Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an addition to lower limb prosthesis, multiaxial ankle with swing 
phase active dorsiflexion feature (L5968) and an all-lower extremity prosthesis, flex-walk system or equal 
(L5981). 
 
You asked the Plan to pre-approve lower prosthetics. You say that you disagree with the denial and have 
attached documentation to show medical necessity. The Plan denied your request. The Plan says that the 
requested prosthetic parts exceed the enrollee'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 lower prosthetics. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found 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 such as the enrollee must need to 
do more than simple walking, or the enrollee must need to cross different barriers (such as walking long 
distances or walking on steep or slippery surfaces). The certified prosthetist/orthotist (CPO) and multiple 
physicians clinic notes from May 2023, more than satisfy Medicare requirements for documenting his K3 
functional potential as well as his need for the new prosthesis and foot in question. LCD L33787 states simply 
flex foot system (L5981) is covered for enrollees 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 flex-walk feet and the various additions chosen by the treating team 
are part of the basic standard of care for all community K3 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. Therefore, the 
requested foot (L5981, L5968) 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 lower prosthetics have been met. Therefore, we decided that the Plan has to pre-
approve an addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature 
(L5968) and an all-lower extremity prosthesis, flex-walk system or equal (L5981).  
 
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.