Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a vacuum-assisted socket system (L5781). We decided that the 
Plan does not have to pre-approve an endoskeletal ankle foot system (L5973).  
 
You asked the Plan to pre-approve a vacuum-assisted socket system (L5781) and endoskeletal ankle foot 
system (L5973). You say that there are multiple documents showing that there have been years of studies 
showing that code L5781 is better, and Medicare will pay for this code. You also say that the patient meets the 
need for the microprocessor ankle/foot. The Plan says that the request for a microprocessor K3 foot does not 
meet Medicare criteria as reasonable and necessary. The Plan also says that a vacuum socket cannot be 
covered, as experimental and investigational items are not covered by Medicare. 
 
We decided that the Plan has to pre-approve a vacuum-assisted socket system (L5781).  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 vacuum-assisted socket system 
(L5781). Our reviewer says that the vacuum assisted socket suspension system (L5781) is medically necessary. 
Our physician reviewer found the patient has experienced a change in the volume of their residual limb and 
their current prosthetic socket no longer fits their residual limb despite attempted modification. The patient 
requires a new prosthetic socket for their prosthesis, which is necessary for mobility and performing daily 
activities. Our reviewer found that the vacuum assisted socket suspension system allows for the best fit and 
accommodation given the irregular shape of their residual limb. Our physician reviewer also found that there is 
medical literature indicating that this type of suspension system can be helpful in patients with volume 
fluctuation.   
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 vacuum-assisted socket system (L5781) have been met. Therefore, we decided 
that the Plan has to pre-approve a vacuum-assisted socket system (L5781).  
 
We also decided that the Plan does not have to pre-approve an endoskeletal ankle foot system (L5973). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 endoskeletal ankle foot system 
(L5973). Our reviewer says that the microprocessor foot/ankle (L5973) is not medically necessary. Our 
physician reviewer found the microprocessor foot/ankle the patient currently has is functional and is only 1 
year and 4 months in age. Our reviewer also found that it is a K3 level foot/ankle and can meet the patients 
mobility needs and mobility related daily activity needs.  
 
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 endoskeletal ankle foot system (L5973) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an endoskeletal ankle foot system (L5973). 
 
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.