Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pay for L5973. We decided that the Plan does not have to pay for L5962.  
 
You asked the Plan to pay for a prosthetic leg with a microprocessor foot and an extra covering system.. You 
say that this is medically necessary. The Plan says that the requested items exceed the enrollee's needs. 
 
We decided that the Plan has to pay for L5973.  
 
The Plan follows Medicare rules. The rules say that coverage is extended only if there is sufficient clinical 
documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 for the microprocessor foot (L5973). Our reviewer 
says that the records are more than sufficient to confirm the enrollee's K3 status. The records go above and 
beyond in showing the foot's functional benefits for the enrollee. The enrollee has resumed independent living, 
and has unlimited community ambulation using the existing prosthesis at the K3 level. The current prosthesis is 
ill-fitting and out of warranty. The certified prosthetist/orthotist (CPO) has trialed multiple styles of feet with 
the enrollee to attempt to mitigate pain. It was found that a microprocessor-controlled foot/ankle system offers 
the smoothest and least painful mode of walking for the enrollee. A microprocessor foot coded with L5973 
only requires documentation of a functional K3 level. This has been documented in the records. It is part of the 
basic standard of care for all community K3 ambulators, given the evidence of benefits that are proven and 
accepted by the clinical community. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the items have been met. Therefore, we decided that the Plan has to pay for 
L5973.  
 
We also decided that the Plan does not have to pay for L5962. 
 
The Plan follows Medicare rules. The rules say that coverage is extended only if there is sufficient clinical 
documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 for the flexible outer cover (L5962). Our reviewer says 
that there is justification or context for this request in the documentation. There is nothing to suggest that the enrollee's prosthesis will be exposed to unusually harsh environments necessitating additional protection 
beyond what is provided with a typical cover, such as L5704, which has already been approved by the plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L5962 have not been met. Therefore, we decided that the Plan does not have to 
pay for L5962. 
 
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.