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 
(L5848), an addition, endoskeletal system, above knee or hip disarticulation, knee extension assist (L5850). 
 
You asked the Plan to pre-approve prosthetics. You say that all prosthetics are medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the request for a K3 microprocessor knee does not 
meet Medicare criteria as reasonable and necessary. 
 
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 prosthetics. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical record (e.g., the certified prosthetist/orthotists (CPO's) note from May and the 
physiatry clinic note April 2023) goes above and beyond in satisfying Medicare policy by demonstrating this 
enrollee has a K3 functional level potential and has specific needs for the requested components. We note that 
these broad, inclusive K3-criteria generally describe the average Medicare enrollee who lives independently at 
home and in the community, which this enrollee very credibly could do without limitation if equipped with the 
proper prosthesis. We also note that the Plan tacitly recognized the enrollee K3 status by approving L5987. 
Regarding the criteria for coverage of the component still in contention, LCD L33787 states simply, "A fluid, 
pneumatic, or electronic/microprocessor knee is covered for enrollees whose functional level is 3 or above." No 
further specific documentation is required in the LCD, the Policy Article, or any of the relevant Medicare 
manuals because Medicare's policy recognizes that microprocessor knees are part of the basic standard of care 
for all community above knee amputee ambulators given that the evidence of their benefits and superiority to 
less sophisticated alternatives are so well proven and long standing. In the case of this enrollee, and all 
comparable K3 ambulators, lesser devices simply cannot meet his long-term functional needs and would 
amount to substandard care. There is no doubt that original Medicare would cover the entirety of the requested 
prosthesis for this K3-level enrollee. Therefore, the requested microprocessor knee (L5828, L5845, 5848, 
L5850, L5856, L5925) 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 prosthetics 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 (L5848), an addition, endoskeletal 
system, above knee or hip disarticulation, knee extension assist (L5850).  
 
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.