Appeal type: Medical Necessity
Decision: Upheld

Physician 1: The patient is a 56-year-old male employed as a supervisor who is required to make frequent field inspections. He is status post a trans-femoral amputation and has been evaluated for the Otto-Bock C-leg prosthesis because of his active lifestyle. The Health Plan has denied authorization for the requested prosthetic device on the basis it is not medically necessary.Currently, there is insufficient scientific evidence demonstrating that the Otto-Bock C-leg prosthetic device is likely to be more efficacious for this patient than a standard prosthetic device.  There is no evidence the patient requires the enhanced features of the Otto-Bock C-leg. Given the absence of sufficient scientific data supporting the superiority of the requested prosthetic device, I have determined it is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Physician 2: The patient is a 56-year-old man who underwent a recent amputation.  Initially he had a below-the-knee amputation, but due to complications an above the knee amputation was necessary.  His occupation requires frequent outside inspections.  He has been fitted for his first prosthetic, and the Otto-Bock C-leg was recommended. The Health Plan denied authorization for this prosthetic device. At issue is whether an Otto-Bock C-leg prosthesis is medically necessary for this patient.The documentation submitted does not confirm the medical necessity of the special features of the Otto-Bock C-leg microprocessor controlled knee.  There is no evidence the patient will be unable to function with a prosthesis that does not utilize a microprocessor control. The microprocessor-controlled knee is still investigational with respect to its safety and reliability in day-to-day active usage.  The device relies on proper placement of electrodes which may fail or shift. The microprocessor itself needs to be reprogrammed frequently. There is no evidence the Otto-Bock C-leg is likely to be superior to a standard prosthesis. As such, I have determined that the requested prosthetic device is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.Physician 3: This patient is a 56-year-old male with a history of peripheral vascular disease. Although multiple surgical procedures were attempted the patient eventually had a below-the-knee amputation. He subsequently developed gangrene of the right stump and in June 2005 underwent a right trans-femoral amputation. An Otto-Bock C-leg prosthesis has been recommended due to the patients active lifestyle. The Health Plan has denied coverage for the requested prosthetic device on the basis it is not medically necessary.There are no case controlled, randomized studies demonstrating the superiority or improved functional outcomes of the Otto-Bock C-leg prosthesis compared to standard prosthetics. The proposed microprocessor knee is not likely to result in a sufficient functional difference in this case. A standard prosthesis is likely to provide the patient with an appropriate level of functioning in his everyday life. Thus, there is insufficient evidence an Otto-Bock C-leg prosthesis is medically warranted. Therefore, I have determined that the requested prosthetic device is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.