Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the microprocessor ankle-foot system. We decided that the Plan 
does not have to pre-approve the residual limb volume management system.  
 
You asked the Plan to pre-approve a microprocessor ankle-foot system with power assist described by code 
L5973 and residual limb volume management system described by code L5781. You say that you disagree with 
the denial. The Plan says that the services are not medically necessary. 
 
We decided that the Plan has to pre-approve the microprocessor ankle-foot system. 
 
The Plan must follow Medicare rules. Medicare rules say that prosthetic accessories are covered when specific 
criteria are met. 
 
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 these services. Our reviewer says that 
the microprocessor ankle-foot system is medically necessary and the residual limb volume management system 
is not medically necessary. Our physician reviewer found that a detailed note dated November 14, 2023 has 
clinical justification for the microprocessor ankle, including increased toe ground clearance during swing 
phase, more efficient and symmetrical gait pattern on all surface gradients, and improvement in sit-to-stand 
action. The records support that the microprocessor ankle-foot system is medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve the microprocessor ankle-foot system described by code L5973. 
 
We also decided that the Plan does not have to pre-approve the residual limb volume management 
system. 
 
The Plan must follow Medicare rules. Medicare rules say that prosthetic accessories are covered when specific 
criteria are met. 
 
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 these services. Our reviewer says that 
the physician notes from September 29, 2023 report that the enrollee tried a multi-axial foot for about a week 
and a significant increase in his mobility and his ability to transverse different terrains. Additionally, the 
physician noted that the current prosthetic limits his ability to perform tasks and makes it difficult for him to 
transverse different terrains, including going up hills. The records do not support that the vacuum pump for 
volume management or moisture control is medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the residual limb volume management system described by code L5781. 
 
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.