Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Complete traumatic amputation at level between 
knee and ankle, left lower leg, subsequent encounter
Treatment: L5647 Addition to Lower Extremity, below knee (BK) Suction Socket, L5910 Addition, Endoskeletal System Below knee (BK) Alignable System, L5665 Addition to Lower Extremity, 
Socket Insert Multidurometer, Below Knee (BK), L5670 Addition to Lower Extremity, Below Knee (BK) Molded Supracondylar Suspension (PTS or similar), L5999 Lower Extremity Prosthesis, Not Otherwise Specified
The insurer denied: L5647 Addition to Lower Extremity, below knee (BK) Suction Socket, L5910 Addition, Endoskeletal System Below knee (BK) Alignable System, L5665 Addition to Lower Extremity, Socket Insert Multidurometer, Below Knee (BK), 
L5670 Addition to Lower Extremity, Below Knee (BK) Molded Supracondylar Suspension (PTS or similar), L5999 Lower Extremity Prosthesis, Not Otherwise Specified
The denial is partially approved.

The patient is an adult female. She underwent a left sided transtibial amputation due to blood clots. Her current prosthetic socket is no longer fitting appropriately due to volume change of 
her residual limb due to weight loss despite modification of her socket and additional padding. She is experiencing pain and skin breakdown of her residual limb. She is noted to have a short residual limb, and she is noted to be a K4 (ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels) level ambulator. Per the documentation, the codes L5999 and L5665 were withdrawn from the requested prosthetic prescription. The requested transtibial prosthesis was considered not medically necessary per guideline policy with the rationale that it exceeds the needs of the patient. This decision is being appealed.

The requested health service is medically necessary, in part.

Specifically, the L5647 Addition to Lower Extremity, below knee (BK) Suction Socket, L5910 Addition, Endoskeletal System Below knee (BK) Alignable System, Below Knee (BK), L5670 
Addition to Lower Extremity, Below Knee (BK) Molded Supracondylar Suspension (PTS [patellar and supracondylar] or similar) are medically necessary.
The L5665 Addition to Lower Extremity, Socket Insert Multidurometer and L5999 Lower Extremity Prosthesis, Not Otherwise Specified are not medically necessary.

The patient is an adult female who underwent a left-sided transtibial amputation due to blood clots. Her current prosthetic socket is no longer fitting appropriately due to volume change of 
her residual limb due to weight loss despite modification of her socket and additional padding. She is experiencing pain and skin breakdown of her residual limb. She is noted to have a short residual limb and to be a K4 (Ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels) level ambulator. Per the documentation, the codes L5999 and L5665 were withdrawn from the requested prosthetic prescription. The patient requires a transtibial prosthesis for mobility and accomplishing daily activities. Her current prosthetic socket is no longer fitting her residual limb due to volume change despite attempted modification of her current socket. Given the short length and shape of her residual limb she requires a suction socket with supracondylar suspension to allow for adequate fit and 
suspension. She requires a new alignable system to attach and align the new socket to her exiting prosthetic foot/ankle. This cannot be re-used and must accommodate the new prosthetic socket. The L5665 Addition to Lower Extremity, Socket Insert Multidurometer and L5999 Lower Extremity Prosthesis, Not Otherwise Specified are not medically necessary. Per the letter of appeal, these codes have been withdrawn.