Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have 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, endoskeletal system, above knee or hip
disarticulation, knee extension assist (L5850), an addition to lower extremity prosthesis, endoskeletal knee-shin
system, microprocessor control feature, swing and stance phase (L5856), an all lower extremity prostheses,
flex-walk system (L5981) and an all lower extremity prostheses, multi-axial rotation unit (L5986).

You asked the Plan to pre-approve these items. You say that you use your leg to walk on uneven terrain and to
walk up and down ramps and steps and also slippery surfaces. The Plan denied your request. The Plan says that
the requested prosthesis/prosthetic parts exceed your needs and cannot be approved.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an addition,
endoskeletal knee-shin system, single axis, fluid swing and stance phase control, an addition, endoskeletal,
knee-shin system, stance flexion feature, adjustable, an addition to endoskeletal knee-shin system, fluid stance
extension, dampening feature, with or without adjustability, an addition, endoskeletal system, above knee or
hip disarticulation, knee extension assist, an addition to lower extremity prosthesis, endoskeletal knee-shin
system, microprocessor control feature, swing and stance phase, an all lower extremity prostheses, flex-walk
system and an all lower extremity prostheses, multi-axial rotation unit. Our Medical Director states that the
Family Medicine visit dated June 2, 2020, documents that you have coronary artery disease, diabetes,
hypertension, heart failure, and chronic kidney disease. It is noted that you were willing and motivated to use
power mobility. The available clinical documentation is insufficient to demonstrate that the requested
prosthetics were medically necessary for you in this case, and that the coverage criteria were met. Our Medical
Director found that your condition does not meet criteria for coverage of these items.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not
have 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, endoskeletal system, above knee or hip disarticulation, knee extension assist
(L5850), an addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control
feature, swing and stance phase (L5856), an all lower extremity prostheses, flex-walk system (L5981) and an
all lower extremity prostheses, multi-axial rotation unit (L5986).