Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an addition, endoskeletal knee-shin system, single axis, fluid 
swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion feature, 
adjustable (L5845), an addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, 
with or without adjustability (L5848), an addition to lower extremity prosthesis, endoskeletal knee-shin system, 
microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856), an all 
lower extremity prostheses, multi-axial rotation unit (L5986) and an all lower extremity prosthesis, shank foot 
system with vertical loading pylon (L5987). 
 You asked the Plan to pre-approve a prosthetic leg with an advanced knee/foot feature. You say that the 
medical records show that the enrollee's treating physicians and certified prosthetist reasonably determined 
based upon the functional needs of the enrollee that he has a K3 level potential functional ability considering 
his past history, current condition and desire to ambulate. The Plan denied your request. The Plan says that the 
requested prosthetic parts exceed the enrollee's need. The notes do not show why the parts of the enrollee's 
prosthesis are needed. 
 
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 a prosthetic leg with an advanced 
knee/foot feature. 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 transfemoral amputation since 2021 
in the setting of peripheral vascular disease. Pre-amputation, he was independent, with activities including 
owning/operating his own lawn care company. His existing prosthesis was designed to K2-level specifications, 
and he is living at home again and going out into the community, but he has also had several falls and frequent 
stumbles on his purely mechanical knee and K2 foot. His CPO and prescriber assess that his functional level is 
returning to his pre-morbid baseline, such that he now has K3 potential, and needs to be upgraded to more 
active components, not least of fall to decrease his fall risk. His socket is also loose and ill fitting. Accordingly, 
the CPO requested a new prosthesis, including a microprocessor knee and shank foot system with multi-axial 
rotation unit, both K3 level components. 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 - The enrollee must need to do more than simple walking. The enrollee must need to cross different 
barriers (such as walking long distances or walking on steep or slippery surfaces). Both the CPO and 
physician are unified on his K3 status (which is even objectively proven by his AMP PRO score and trial of the 
MPK knee), and they both go to lengths to specifically explain the medical necessity of the prosthetic design 
requested, most especially to end his pattern of falling on a less sophisticated components.  While there is 
mention of other assistive devices, those are not inherently disqualifying characteristics per Medicares specific 
K3 definition, and a proper microprocessor knee and appropriate foot will likely reduce his use of these other 
assistive devices, in any event. Moreover, LCD L33787 states A fluid, pneumatic, or 
electronic/microprocessor knee is covered for beneficiaries whose functional level is 3 or above, and it also 
states, shank foot system with vertical loading pylon (L5987) 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 microprocessor knees and shank system 
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. 
There is no doubt that original Medicare would cover the requested prosthesis for this K3- level enrollee.  The 
originally requested knee and foot 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 a prosthetic leg with an advanced knee/foot feature have not been met. 
Therefore, we decided that the Plan has to pre-approve an addition, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion 
feature, adjustable (L5845), an addition to endoskeletal knee-shin system, fluid stance extension, dampening 
feature, with or without adjustability (L5848), an addition to lower extremity prosthesis, endoskeletal knee-shin 
system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856), an all lower extremity prostheses, multi-axial rotation unit (L5986) and an all lower extremity 
prosthesis, shank foot system with vertical loading pylon (L5987).  
 
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.