Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve energy storing foot. We decided that the Plan does not have to pre-
approve flexible protective outer surface covering system.  
 
You asked the Plan to pre-approve an energy storing foot and flexible protective outer surface covering 
system.. You say that you disagree with the Plan's denial. The Plan says that the requested items are not 
medically necessary. 
 
We decided that the Plan has to pre-approve energy storing foot.  
 
The Plan follows Medicare rules. Medicare rules say that a microprocessor controlled ankle foot system 
(L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system 
(L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is 
covered for beneficiaries whose functional level is 3 or above. 
 
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 energy storing foot and flexible 
protective outer surface covering system. Our reviewer says that the documentation supports that the energy 
storing foot is medically reasonable and necessary. The documentation does not support that the flexible 
protective outer surface covering system is medically reasonable or necessary. Our physician reviewer found 
the enrollee right transtibial amputation which occurred decades ago in the setting of a traumatic motor vehicle 
accident. The enrollee has been a life-long successful prosthetic ambulator, and active in the community, both 
holding down a job and raising a family without any notable physical limitations. Recently the enrollee had a 
fibular wound on his residual limb that required excision of the fibula in November 2022, necessitating a new 
socket. The certified prosthetist/orthotist (CPO) notes regarding the enrollees K3-functional status and the 
enrollees generally independent, unlimited ambulation and activity are corroborated by the surgeon. The 
record substantiates that this is a generally healthy enrollee who has no physically limiting musculoskeletal, 
cardiovascular, pulmonary or neurological conditions, such that there is no reason to expect that he would have 
any limitations to normal community ambulation when given the proper prosthesis. Per LCD L33787, L5976 is 
broadly covered for any K3 ambulator, which the enrollee clearly is. Therefore, the enrollee does meet criteria 
for the requested energy storing foot. 
 
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 energy storing foot and flexible protective outer surface covering system 
have been met. Therefore, we decided that the Plan has to pre-approve energy storing foot.  
 
We also decided that the Plan does not have to pre-approve flexible protective outer surface covering 
system. 
 
The Plan follows Medicare rules. Medicare rules say that protective outer surface covering systems (L5962, 
L5964, and L5966) are specialized covers intended to be worn over an existing prosthesis. They are used by a 
beneficiary who has special needs for protection against unusually harsh environmental situations where it is 
necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by L5704, L5705, 
L5706, and L5707. They are not for cosmetic or convenience reasons, or for everyday usage in a typical 
environment. 
 
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 flexible protective outer surface 
covering system. Our reviewer says that the documentation supports that the energy storing foot is medically 
reasonable and necessary. The documentation does not support that the flexible protective outer surface 
covering system is medically reasonable or necessary. Our physician reviewer found the enrollee right transtibial amputation which occurred decades ago in the setting of a traumatic motor vehicle accident. The 
enrollee has been a life-long successful prosthetic ambulator, and active in the community, both holding down 
a job and raising a family without any notable physical limitations. Recently the enrollee had a fibular wound 
on his residual limb that required excision of the fibula in November 2022, necessitating a new socket. The 
certified prosthetist/orthotist (CPO) notes regarding the enrollees K3-functional status and the enrollees 
generally independent, unlimited ambulation and activity are corroborated by the surgeon. The record 
substantiates that this is a generally healthy enrollee who has no physically limiting musculoskeletal, 
cardiovascular, pulmonary or neurological conditions, such that there is no reason to expect that he would have 
any limitations to normal community ambulation when given the proper prosthesis. Protective outer surface 
covering systems (L5962, L5964, and L5966) are specialized covers intended to be worn over an existing 
prosthesis. They are used by an enrollee who has special needs for protection against unusually harsh 
environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of 
protection that is afforded by L5704, L5705, L5706, and L5707. They are not for cosmetic or convenience 
reasons, or for everyday usage in a typical environment. Given the specific documentation requirements for this 
component, it is incumbent on the CPO to provide a medical record that provides a higher level of specificity to 
justify coverage.  However, in this case, no such justification or context is provided to suggest that this 
Beneficiarys prosthesis will be exposed to unusually harsh environments necessitating additional protection 
beyond what can be provided with a typical cover. Therefore, the enrollee does not meet criteria for the 
requested flexible protective outer surface covering system. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of flexible protective outer surface covering system have not been met. Therefore, 
we decided that the Plan does not have to pre-approve flexible protective outer surface covering system. 
 
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.