Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a single axis, fluid swing and stance phase control (L5828), a 
knee-shin system, stance flexion feature, adjustable (L5845), a fluid stance extension, dampening feature, with 
or without adjustability (L5848) and microprocessor control feature, swing and stance phase, includes 
electronic sensor(s) (L5856). 
 
You asked the Plan to pre-approve leg prosthetics. You say that the enrollee is recently homeless and displaced. 
She is waiting for her prosthetic leg. The Plan denied your request. The Plan says that the computerized knee 
exceeds the enrollee's medical 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 leg 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 more than satisfies Medicare coverage policy for this component, first and 
foremost in demonstrating this enrollee has a K3 functional level, which the Plan has tacitly already accepted 
by way of approving L5981. LCD L33787 states simply "A fluid, pneumatic, or electronic/microprocessor 
knee is covered for beneficiaries 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 the basic standard of care for all community above knee amputee 
ambulators given that the evidence of their benefits and superiority to alternatives are so well proven and long 
standing. Less sophisticated technology would amount to sub-standard care and would not meet her needs. 
There is no doubt that original Medicare would cover the requested prosthesis for this K3- level Beneficiary. 
Therefore, the requested 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 leg prosthetics have been met. Therefore, we decided that the Plan has to pre-
approve a single axis, fluid swing and stance phase control (L5828), a knee-shin system, stance flexion feature, 
adjustable (L5845), a fluid stance extension, dampening feature, with or without adjustability (L5848) and 
microprocessor control feature, swing and stance phase, includes electronic sensor(s) (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.