Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a vertical shock reducing pylon feature. We decided that the Plan 
does not have to pre-approve flexible protective outer surface covering system.  
 You asked the Plan to pre-approve a vertical shock reducing pylon feature (L5988) and flexible protective 
outer surface covering system (L5964). 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 vertical shock reducing pylon feature.  
 
The Plan follows Medicare rules. Medicare rules say that that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury.  
 
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 vertical shock reducing pylon feature. 
Our reviewer says that the services are medically necessary. Our physician reviewer found the physicians 
February 2023 clinic note, documents your K3 level, and gives concrete reasons for his treatment plan specific 
to your high-level of function. The medical record in this case is therefore more than sufficient on its own 
merits to approve all of the knee and feet codes originally requested. 
 
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 vertical shock reducing pylon feature have been met. Therefore, we decided 
that the Plan has to pre-approve a vertical shock reducing pylon feature.  
 
We also decided that the Plan does not have to pre-approve flexible protective outer surface covering 
system. 
 
The Plan follows Medicare rules. Medicare rules say that that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. 
 
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 flexible protective outer surface 
covering system. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found in this case, no such justification or context is found in the record to suggest that your prosthesis will be 
exposed to unusually harsh environments necessitating additional protection beyond what is provided with a 
typical cover.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of flexible protective outer surface covering system have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 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.