Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pay for L5910, L5968, and L5972. We decided that the Plan does not have to 
pay for L5962.  
 
You asked the Plan to pay for a prosthetic leg with a foot feature, extra covering, and other parts.. You say that 
this is medically necessary. The Plan says that the requested parts do not meet the criteria for being reasonable 
and necessary. 
 
We decided that the Plan has to pay for L5910, L5968, and L5972.  
 
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 L5910, L5968, and L5972. Our reviewer says that 
the question is whether the enrollee qualifies for a replacement foot at this juncture. One of the criteria that is 
sufficient for replacement of a prosthesis/component per Policy Article A52496 is change in the physiological 
condition of the beneficiary. Meanwhile the medical record provided establishes that his functional potential 
has improved since his existing prosthesis was designed, and this certainly is accepted as a sufficient 
physiological change to approve coverage of replacement componentry. Notably, having looked at the 
construction of his existing prosthetic foot, this review finds that it barely qualifies as K2 level foot, and 
probably could have been coded as a mere single axis L5974, making the certified prosthetist/orthotists (CPO) 
comments about the enrollees need for a more functional ankle highly credible. The warranty on this existing 
foot cannot change its basic inability to meet his functional needs. 
 
Regarding L5910, it is highly unusual for a Plan to approve a replacement socket but then specifically deny a 
small, inexpensive constituent part that is essential to the use of device, such as the alignable system.  Given 
that the medical record overall has been deemed to be sufficient to cover the replacement socket generally, it 
creates an undue burden, which is not supported nor called for in Medicare policy, on the beneficiary to 
demand that the record specifically address the re-usability of a small subpart of the overall approved service 
which neither a prosthetist nor a prescribing MD would think to speak to in the creation of authentic medical 
records. Indeed, the alignable system is not usually recycled between sockets precisely because key parts of it 
are laminated directly into the structure of the previous socket. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
L5910, L5968, and L5972.  
 
We also decided that the Plan does not have to pay for L5962. 
 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 L5962. Our reviewer says that there is no justification 
found in the records 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.