Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the electronic knee and L5999. We decided that the Plan does 
not have to pre-approve L5964.  
 
You asked the Plan to pre-approve the Ottobock C-leg microprocessor knee.. You say that this is medically 
necessary. The Plan says that the provider's notes do not show why a mechanical knee cannot be used. 
 
We decided that the Plan has to pre-approve the electronic knee and L5999.  
 
The Plan follows Medicare rules. Medicare 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 these items. Our reviewer says that the Plan erred 
in its denial of the requested microprocessor knee and the positional rotation unit. The medical record, which 
includes the certified prosthetist/orthotist's (CPO) clinic note from April, and the physiatrist's note from March, 
goes above and beyond in satisfying the Medicare policy by demonstrating the enrollee has K3 functional level 
potential, and has specific needs for the requested knee and positional rotational unit. 
 
The enrollee's K3 potential is well documented in both the records, and in the fact that the plan has tacitly 
recognized this ambulation level by approving L5981. The LCD simply states that a microprocessor knee is 
covered for beneficiaries whose functional level is 3 or above. No further specific documentation is required in 
the LCD, the Policy Article, or any of the relevant Medicare manuals because Medicares policy recognizes 
that microprocessor knees 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. In the case of this enrollee, and all comparable K3 ambulators, lesser devices simply 
do not meet their functional needs and would amount to substandard care. 
 
As for the L5999 positional rotation unit, the Plan is incorrect that it is miscoded. The component requested 
here goes between the knee and the socket (not at the ankle like all other rotation units already coded for) and 
allows for repositioning of the knee in a wide arc in the coronal plane when the user is statically 
standing/sitting in positions where the knee might otherwise be in the way. It is explicitly reasonable and 
necessary for this enrollee given his very active, ergonomically challenging occupation as a trade show 
stagehand, where is it readily conceivable he will need that adjustability in order stand/sit safely in various tight 
or precarious places. 
 
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 pre-approve 
the electronic knee and L5999.  
 
We also decided that the Plan does not have to pre-approve L5964. 
 The Plan follows Medicare rules. Medicare 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 protective cover - L5964. Our reviewer says 
that given the specific documentation requirements for this item, it is incumbent on the CPO to provide a 
medical record that meets these requirements. However, in this case, no such justification or context is found in 
the record to suggest that this enrollees prosthesis will be exposed to unusually harsh environments 
necessitating additional protection beyond what is provided with a typical cover. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L5964 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve L5964. 
 
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.