Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve dampening feature (L5848), single axis, fluid swing and stance 
phase control (L5828), microprocessor control feature (L5856), flex-walk system or equal (L5981), molded 
socket, open end, SACH foot (L5321), test socket (L5624), acrylic socket (L5631), ischial containment/narrow 
M-L socket (L5649), total contact, above knee (AK) or knee disarticulation socket (L5650), flexible inner socket, external frame (L5651), suction suspension (L5652), silicone gel socket insert (L5679), adjustable 
stance flexion feature (L5845), alignable system (L5920), ultra-light material (titanium, carbon fiber or equal) 
(L5950), prosthetic sock, multiple ply (L8430), prosthetic shrinker (L8460), prosthetic sock, single ply 
(L8480). 
 
You asked the Plan to pre-approve the prosthetic and accessories. You say that the enrollee has demonstrated 
K3 ambulation. You also say that the proposed device is the least costly device which can provide the needed 
and appropriate therapeutic benefit for the enrollee.  The Plan denied your request. The Plan says that the 
enrollee's abilities are at either a K1 or K2 level at this time and therefore do not qualify for a K3. The records 
do not demonstrate the medical need for a microprocessor knee or L5981-Flex walk System (foot).  
 
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 the prosthetic and accessories. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case.   
Our physician reviewer found the enrollee was seen by their treating provider on March 15, 2023, and was 
noted to be a K3 ambulator. The enrollee was seen on March 31, 2023, in physical therapy and was noted to 
have scored a 37 on the AmpPro indicating that the enrollee had progressed to a K3 ambulator in four (4) visits. 
The documentation supports that the enrollee has progressed to a K3 ambulator and was noted to have hit this 
as of March 10, 2023. The enrollee was seen by a prosthetist, their treating provider, and physical therapist who 
all agree that the requested microprocessor knee is medically indicated for the enrollee. Specific tasks the 
enrollee does or is expected to do to justify the K-level include: use of a stationary bike, walk quickly across 
parking lots, walk dogs, use stairs, and be an unlimited community ambulator. Therefore, the enrollee is a level 
3 ambulator and therefore, indicated for these requested items.  
 
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 prosthetic and accessories have been met. Therefore, we decided that the 
Plan has to pre-approve dampening feature (L5848), single axis, fluid swing and stance phase control (L5828), 
microprocessor control feature (L5856), flex-walk system or equal (L5981), molded socket, open end, SACH 
foot (L5321), test socket (L5624), acrylic socket (L5631), ischial containment/narrow M-L socket (L5649), 
total contact, above knee (AK) or knee disarticulation socket (L5650), flexible inner socket, external frame 
(L5651), suction suspension (L5652), silicone gel socket insert (L5679), adjustable stance flexion feature 
(L5845), alignable system (L5920), ultra-light material (titanium, carbon fiber or equal) (L5950), prosthetic 
sock, multiple ply (L8430), prosthetic shrinker (L8460), prosthetic sock, single ply (L8480).  
 
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.