Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an endoskeletal ankle foot system, microprocessor-controlled 
feature, dorsiflexion and/or plantar flexion control, includes power source (L5973). 
 
You asked the Plan to pre-approve a microprocessor foot. You say that the enrollee's current prosthesis does 
not meet his current functional needs. The enrollee needs a new foot that fits. The Plan denied your request. 
The Plan says that the request for a K3 microprocessor foot does not meet Medicare criteria as reasonable and 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a microprocessor foot. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found 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 enrollee. The Plan seems to have 
accepted that such a change has occurred both by virtue of approving the replacement socket, and in its first 
denial letter where is overtly states that a new foot could be covered if it were simpler in design. This evidence 
inherently undercuts the credibility of the Plans later position that no new foot can be covered at all because the existing one appears to be under warranty. Therefore, the enrollee does qualify for a new foot at this point 
in the light of repeated falls, stemming from a change in his ability to get through a physiologically normal gait 
cycle (which necessarily involves being able to reliably clear the toe during swing phase on all surfaces) using 
his existing foot. The medical doctor note from March and the certified prosthetist/orthotist (CPO) notes from 
April clearly establish his K3-activity level, and specific reasonableness and necessity of the requested 
foot. LCD L33787 explicitly establishes that L5973 is one of the foot types covered for K3-level ambulators, 
without further specific documentary requirements, since this foot is part of the mainstream standard of care for 
an ambulator like this enrollee. Given all of the above, it is highly likely that traditional Medicare would cover 
the requested foot for this enrollee. Therefore, L5973 is hereby approved. 
 
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 microprocessor foot have been met. Therefore, we decided that the Plan has to 
pre-approve an endoskeletal ankle foot system, microprocessor-controlled feature, dorsiflexion and/or plantar 
flexion control, includes power source (L5973).  
 
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.