishing the enrollee's K-level and need for 
replacement components generally. There is no doubt that original Medicare would cover the requested 
prosthesis for this K3-level enrollee. Therefore, L5828, L5845, L5848, L5850, and L5856 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 prosthetic leg parts 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) and 
an addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing 
and stance phase (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.