Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an endoskeletal ankle foot system (L5973). We decided that the 
Plan does not have to pre-approve a flex-walk system or equal (L5981).  
 
You asked the Plan to pre-approve an endoskeletal ankle foot system (L5973) and flex-walk system or equal 
(L5981). The Plan says that this request for a K3 microprocessor foot does not meet Medicare criteria as 
reasonable and necessary. 
 
We decided that the Plan has to pre-approve an endoskeletal ankle foot system (L5973).  
 
The Plan follows Medicare rules. Medicare rules say that a microprocessor controlled ankle foot system 
(L5973) is covered for beneficiaries whose functional level is 3 or above.  
 
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 an endoskeletal ankle foot system 
(L5973). Our reviewer says that the Plans particular reasons for denying L5973 are without merit, because 
there is every reason to expect based on the medical record that this Beneficiary has K3-level potential and is 
therefore entitled to receive the K3-level care requested by her treating Certified Prosthetist/Orthotist (CPO). 
Our physician reviewer found the prosthetists treatment decision as documented falls well within the scope of 
standard care in choosing the foot in question for this enrollee whose activity would benefit from prosthetic 
foot that closely mimics normal physiology. The Plans specific objections to appropriateness of the foot in 
question are without basis. The Elan is not more prone to corrosion than a mechanical foot, it comes with a 3-
year warranty, and it is not significantly heavier than many other K3 feet. Our reviewer also found that there is 
every reason to expect that Original Medicare would cover the requested foot for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an endoskeletal ankle foot system (L5973) have been met. Therefore, we 
decided that the Plan has to pre-approve an endoskeletal ankle foot system (L5973).  
 
We also decided that the Plan does not have to pre-approve a flex-walk system or equal (L5981). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
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 flex-walk system or equal (L5981). 
Our physician reviewer found that the CPO explains only the L5973 Elan foot in their clinic note and makes no 
mention at all of considering a flex-walk alternative to this. These are both base codes, and getting two separate 
K3 feet for community ambulation for a single prosthesis would certainly exceed the enrollees needs.  
 
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 flex-walk system or equal (L5981) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a flex-walk system or equal (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.