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202108-140547

2021

Excellus

Indemnity

Orthopedic/ Musculoskeletal

Durable Medical Equipment (DME) (including Wearable Defibrilllators)

Medical necessity

Upheld

Case Summary

Diagnosis: Right above knee amputation.
Treatment: Prosthetic (L5856).

The insurer denied the Prosthetic (L5856).
The denial is upheld.

The patient is a male with a history that includes traumatic right above knee amputation due to a motor vehicle accident. He has been a K3 (Ability or potential to ambulate with variable cadence) level ambulator with a prosthesis.

The patient presented to a prosthetist, noting that his C-Leg microprocessor knee (serviced several times over the course of several years) was "acting strange." There were instability episodes. It was deemed that the knee was damaged and in need of replacement. It was noted that the knee was over three years old and no longer covered by warranty. A loaner knee was installed and the plan was a replacement C-Leg microprocessor knee.

The patient received a new loaner knee.

The patient received a new C-Leg microprocessor knee and a new College Park Odyssey K3 foot.

The health plan denied coverage of the service under review as it concluded that the costs of the service exceed the costs for a repair of the prior prosthesis.

The service provider has argued that the price for the repairs exceeded the price of a new device.

No, the Prosthetic (L5856) was not medically necessary.

The records indicate that the member had a C-Leg microprocessor knee for his right leg prosthesis received several years prior. The C-Leg knee was serviced multiple times. The knee was approximately 3.5 years old, but causing difficulties, including instability. The records indicate that it could have been repaired. Therefore, there was no medical necessity of a replacement prosthetic knee.

The records indicate that the device in question was approximately 3.5 years old and could have been repaired. The records do not show that the knee could not have been repaired. There are multiple quotes that have been generated by the service provider, which do not consistently indicate prices for the services in question. The invoice that was generated on the actual date of service indicated a much more substantial cost for the new replacement prosthetic knee in question (even after removing the costs for the prosthetic foot-ankle) than the quote for the repair of the older knee. There are no clear indications, overall, that the service that was provided was reasonable from the standpoint of use of the patient's benefits. The denial of coverage as noted in the health plan's correspondence, therefore, was appropriate. The argument made by the service provider that the cost of the replacement knee was lower than the repair cost is contradicted in the available documentation.

Regardless of cost issues, as stated above, the replacement was not medically necessary, as the original device could have been repaired.

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