Appeal type: Other
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a shank foot system with vertical loading pylon. We decided that 
the Plan does not have to pre-approve a multi-axial rotation unit and flexible protective outer surface covering 
system.  
 
You asked the Plan to pre-approve a shank foot system with vertical loading pylon (L5987), multi-axial 
rotation unit (L5986), and flexible protective outer surface covering system (L5962). You say that the services 
are necessary. The Plan says that based on the documentation provided, coverage criteria have not been met. 
 
We decided that the Plan has to pre-approve a shank foot system with vertical loading pylon.  
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific 
criteria are met. 
 
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 shank foot system with vertical 
loading pylon. Our reviewer says that the services are medically necessary. Our physician reviewer found your 
K3 functional level is documented in the signed Standard Written Order (SWO) and corroborated in physician 
and prosthetist notes as you can vary cadence, current occupation, and every day activities indicating you meet 
criteria. However, the prosthetist's e-mail indicated you are currently wearing a Rush Rogue 2 and they wish to 
keep you in the same foot but at a higher stiffness category. 
 
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 shank foot system with vertical loading pylon have been met. Therefore, we 
decided that the Plan has to pre-approve a shank foot system with vertical loading pylon.  
 
We also decided that the Plan does not have to pre-approve a multi-axial rotation unit and flexible 
protective outer surface covering system. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific 
criteria are met. 
 
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 multi-axial rotation unit and flexible 
protective outer surface covering system. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the prosthetist's e-mail indicated you are currently wearing a Rush Rogue 2 and they 
wish to keep you in the same foot but at a higher stiffness category. Provided documentation does not indicate 
why the already approved custom shaped protective cover will not suffice in your daily environments. 
 
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 multi-axial rotation unit and flexible protective outer surface covering system 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a multi-axial rotation unit 
and flexible protective outer surface covering system. 
 
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.