Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a PTB brim (L5632), flexible inner socket (L5645), acrylic 
lamination (L5629), ultralight material (L5940), and distal cushion (L5668). We decided that the Plan does 
not have to pre-approve an alignable system (L5910), and closures (L2330).  
 
You asked the Plan to pre-approve a PTB brim (L5632), flexible inner socket (L5645), acrylic lamination 
(L5629), ultralight material (L5940), distal cushion (L5668, alignable system (L5910), and closures (L2330). 
You say that the items are medically necessary. The Plan says that these items are already included in the base 
foot and these codes are unbundled. 
 
We decided that the Plan has to pre-approve a PTB brim (L5632), flexible inner socket (L5645), acrylic 
lamination (L5629), ultralight material (L5940), and distal cushion (L5668).  
 
The Plan follows Medicare rules. Medicare rules say that L5020 describes a partial foot device including a 
molded socket for the residual limb with a proximal height terminating at or near the tibial tubercle to achieve 
appropriate support and function. L5020 is inclusive of a rigid longitudinal arch support that also incorporates 
material accommodating the void left by the missing digit(s) or forefoot. Additional soft material is added 
where contact is made with the residual limb or toes. L5020 devices are designed to provide standing balance 
and toe off support for improved gait. All closures are included, any type. L5020 is inclusive of variations in 
materials or combinations such as differing stiffnesses or Shore value. 
 
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 PTB brim (L5632), flexible inner 
socket (L5645), acrylic lamination (L5629), ultralight material (L5940), and distal cushion (L5668). Our 
reviewer says that per the above rule, L5632, L5645, L5629, L5940, and L5668 are not explicitly disallowed.   
Our physician reviewer found each of these codes are billable descriptors of essential custom fabricated aspects 
of the prosthesis needed by this enrollee to be functional. These codes are not already accounted for in the 
L5020 definition. 
 
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 PTB brim (L5632), flexible inner socket (L5645), acrylic lamination (L5629), 
ultralight material (L5940), and distal cushion (L5668) have been met. Therefore, we decided that the Plan has 
to pre-approve a PTB brim (L5632), flexible inner socket (L5645), acrylic lamination (L5629), ultralight 
material (L5940), and distal cushion (L5668).  
 
We also decided that the Plan does not have to pre-approve an alignable system (L5910), and closures 
(L2330). 
 
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. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 an alignable system (L5910), and 
closures (L2330). Our reviewer says that these items are not medically necessary. Our physician reviewer 
found the cost of "closures" is already included, therefore billing L2330 would in fact count as unbundling. 
Meanwhile, L5910 is specifically a below knee-component, and would not typically be considered reasonable 
and necessary for a partial foot prosthesis that does not include a whole foot component separate from the 
socket. There has been no attempt to explain how an alignable system specifically could figure into the design 
of prosthesis with no spare build height, and where the alignment is effectively fixed by the alignment of the 
cast layup before lamination. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an alignable system (L5910), and closures (L2330) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an alignable system (L5910), and closures 
(L2330). 
 
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.