Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
You asked the Plan to pre-approve a microprocessor knee with axial rotation unit (L5984, L5828, L5845, 
L5856, and L5984) and protective outer surface covering (L5964). You say that alternative prosthetics would 
not meet the enrollee's needs. The Plan says that these components are not medically necessary. 
 
We decided that the Plan has to pre-approve microprocessor knee and axial rotation unit.  
 
The Plan follows Medicare rules. Medicare rules state that lower limb prosthetic components may be covered 
when medically necessary. 
 
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 the item/service at issue. Our reviewer 
says that the enrollee meets criteria for a microprocessor knee and axial rotation unit. Our physician reviewer 
found both prescribing physician and prosthetist documentation corroborate enrollee's need. The enrollee is 
well documented at K3 level functional level. The enrollee is motivated to use a prosthesis. Prior to 
amputation, the enrollee regularly ambulated on uneven terrain within in the community, on trails and the 
beach. Enrollee scored a 59 on the Patient Assessment Validation Evaluation Test (PAVET) indicating 
potential for microprocessor knee (MPK) use. Without the advanced settings and safety provided by an MPK 
such as in-real time resistance adjustment and stumble recovery, enrollee would at a greater risk of falls and 
adverse injuries with use of a mechanical knee versus a microprocessor prosthetic knee. This was well 
documented and supported by both the prosthetist and physician notes. 

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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pre-approve microprocessor knee and axial rotation unit.  
 
We also decided that the Plan does not have to pre-approve protective outer surface covering. 
 
The Plan follows Medicare rules. Medicare rules state that protective outer surface coverings may be covered 
when needed for unusually harsh environmental situations.  
 
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 the item/service at issue. Our reviewer 
says that the enrollee does not meet criteria for a protective outer surface covering. Our physician reviewer 
found the documentation does not provide justification for protection against unusually harsh environments.  
 
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 item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pre-approve protective outer surface covering. 
 
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.