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) and 
an addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing 
and stance phase, includes electronic sensor(s) (L5856). You asked the Plan to pre-approve prosthetics. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the request for a K3 foot and microprocessor knee 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 not only does the medical record satisfy Medicare policy in demonstrating this enrollee has K3 
functional potential, but the Plan also attempts to create a more restrictive policy for defining K3 function than 
Medicare policy would allow. In contrast to these broad, inclusive K3-criteria that generally describe the 
average Medicare enrollee who lives independently at home and 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 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). Both the certified prosthetist/orthotist (CPO) in his April 
clinic note, and the medical doctor (MD) in the May clinic note, are explicit about her K3 status and the 
medical record provided adequately explains the medical necessity of the microprocessor knee. Meanwhile 
LCD L33787 states 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 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.  Lesser components, for this 
enrollee and all other K3 ambulators like her, would amount to substandard care. There is no doubt that 
original Medicare would cover the requested prosthesis for this K3-level enrollee. Therefore, the requested 
microprocessor knee (L5828, L5845, L5848, 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 prosthetics 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) and an addition to lower extremity prosthesis, 
endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic 
sensor(s) (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.