Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an addition, endoskeletal knee-shin system, single axis, fluid 
swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion feature 
(L5845), an addition to endoskeletal knee-shin system, fluid stance extension, dampening feature (L5848), an 
addition, endoskeletal system, above knee or hip disarticulation, knee extension assist (L5850), an addition to 
lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance 
phase (L5856). You asked the Plan to pre-approve a prosthetic leg with an electronic knee feature. You say that you disagree 
with the denial. The Plan denied your request. The Plan says that the enrollee does not meet criteria for the 
requested prosthetics. 
 
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 electronic knee 
feature. Our reviewer says that the requested items/services are considered medically reasonable and necessary 
in this case. Our physician reviewer found the medical record (e.g., the certified prosthetist/orthotist, (CPO) 
and orthopedist note from May, as well as the prescribers July 2023 appeal) goes above and beyond in 
satisfying Medicare policy by demonstrating this enrollee has a K3 functional level potential and has specific 
needs for the requested components. We note that these broad, inclusive K3-criteria generally describe the 
average Medicare enrollee who lives independently at home and in the community, which this enrollee very 
credibly could do without limitation if equipped with the proper prosthesis. The reviewer also noted that the 
Plan tacitly recognized the enrollee's K3 status by approving L5981. Regarding the criteria for coverage of the 
component still in contention, LCD L33787 states simply, A fluid, pneumatic, or electronic/microprocessor 
knee is covered for enrollees 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 Medicares policy 
recognizes that microprocessor knees 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 less sophisticated alternatives 
are so well proven and long standing. In the case of this enrollee, and all comparable K3 ambulators, lesser 
devices simply cannot meet his functional needs and would amount to substandard care. There is no doubt that 
original Medicare would cover the entirety of the requested prosthesis for this K3-level enrollee. Therefore, the 
requested microprocessor knee (L5828, L5845, 5848, L5850, 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 a prosthetic leg with an electronic knee feature have been met. Therefore, we 
decided that the Plan has to pre-approve an addition, endoskeletal knee-shin system, single axis, fluid swing 
and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion feature (L5845), 
an addition to endoskeletal knee-shin system, fluid stance extension, dampening feature (L5848), an addition, 
endoskeletal system, above knee or hip disarticulation, knee extension assist (L5850), an addition to lower 
extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase 
(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.