Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a fluid swing and stance phase control (L5828), stance flexion 
feature (L5845) fluid stance extension (L5848), microprocessor control feature (L5856), endoskeletal knee-shin 
system (L5859), flex-walk system or equal (L5981), axial rotation unit (L5984), and multi-axial rotation unit 
(L5986). 
 
You asked the Plan to pre-approve the items. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that this request for a K3 foot and microprocessor knee 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 the items. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the Plan erred in its denials of each and every code at issue here. The medical record (e.g., the Certified Prosthetist/Orthotist (CPO) notes from July and August, corroborated by the primary care physician 
(PCP) note from July) establishes that this is a bilateral above knee amputee with hip contractures, but also a 
demonstrated ability to walk normally when equipped with the right prostheses. The regulatory issue here 
hinges on the enrollee's bilateral amputations. We note that LCD 33787 is specifically lenient on this 
population when it says, It is recognized, within the functional classification hierarchy, that bilateral amputees 
often cannot be strictly bound by functional level classifications. Therefore, to the extent that the Plan 
attempts to misinterpret Medicares K3 functional level criteria in its denial letters, we can set that aside as 
moot. This enrollee is entitled to all of the requested components based on their specific medical needs without 
regard to what the enrollee's functional level is at present (though any knowledgeable clinician would agree 
that she has demonstrated K3 potential in the enrollee's trials of the Power Knees and flex-walk feet). 
Therefore, requested feet and socket inserts are generally coverable as reasonable and necessary for this 
enrollee given the record. This bilateral amputee needs appropriately dynamic feet, a characteristic that 
standard flex-walk feet will definitely provide. The socket inserts x4 should be non-controversial given the fact 
the Plan saw fit to approve the socket generally, which implies coverage of 2 socket inserts per prosthesis per 
the LCD.   
 
Finally, looking further at the coverage criteria for the Power Knee specifically, as compared to a standard 
microprocessor knee, LCD 33787 makes clear that the main characteristic of candidates for the Power Knee is 
that such a patient Has a documented comorbidity of the spine and/or sound limb affecting hip extension 
and/or quadriceps function that impairs K-3 level function with the use of a microprocessor-controlled knee 
alone.  This patients bilateral hip flexion contractures satisfies that criterium, and the rest of her presentation 
clearly satisfies the intent of the policy. There is no doubt that traditional Medicare would cover all of the 
requested components for this enrollee. Therefore, the socket inserts (L5673 x4), the bilateral power knees 
(L5828, L5845, L5848, L5856, L5859  all x2), as well as flex-walk style feet with axial and multi-axial 
rotation units (L5981, L5984, L5986  all x2) 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 items have been met. Therefore, we decided that the Plan has to pre-approve 
a fluid swing and stance phase control (L5828), stance flexion feature (L5845) fluid stance extension (L5848), 
microprocessor control feature (L5856), endoskeletal knee-shin system (L5859), flex-walk system or equal 
(L5981), axial rotation unit (L5984), and multi-axial rotation unit (L5986).  
 
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.