Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve single axis, fluid swing and stance phase control (L5828) stance 
flexion feature, adjustable (L5845) fluid stance extension, dampening feature, with or without adjustability (L5848) above knee or hip disarticulation, knee extension assist (L5850) microprocessor control feature, swing 
and stance phase, includes electronic sensor(s), any type (L5856). 
 
You asked the Plan to pre-approve the advanced knee and foot features. You say that the medical records 
provided will show proof of medical necessity. The Plan denied your request. The Plan says that the request for 
a K3 knee and K3 foot exceed the member's need and does not meet the Medicare criteria of reasonable and 
necessary  
 
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 advanced knee and foot features. 
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 (e.g. the certified prosthetist/orthotist 
clinic note and appeal letter from May as well as the medical doctors clinic note from January) go above and 
beyond in satisfying Medicare policy by demonstrating this enrollee has K3 functional level potential and has 
specific needs for the requested components, 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 Beneficiary 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 - You must need to do more than simple walking. You must 
need to cross different barriers (such as walking long distances or walking on steep or slippery surfaces). 
 
Regarding the criteria for coverage of the requested components, LCD L33787 states simply A fluid, 
pneumatic, or electronic/microprocessor knee is covered for beneficiaries whose functional level is 3 or 
above. It also states, flex foot system (L5981) is covered for beneficiaries whose functional level is 3 or 
above.  No further specific documentation is required in the LCD, the Policy Article, or any of the relevant 
Medicare manuals because Medicares policy recognizes that microprocessor knees and flex-walk feet are part 
of the basic standard of care for all community above knee amputee ambulators given that the evidence of their 
benefits and superiority to less sophisticated alternatives are so well proven and long standing. In the case of 
this enrollee, and all comparable K3 ambulators, lesser devices simply do not meet their functional needs and 
amount to substandard care. There is no doubt that original Medicare would cover the requested prosthesis for 
this K3-level enrollee. Therefore, the requested microprocessor knee (L5828, L5845, L5848, L5850, L5856) 
and foot (L5981) are 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 the advanced knee and foot features have been met. Therefore, we decided that 
the Plan has to pre-approve single axis, fluid swing and stance phase control (L5828) stance flexion feature, 
adjustable (L5845) fluid stance extension, dampening feature, with or without adjustability (L5848) above knee 
or hip disarticulation, knee extension assist (L5850) microprocessor control feature, swing and stance phase, 
includes electronic sensor(s), any type (L5856).  
 
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.