Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that a lower limb prosthesis is covered when the beneficiary: Will reach or maintain a defined functional state within a reasonable period of time; and Is motivated to ambulate. A determination of the medical necessity for certain components/additions to the prosthesis is based on the beneficiary's potential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist, and treating practitioner, considering factors including, but not limited to: The beneficiary's past history (including prior PROSTHETIC use if applicable); and The beneficiary's current condition including the status of the residual limb and the nature of other medical problems; and The beneficiary's desire to ambulate. Clinical assessments of beneficiary rehabilitation potential must be based on the following classification levels: Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility. Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator. Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands PROSTHETIC utilization beyond simple locomotion. Level 4: Has the ability or potential for PROSTHETIC ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the PROSTHETIC demands of the child, active adult, or athlete.
The records must document the beneficiary's current functional capabilities and his/her expected functional potential, including an explanation for the difference, if that is the case. It is recognized, within the functional classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level classifications. If a prosthesis is denied as not reasonable and necessary, related additions will also be denied as not reasonable and necessary. Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or
design feature of a given type of foot. This information must be retained in the treating practitioner's or prosthetist's files. Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of knee. This information must be retained in the treating practitioner's or prosthetist's files. Socket replacements are considered reasonable and necessary if there is adequate documentation of functional and/or physiological need. It is recognized that there are situations where the explanation includes but is not limited to: changes in the residual limb; functional need changes; or irreparable damage or wear/tear due to excessive beneficiary weight or PROSTHETIC demands of very active amputees. You can find this information in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787).