Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve a new prosthesis including a custom socket, cover, socks (L5321, 
L5624, L5631, L5649, L5650, L5651, L5671, L5673, L5705, L5950, L5920, L8430, L8460) and componentry 
upgraded to K3 level - a microprocessor knee (L5850, L5856, L5845, L5828, L5848) and flex-walk style foot 
(L5981).  
 
You asked the Plan to pre-approve a new prosthesis including a custom socket, cover, socks, componentry 
upgraded to K3 level - a microprocessor knee, and flex-walk style foot. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested prosthesis/prosthetic parts exceed the 
member's need and cannot be approved.  
 
The Plan follows Medicare rules. Medicare rules say that prostheses are only covered for certain indications. 
 
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 new prosthesis including a custom 
socket, cover, socks, componentry upgraded to K3 level - a microprocessor knee, and flex-walk style foot. Our 
reviewer says that the documentation supports that the requested items are medically reasonable and necessary. 
Our physician reviewer found the  certified prosthetist/orthotist note from May with corroboration by the 
Medical Doctors note from June, establishes that the enrollees functional status has advanced since the 
enrollees preparatory prosthesis was designed, and going from K2 to K3 certainly qualifies as a physiological 
change given the musculoskeletal / cardiovascular function inherent in the ability to function as an unlimited 
community ambulator compared to someone that primarily stays at home. The K3 functional level merely 
describes the average person who lives independently and goes out into the community the way this enrollee 
clearly would do more with componentry that would permit variable cadence and give reasonable assurance 
against falling. This enrollee clearly has K3-level potential based on the documentation provided. 
The LCD states that a fluid, pneumatic, or electronic/microprocessor knee is covered for beneficiaries whose 
functional level is 3 or above. The LCD also states that the flex foot system (L5981) is covered for 
beneficiaries whose functional level is 3 or above. No further component-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. Lesser components amount to sub-standard care and will not 
meet the enrollees needs in the long-term. Therefore, the enrollee meets criteria for the entirety of the 
prosthesis and all requested knee and foot components and their codes. 
 
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 new prosthesis including a custom socket, cover, socks, componentry 
upgraded to K3 level - a microprocessor knee, and flex-walk style foot have been met. Therefore, we decided 
that the Plan has to pre-approve a new prosthesis including a custom socket, cover, socks (L5321, L5624, 
L5631, L5649, L5650, L5651, L5671, L5673, L5705, L5950, L5920, L8430, L8460) and componentry 
upgraded to K3 level - a microprocessor knee (L5850, L5856, L5845, L5828, L5848) and flex-walk style foot 
(L5981).   
 
 
 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.