Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve all-lower extremity prostheses, flex-walk system or equal (L5981). 
 
You asked the Plan to pre-approve a prosthetic foot. You say that the enrollee's daily activities require that she 
do more than simple walking. The enrollee exhibits all necessary physical needs to successfully utilize a 
prosthesis as a K3 ambulator. The Plan denied your request. The Plan says that the enrollee does not meet 
criteria for the requested prosthetic. 
 
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 foot. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that not only does the medical record satisfy Medicare policy in demonstrating this enrollee has 
a K3 functional level, but the Plan also attempts to create a more restrictive policy for defining K3 function 
than Medicare policy would allow. In contrast to these broad, inclusive K3-criteria that generally describe the 
average Medicare enrollee who lives independently at home and in the community, the Plans denial letter sets 
more stringent requirements than Medicare. In its own definition of the K3 level, the Plan seeks to create strict 
use-case criteria with a level of specificity that does not appear in the LCD, The enrollee must need to do 
more than simple walking, the enrollee must need to cross different barriers (such as walking long distances or 
walking on steep or slippery surfaces). The certified prosthetist/orthotists (CPOs) clinic note from December 
2022, and his appeal letter, corroborated by the physicians note from January 2023, more than satisfy 
Medicare requirements for documenting the enrollees K3 functional potential as well as her need for the new 
prosthesis generally and the foot specifically. LCD L33787 states simply flex foot system (L5981) 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 flex-walk feet are part of the basic standard of care for all community K3 amputee ambulators given that 
the evidence of their benefits and superiority to less sophisticated alternatives are so well proven and long 
standing. Forcing this enrollee to use K2 level componentry is simply sub-standard care. There is no doubt that 
original Medicare would cover the requested prosthesis for this K3-level enrollee. Therefore, the requested foot 
(L5981) 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 foot have been met. Therefore, we decided that the Plan has to pre-
approve all-lower extremity prostheses, flex-walk system or equal (L5981).  
 
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.