Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve L5986 and L5987. We decided that the Plan does not have to pre-
approve L5962.  
 
You asked the Plan to pre-approve a replacement prosthetic leg with an advanced foot (L5962, L5986, L5987 - 
Allpro K3 foot).. You say that this is medically necessary. The Plan says that this is not medically necessary. 
 
Please note, that our reviewer found additional information showing an additional letter from Certified 
Prosthetist/Orthotist (CPO) from September 12, 2023 and an updated standard written order from 9/8/23. Our 
reviewer found that the CPO admits that the originally requested L5968 was a typo, and that the desired code is 
L5986, as reflected in the new standard written order. The review will address L5986, L5987, and L5962. 
 
We decided that the Plan has to pre-approve L5986 and L5987.  
 
The Plan follows Medicare rules. The rules say that coverage is extended only if there is sufficient clinical 
documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 for L5986 and L5987. Our reviewer says that these 
items are covered for beneficiaries whose functional level is 3 or above. No further specific documentation is 
actually required in the LCD, the Policy Article, or any of the relevant Medicare manuals because Medicares 
policy recognizes that these dynamic feet (with permitted additions such as L5968) are part of the basic 
standard of care for all unlimited community (K3) amputee ambulators given that the evidence of their benefits 
and superiority to less sophisticated alternatives are so well proven and long standing. The documentation of 
the enrollees K3 status by the prescribing physican (e.g., in the June clinic note) is sufficient to grant coverage 
for L5987 + L5968 generally, regardless of which foot is ultimately delivered.  
 
As for the plan's assertion that the foot that will be used here is miscoded, there is no evidence of this in the 
file. Given the deference normally afforded to the treating team to select a specific prosthetic foot, among the 
multitude that are available, for a given patient, there is no reason to deny this medically necessary care in 
general based merely on an unproven coding technicality. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve L5986 and L5987.  
 
We also decided that the Plan does not have to pre-approve L5962. 
 
The Plan follows Medicare rules. Medicare rules say that protective outer surface covering systems are used for 
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 usual level of protection. 
 
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 for L5962. Our reviewer says that given the specific 
documentation requirements for this component, it is incumbent on the CPO / prescriber to provide a medical 
record that meets these requirements.  However, in this case, no such justification is found in the record to 
suggest that this Beneficiarys prosthesis will be exposed to unusually harsh environments necessitating 
additional protection beyond what is provided with a typical cover (e.g., L5704, which has already been approved by the Plan).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L5962 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve L5962. 
 
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.