Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a level 3 (K3) foot and microprocessor knee. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is an active community 
ambulator. The Plan denied your request. The Plan says that the request exceeds the enrollee's needs.  
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are covered under certain 
medical indications. 
 
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 the requested services. Our physician 
reviewer found that a level 3 classification has the ability or potential for ambulation with variable cadence. 
Typical of the community ambulator who has the ability to traverse most environmental barriers and may have 
vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. 
 
In contrast to these broad, inclusive K3-criteria that generally describe the average Medicare Beneficiary who 
lives independently at home and can go out without restriction 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 - You must need to do more than 
simple walking...You must need to cross different barriers (such as walking long distances or walking on steep 
or slippery surfaces). Meanwhile, both the prosthetist and prescribers notes submitted very thoroughly and explicitly document the 
enrollees K3 status, and his overall medical condition appears stable and well managed. The use of an assistive 
device, such as a cane or even a rolling walker is not necessarily a factor in determining K-level. Medicares 
policy recognizes that microprocessor knees and flex-walk feet 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 
alternatives are so well proven and long standing. 
 
The medical record in this case more than meets the standard for documenting the enrollees K3-status, and 
then goes above and beyond by describing the requested components particular uses for the enrollee. The 
alternative components suggested by the Plan would be sub-standard care for an enrollee like this. Therefore, 
the requested microprocessor knee (L5828, L5845, L5848, L5856) and foot (L5981, L5986) are medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve a level 3 (K3) foot and microprocessor knee.  
 
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.