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) and an addition to lower extremity prosthesis, endoskeletal knee-shin 
system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type 
(L5856). 
 
You asked the Plan to pre-approve a prosthetic leg with an electronic knee feature and other parts. You say that 
the enrollee is currently using a K3 mechanical knee, the ST&G 1322, but is being held back by this 
componentry, which is limiting his activities of daily living, as well as putting him in danger due to the lack of 
stability. He is frequently on ladders, doing HVAC mechanic work, maneuvering in small areas and on his feet 
for extended periods of time. The has had many falls due to the limitations of his current K3 knee. The stumble 
recovery features of a microprocessor knee will help to prevent falls. He is fairly young, very active and strong, 
and would like to return to his pre-amputation level of activity. The Plan denied your request. The Plan says 
that  the request for prosthesis with microprocessor knee does not meet Medicare criteria as reasonable and 
necessary. Medicare Guidance says that a prosthesis that meets, but does not exceed, the member's need can be 
provided. The requested microprocessor knee exceeds the member's need. 
 
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 electronic knee 
feature and other parts. 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 vasculopathy. He was previously classified at the K2 functional level, but he 
has since returned to a high level of activity at the unlimited community ambulator level, and works as an 
HVAC repairman, consistent with a K3 level. His current prosthesis is ill-fitting, and includes a non-
microprocessor, hydraulic, 4-bar knee, which has contributed to multiple falls. The medical record from the 
prescribers notes from earlier this year, in this case more than meets the standard for documenting the 
enrollees K3-status, and then goes above and beyond by describing the microprocessor knees particular uses 
for the enrollee, including reducing his fall risk. The Plan meanwhile appears to not dispute the enrollees K3 
status, in that they have approved L5981. Rather, it seems to want to exercise its own clinical judgement, 
asserting that this very active enrollee should settle for a less sophisticated knee. A non-microprocessor knee 
would be sub-standard care for an enrollee like this for numerous reasons that are beyond the scope of this 
review, but in any event, it is not up to the Plan to second guess the treatment decisions of the local physician 
and CPO, who met their documentary burden up front simply by proving the enrollees K3-level. The 
microprocessor knee (L5828, L5845, L5848, L5856) 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 a prosthetic leg with an electronic knee feature and other parts have 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) and an addition to lower extremity prosthesis, endoskeletal knee-
shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type 
(L5856).  
 
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.