Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an all-lower extremity prosthesis, flex-walk system (L5981) and 
an all-lower extremity prosthesis, multi-axial rotation unit (L5986). You asked the Plan to pre-approve all-lower extremity prosthetics. You say that the requested prosthetics are 
medically necessary for the enrollee as the current foot is not providing enough energy return to allow the 
enrollee to have a smooth rollover when he is walking causing him to stub his toe and trip. The Plan denied 
your request. The Plan says that the requested advanced foot-ankle exceeds 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 all-lower extremity prosthetics. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found 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. 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, or 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) March clinic note, with corroboration from the 
surgeons January 2023, note, satisfy Medicare requirements for documenting his K3 functional potential as 
well as his need for the new foot in question. LCD L33787 states simply a 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 and the various additions chosen by the treating team 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. This enrollee should probably have never 
received a mere SACH foot given his functional level/potential level, so an upgrade is clinically indicated on 
those grounds alone. Moreover, it is wholly believable that his SACH foot is beyond warranty and repair, given 
that standard warranties for such old, outdated technology are generally not even 3 years in length. There is no 
doubt that original Medicare would cover the requested prosthesis for this K3-level enrollee. Therefore, the 
requested foot (L5981, 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 all-lower extremity prosthetics have been met. Therefore, we decided that the 
Plan has to pre-approve an all-lower extremity prosthesis, flex-walk system (L5981) and an all-lower extremity 
prosthesis, multi-axial rotation unit (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.