Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an addition to lower limb prosthesis, multiaxial ankle with swing 
phase active dorsiflexion feature (L5968) and an all-lower extremity prosthesis, flex-walk system or equal 
(L5981). 
 
You asked the Plan to pre-approve prosthetics. You say that the enrollee is in need of prosthetics to reduce 
energy expenditure. The articulating ankle will help reduce energy expenditure in this enrollee's case. The Plan 
denied your request. The Plan says that the request for prosthesis with K3 foot does not meet Medicare criteria 
as 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 prosthetics. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a left transtibial amputation, who has become a successful unlimited 
community ambulator. Her current prosthesis is ill fitting, malfunctioning, and off-warranty. 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 - 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). The 
prescribers notes from April of this year, more than satisfy Medicare requirements for documenting her K3 
functional potential and need for a new prosthesis.  Meanwhile, the Plans focus on the enrollees future use of 
a wheelchair is misplaced, given that the record shows that it is the problems with her existing prosthesis that 
are leading to requests for additional assistive devices.  Moreover, the line of argument regarding the 
wheelchair is irrelevant to this request since some use of other assistive devices is not, on its own, disqualifying 
of a K3 status. LCD L33787 states flex foot system (L5981) is covered for enrollees 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 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. There is no doubt that 
original Medicare would cover the requested prosthesis for this K3-level enrollee. Therefore, the requested foot 
(L5981, L5968) 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 prosthetics have been met. Therefore, we decided that the Plan has to pre-
approve an addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature 
(L5968) and an all-lower extremity prosthesis, 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.