Diagnosis: Below knee amputation
Treatment: Durable Medical Equipment (replacement socket prosthesis)
The insurer denied the Durable Medical Equipment (replacement socket prosthesis)
The denial is overturned

The patient is a male with history of Right Below-Knee-Amputation secondary to trauma. The request is for replacement of components of a BKA (below knee amputation) prosthetic mostly Right Transtibial replacement Socket, prosthetic socks, etc.

The patient had a new socket based on measurement and has since then had a significant decrease in the BKA (below knee amputation) volume with reductions in all dimensions with 1.7-4.5 cm (centimeter) difference from that measurement compared to a new one and the reason for a new in less than a year, thereby exceeding the limit within the stated period.

Yes, the replacement socket prosthesis is medically necessary.
The replacement below knee socket is medically necessary because the patient has met the generally accepted criteria for the replacement of a previously approved external prosthetic device or one or more of its components (parts) or supplies.

The replacement device is provided by an eligible ancillary provider. The continued use of the device remains medically necessary for the individual and appropriate for the individual's condition. The replacement is not an additional device (e.g., for use when traveling or for an additional residence) but rather a replacement of an ineffective component. The replacement is equivalent to a previously approved external prosthetic device/component. The device itself is not under a manufacturer's warranty. The replacement device is for an individual who has either one of the following: A change in condition that impacts the fit or function of the device and, therefore, requires its replacement which in this case is due to the significant loss of volume of the limb making it not to fit; A device that does not function properly due to lack of proper fitting.

Therefore, based on the above, the requested health service is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

The essence of the prosthetics is to enable the patient to have a limb device that will allow him to ambulate as near-normal as possible as part of his functionality.

A non-fitting or badly-fitting socket makes the entire prosthetics useless and unusable and therefore not providing the necessary purpose for it. An attempt to use a non-fitting socket can also lead to a bad gait-pattern that will inevitably lead to more serious injuries.