Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an addition, endoskeletal knee-shin system, polycentric, hydraulic 
swing phase control, mechanical stance phase lock (L5814), an addition, endoskeletal, knee-shin system, stance 
flexion feature, adjustable (L5845), an addition, endoskeletal system, above knee or hip disarticulation, knee 
extension assist (L5850), an addition to lower limb prosthesis, multiaxial ankle with swing phase active 
dorsiflexion feature (L5968) and all lower extremity prostheses, flex-walk system or equal (L5981). 
 
You asked the Plan to pre-approve prosthetics. You say that the enrollee is in desperate need of this prosthesis 
so she can continue on with her daily activities. The Plan denied your request. The Plan says that the request 
for prosthesis with K3 knee and foot 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 Plan erred in its denials of the hydraulic knee and flex-walk style foot. Based on the 
medical record provided, it is clear that the treating team is justified in its plan to treat this complex, bilateral 
amputee with the componentry in question in this case. Though the Plan attempts to set an inappropriately high 
bar for this enrollee to qualify as K3, with strict use-case criteria and a level of specificity that do 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), this enrollee's 
functional level is moot in this case. Medicare, through its regulations in LCD L33787, signals its intent to be 
very lenient on prosthetic coverage criteria for bilateral amputees, when it states, It is recognized, within the 
functional classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level 
classifications. K1-2 knees and less-well articulated feet are vastly inferior to K3 level components, lead to 
more falls by comparison, and will not meet her needs. There is no doubt that original Medicare would cover 
the entirety of the originally requested prostheses with this enrollee regardless of whatever her K-level 
technically is at this juncture, though she could credibly have K3 potential if given the right device. 
Therefore, the requested hydraulic knee (L5814, L5845, L5850) and a flex-walk style foot with active 
dorsiflexion ankle (L5981, L5968) are 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, polycentric, hydraulic swing phase control, mechanical 
stance phase lock (L5814), an addition, endoskeletal, knee-shin system, stance flexion feature, adjustable 
(L5845), an addition, endoskeletal system, above knee or hip disarticulation, knee extension assist (L5850), an 
addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968) and all 
lower extremity prostheses, 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.