Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an all-lower extremity prosthesis, multi-axial rotation unit (L5986) 
and an all-lower extremity prosthesis, shank foot system with vertical loading pylon (L5987). 
 
You asked the Plan to pre-approve a prosthetic leg with an advanced foot and ankle feature. You say that the 
enrollee is a double amputee. The provider previously obtained an authorization for the right leg. All codes 
were approved. This is for the left leg. The Plan denied your request. The Plan says that the requested 
prosthetics are not covered by Medicare or the health plan. The prosthetics exceed the enrollee's need. 
 
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 prosthetic leg with an advanced foot 
and ankle feature. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the medical record satisfies Medicare policy in 
demonstrating this enrollee has K3 functional potential, and even if his functional level really were 
controversial, he would still qualify for the requested foot as a bilateral amputee. We note, on one hand, that 
these broad, inclusive K3-criteria generally describe the average Medicare enrollee who lives independently at 
home and in the community, which this enrollee could very credibly do with the proper prostheses. On the 
other hand, the LCD is specifically lenient in prosthetic coverage criteria for bilateral amputees, in that it does 
not strictly hold them to K-level thresholds. The certified prosthetist/orthotist (CPO) note from July and the 
prescriber note August more than satisfy Medicare requirements for documenting his K3 functional potential as 
well as his particular need for the new prosthetic foot in question. LCD L33787 also states shank foot system 
with vertical loading pylon (L5987) is covered for enrollees whose functional level is 3 or above.  No further 
specific documentation is actually required in the LCD, the Policy Article, or any of the relevant Medicare 
manuals because Medicares policy recognizes that these dynamic feet (with permitted additions such as 
L5986) are part of the basic standard of care for all unlimited community (K3) amputee ambulators given that 
the evidence of their benefits and superiority to less sophisticated alternatives are so well proven and long 
standing. There is no doubt that original Medicare would cover the requested prosthesis for this enrollee, a 
bilateral amputee with K3-level potential. Therefore, the requested foot (L5987, L5986) 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 prosthetic leg with an advanced foot and ankle feature have been met. 
Therefore, we decided that the Plan has to pre-approve an all-lower extremity prosthesis, multi-axial rotation 
unit (L5986) and an all-lower extremity prosthesis, shank foot system with vertical loading pylon (L5987).  
 
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.