Appeal type: DME/ Orthotics
Decision: Partially Favorable

 We decided that the Plan has to pre-approve an alignable system (L5920). We decided that the Plan does not 
have to pre-approve the WillowWood Meta Shock foot (L5987).  
 
You asked the Plan to pre-approve an alignable system (L5920) and the WillowWood Meta Shock foot 
(L5987). You say that the items are medically necessary. The Plan says that the items are not medically 
necessary. 
 
We decided that the Plan has to pre-approve an alignable system (L5920).  
 
The Plan follows Medicare rules. Medicare rules say that overage 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. Our reviewer says that this 
item is medically necessary. Our physician reviewer found that a new alignable system is necessary every time 
a new lower extremity prosthetic socket is fabricated. 
 
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 have been met. Therefore, we decided that the Plan has to 
pre-approve an alignable system (L5920).  
 
We also decided that the Plan does not have to pre-approve the WillowWood Meta Shock foot (L5987). 
 
The Plan follows Medicare rules. Medicare rules say that replacement of a prosthesis or prosthetic component 
is covered if the treating practitioner orders a replacement device or part because of any of the following: 
1. A change in the physiological condition of the beneficiary; or 
2.  Irreparable wear of the device or a part of the device; or 
3.The condition of the device, or part of the device, requires repairs and the cost of such repairs would be more 
than 60% of the cost of a replacement device, or of the part being replaced. 
 
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 WillowWood Meta Shock foot 
(L5987). Our reviewer says that the item is not medically necessary. Our physician reviewer found that the sole 
reason for requesting a replacement for the enrollees warrantied foot is that it is too long. That is simply not a 
problem Medicares policy above would permit coverage of a new foot to address.  Because the Beneficiarys 
sound side foot is likely the same size today as it was in 2021, it is therefore likely that the existing foot has 
been too long since the time it was originally ordered and should have been ordered at a smaller size back in 
2021. 
 
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 WillowWood Meta Shock foot (L5987) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the WillowWood Meta Shock foot (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.