Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a replacement fluid swing and stance phase control (L5828), fluid 
stance extension (L5848), microprocessor control feature (L5856), endoskeletal ankle foot system (L5973), and 
stance flexion feature (L5845). 
 
You asked the Plan to pre-approve a replacement fluid swing and stance phase control, fluid stance extension, 
microprocessor control feature, endoskeletal ankle foot system, and stance flexion feature. You say that the 
proposed prosthesis is the most basic to meet the enrollee's needs. The Plan denied your request. The Plan says 
that this request for replacement K3 microprocessor knee and foot does not meet Medicare criteria as 
reasonable and necessary. 
 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 replacement fluid swing and stance 
phase control, fluid stance extension, microprocessor control feature, endoskeletal ankle foot system, and 
stance flexion feature. Our reviewer says that this request is medically reasonable and necessary for the 
enrollee. Our physician reviewer found dispensing with the medical record, it meets criteria in that the 
enrollees need for a new prosthesis is explicitly documented by both the Certified Prosthetist/Orthotist (CPO) 
and the prescribing medical doctor (MD), and their K3 level is not in dispute. The CPO credibly cites leaking 
of hydraulic fluid from the existing foot/ankle as well as locking up of the knee component which has been 
causing the enrollee to stumble and increase his fall risk. Our reviewer found that this is to be expected in 
componentry like this that is 5 years old, whether we are discussing microprocessor-controlled or even strictly 
mechanical lower extremity components, especially for active users like this enrollee. It is highly irregular to 
attempt to repair, rather than replace, this kind of sophisticated microprocessor componentry that is multiple 
years beyond warranty precisely because repairing it inevitably proves more expensive to Medicare than 
simply replacing it when it starts to demonstrate these failures which are typical at the end of its useful lifetime. 
Our physician reviewer found that in effect, devices of this age are in fact irreparably worn when they start to 
show failure like those described in the record because the repair will not last, and any futile repairs attempted 
will certainly cost more than 60% of replacement value. Our reviewer also found that the LCD expressly 
permits microprocessor knees and ankles to be provided for K3 ambulators such as this without other specific 
documentary requirements because they are the standard of care and can be counted on to function for at least 3 
years at a time. 
 
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 replacement fluid swing and stance phase control, fluid stance extension, 
microprocessor control feature, endoskeletal ankle foot system, and stance flexion feature have not been met. 
Therefore, we decided that the Plan has to pre-approve a replacement fluid swing and stance phase control 
(L5828), fluid stance extension (L5848), microprocessor control feature (L5856), endoskeletal ankle foot 
system (L5973), and stance flexion feature (L5845).  
 
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.