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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 in 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 cl aim 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. "A 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). 
 
The rules say that a microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), 
dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal 
(L5981), or shank foot system with vertical loading pylon (L5987) is covered for beneficiaries whose 
functional level is 3 or above.  
 
A lower limb prosthesis is covered when the beneficiary: 
 
   1. Will reach or maintain a defined functional state within a reasonable period of time; and 
 
 2. 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: 
 
    1. The beneficiary's past history (including prior prosthetic use if applicable); and 
 
    2. The beneficiary's current condition including the status of the residual limb and the nature of other 
medical problems; and 
 
    3. The beneficiary's desire to ambulate. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Lower Limb Prostheses 
(L33787). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.