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), an all-lower extremity prosthesis, flex-walk system (L5981) and an 
addition to lower limb prosthesis, vertical shock reducing pylon feature (L5988). 
 
You asked the Plan to pre-approve a prosthetic leg with an advanced foot-ankle feature. You say that the 
enrollee needs this hydraulic foot to remain active in his daily activities. The Plan denied your request. The 
Plan says that the records we have do not show why the requested advanced foot and upgraded pylon are 
needed. 
 
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 a prosthetic leg with an advanced foot-
ankle feature. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found that 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. The 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, the enrollee must need to cross different barriers 
(such as walking long distances or walking on steep or slippery surfaces). The clinic notes from the past three 
months 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 (such as L5968 and L5988) 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, L5988) 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 a prosthetic leg with an advanced foot-ankle feature 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), an all-lower extremity prosthesis, flex-walk system (L5981) and an 
addition to lower limb prosthesis, vertical shock reducing pylon feature (L5988).  
 
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.