Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the prosthetic component described by code L5910. We 
decided that the Plan does not have to pre-approve the Level 3 prosthetic foot consisting of L5981 and L5986.  
 
You asked the Plan to pre-approve a below the knee alignable system (L5910), a Level 3 prosthetic foot 
consisting of L5981 and L5986. You say that all requested components should be covered. The Plan says that 
the components described by codes L5910, L5981, and L5986 are not medically necessary. Other requested 
items have been approved. 
 
We decided that the Plan has to pre-approve the prosthetic component described by code L5910.  
 
The Plan follows Medicare rules. Medicare rules say that a determination of the medical necessity for certain 
components/additions to the prosthesis is based on the beneficiarys potential functional abilities.  
  
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 prosthetic component described by 
code L5910. Our reviewer says that the denial of the item described by code L5910 is not supported by the 
Plan. Our physician reviewer found it is generally not appropriate for a Plan to approve a replacement socket, 
but specifically deny a small, inexpensive constituent part that is essential to the use of device. Given that the 
medical record overall has been deemed to be sufficient to cover the replacement socket generally, it creates an 
undue burden on the enrollee, which is not supported nor called for in Medicare policy, to demand that the 
record specifically address a small subpart of the overall approved service which neither a prosthetist nor a 
prescribing physician would think to speak to in the creation of authentic medical records. There are no specific 
regulations regarding this component likely because this part is not usually recycled between sockets since it is 
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 prosthetic component described by code L5910 have been met. Therefore, 
we decided that the Plan has to pre-approve the prosthetic component described by code L5910.  
 
We also decided that the Plan does not have to pre-approve the Level 3 prosthetic foot consisting of 
L5981 and L5986. 
 
The Plan follows Medicare rules. Medicare rules say that items covered under manufacturer warranty may not 
be covered by Medicare.   
 
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 Level 3 prosthetic foot consisting of 
L5981 and L5986. Our reviewer says that the treating providers did not submit sufficient information to justify 
coverage of a new prosthetic foot. Our physician reviewer found the Plan has shown that a similar foot was 
authorized in 2020. The prosthetist and treating physician did not indicate that this new foot was not covered 
under the manufacturers warranty. Coverage under the warranty would need to be exhausted prior to coverage 
under Medicare. 
 
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 Level 3 prosthetic foot consisting of L5981 and L5986 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Level 3 prosthetic foot consisting of 
L5981 and L5986. 
 
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.