A Letter of Medical Necessity to a health insurance carrier or Medicare
should be clear, concise and focused. The purpose is to present a credible
argument as to why the carrier should cover the device. The argument should
focus on the specific needs and medical condition of your patient as well as how
the device will assist the patient in their home. It should state how and why
the LegSim device is superior to other available walking assist devices
(crutches, walkers, wheelchairs and prosthesis). It should clearly state why
other devices either have not been successful or are not appropriate to use with
this specific patient.
The design of the LegSim promotes mobility and a more upright life style. Its
size and weight makes it more easily transported than a wheelchair. The
simplicity of use lends itself well to movement during emergency situations
where a wheelchair can be problematic. Early adoption of the device soon after
surgery should minimize muscle atrophy, decrease recovery times, shorten
hospital length of stay, and ultimately improve patient outcomes. The ability to
modify the device for patients with other complex medical needs further widens
You may be eligible for reimbursement if you're in the VA System, or have a
compensation claim. Medicare and health insurance carriers are also eligible
with a letter from your doctor stating that you have a medical necessity, using
the code L5999.
It would be important to refer to the LegSim as a SUPPLEMENT to, not a
REPLACEMENT for, an existing prosthesis UNLESS the patient will not be using a
conventional prosthesis ever again.
Hartford Walking Systems would like to offer our expertise and assistance in
helping you craft an effective and appropriate Letter of Medical Necessity for
The letter should include certain general comments about the LegSim device
which would be informative to the Medical Director of the Health Plan. These
- The LegSim device provides patients a more independent,
upright lifestyle allowing patients to view the world at "eye
- The LegSim device is designed for patients who are unable to
use prosthesis for various reasons.
- The LegSim device increases a patient's mobility helping to
limit muscle atrophy, weight gain and other complications of a
sedentary lifestyle (diabetes, DVT, or depression).
- The LegSim will enhance a patients sense of independence
which improves their overall feeling of well-being.
The letter should also include specific information describing why
the LegSim device is uniquely suited for your patient's specific medical
needs and clinical condition. This section should include the co-morbitities
that may preclude the use of crutches or limit the effectiveness of a
wheelchair or prosthesis. These could include:
- The LegSim is uniquely suited for patients who are unable to
use a traditional prosthesis because of:
a. Heterotopic Ossification (HO) causing improper fitting
of the prosthesis
b. Neuroma of the stump which cause pain and inability of
patients to wear a prosthesis
c. Improper fitting of the prosthesis because of weight
gain, stump breakdown or phantom pain
- The LegSim device is uniquely suited for patients who can
not use traditional crutches because of:
a. Shoulder injury or rotator cuff problems
b. Upper extremity paralysis or hemi paresis secondary to
c. PIC line placement
d. Brachial plexus injury
The Letter of Medical Necessity should also include specific reasons
why the LegSim device would be useful in the context of the patient's
home situation performing activities of daily life. These include:
- The LegSim device is uniquely useful for patients whose home
has narrow corridors and hallways limiting the usefulness of a
- The LegSim device is uniquely useful for patients whose
house has many stairs or lives in a split-level house.
- The LegSim device allows quick and easy exit from a home
during an emergency situation.
- The LegSim device allows patients to stand stationary while
using both hands for activities of normal daily life.
The letter should also include the LegSim web site which provides
additional information including video of patients using the device in
various life situations. The site can be accessed at
which will link the user directly into Hartford Walking Systems.
If the carrier renders a denial decision, a letter of appeal is
always a reasonable next step. In the second letter specific information
on the experience of the LegSim with other regulatory agencies and
health insurance carriers would be important to state. Although this
information may support your argument, regulatory approval does not
guarantee reimbursement. Important information to cite in the appeal
letter would include:
- The LegSim is an FDA listed device under the code of ITJ,
which is a unique prosthetic code that does not compete with any
other prosthetic code.
- The LegSim has been prescribed at Walter Reed Medical Center
through TRICARE and for retired veterans at various VA hospitals
In closing, an effective Letter of Medical Necessity should provide
information tailored to your patient's specific clinical condition while
reinforcing the utility of the device as it relates to the performance
of activities of normal daily life. If I can be an additional
assistance, please free to contact me at
John A. Tata, MD
Hartford Walking Systems