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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 say that protective outer surface covering systems (L5962, L5964, and L5966) are specialized covers
intended to be worn over an existing prosthesis. They are used by a beneficiary who has special needs for
protection against unusually harsh environmental situations where it is necessary to protect the lower limb
prosthesis beyond the level of protection that is afforded by L5704, L5705, L5706, and L5707. They are not for
cosmetic or convenience reasons, or for everyday usage in a typical environment. Protective outer surface
coverings are different from the covering that is already reimbursed as part of L5704, L5705, L5706, and
L5707. You can find this information in Medicare's Local Coverage Article: Lower Limb Prostheses - Policy
Article (A52496).
The rules say that a determination of the type of knee for the prosthesis will be made by the treating
practitioner and/or the prosthetist based upon the functional needs of the beneficiary. Basic lower extremity
prostheses include a single axis, constant friction knee. Other prosthetic knees are considered for coverage
based upon functional classification.
A high activity knee control frame (L5930) is covered for beneficiaries whose functional level is 4.
A fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, L5724, L5726, L5728,
L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858) is covered for
beneficiaries whose functional level is 3 or above.
L5859 (ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM,
POWERED AND PROGRAMMABLE FLEXION/EXTENSION ASSIST CONTROL, INCLUDES ANY
TYPE MOTOR(S)) is only covered when the beneficiary meets all of the criteria below:
1. Has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee
2. K3 functional level only
3. Has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps
function that impairs K-3 level function with the use of a microprocessor-controlled knee alone
4. Is able to make use of a product that requires daily charging
5. Is able to understand and respond to error alerts and alarms indicating problems with the function of the
unit
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 Medicare's Local Coverage Determination (LCD): Lower Limb Prostheses
(L33787).
The rules say that n the event of a claim review, information contained directly in the contemporaneous
medical record is the source required to justify payment except as noted elsewhere for prescriptions and CMNs.
The medical record is not limited to treating physician/practitioner's office records but may include records
from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc. (not all-inclusive).
Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not
considered sufficient by themselves for determining that an item is reasonable and necessary. DMEPOS
suppliers are reminded that: supplier-produced records, even if signed by the prescribing physician/practitioner,
and attestation letters (e.g., letters of medical necessity) are deemed not to be part of a medical record for
Medicare payment purposes.
Templates and forms, including CMS CMNs, are subject to corroboration with information in the medical
record.
Prescription is not considered to be part of the medical record. Medical information intended to demonstrate
compliance with coverage criteria may be included on the prescription but must be corroborated by information
contained in the medical record. In addition to the general requirements discussed above, certain DMEPOS
items may have specific documentation requirements. Details regarding these policy specific requirements are
contained in the applicable LCD-related Policy Article. You can find this information in Medicare's Local
Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs ((A55426).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.