Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve endoskeletal knee-shin system, single axis, fluid swing and stance 
phase control (L5828), a knee-shin system, stance flexion feature (L5845), a fluid stance extension (L5848), a 
microprocessor control feature, swing and stance phase (L5856), an all-lower extremity prosthesis, flex-walk 
system (L5981) and an all-lower extremity prosthesis, multi-axial rotation unit (L5986). 
 
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 requested prosthetic parts exceed the enrollee's need. 
 
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 go above and beyond in satisfying Medicare policy by 
demonstrating this enrollee has K3 level potential and has specific needs for the requested components, but the 
Plan also attempts to create a more restrictive policy for defining K3 function than Medicare policy would 
allow. 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, The enrollee must need to do more than simple walking, the enrollee must need to cross 
different barriers (such as walking long distances or walking on steep or slippery surfaces). Regarding the 
criteria for coverage of the requested components, LCD L33787 states simply A fluid, pneumatic, or 
electronic/microprocessor knee is covered for enrollees whose functional level is 3 or above, and it also states 
flex foot system (L5981) 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 and flex-walk feet (and their various normal addition 
codes) 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 requested prosthesis for this K3-level enrollee. Therefore, the requested hydraulic knee (L5828, L5845, 
L5848, L5856) and flex-walk style foot with multi-axial rotation unit (L5981, L5986) are 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 endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828), a knee-shin 
system, stance flexion feature (L5845), a fluid stance extension (L5848), a microprocessor control feature, 
swing and stance phase (L5856), an all-lower extremity prosthesis, flex-walk system (L5981) and an all-lower 
extremity prosthesis, multi-axial rotation unit (L5986).  
 
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.