Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an all-lower extremity prosthesis, flex-walk system (L5981). 
 
You asked the Plan to pre-approve an all-lower extremity prosthesis. You say that the prosthetic is medically 
necessary. The Plan denied your request. The Plan says that the requested prosthesis exceeds 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 an all-lower extremity prosthesis. 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 a K3 functional level, but the Plan also attempts to create a more restrictive policy for defining K3 
function than Medicare policy would allow. 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). The certified prosthetist/orthotist (CPO) note from the August and September appeal letter, 
corroborated by the primary care physician (PCP) note from September, more than satisfy Medicare 
requirements for documenting his K3 functional potential as well as his need for the new prosthesis generally 
and the foot specifically. LCD L33787 states simply flex foot system (L5981) is covered for enrollees whose 
functional level is 3 or above. No further specific documentation is actually required in the LCD, the Policy 
Article, or any of the relevant Medicare manuals because Medicares policy recognizes that flex-walk feet are 
part of the basic standard of care for all community K3 amputee ambulators given that the evidence of their 
benefits and superiority to less sophisticated alternatives are so well proven and long standing. There is no 
doubt that original Medicare would cover the requested prosthesis for this enrollee. Therefore, the requested 
foot (L5981) 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 an all-lower extremity prosthesis have been met. Therefore, we decided that the 
Plan has to pre-approve an all-lower extremity prosthesis, flex-walk system (L5981).  
 
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.