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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 ankle-foot orthoses (AFO) described by codes L1900, L1902, L1904, L1906, L1907, L1910, 
L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2106, L2108, 
L2112, L2114, L2116, L4350, L4360, L4361, L4386, L4387 and L4631 are covered for ambulatory 
beneficiaries with weakness or deformity of the foot and ankle, who: 
1. Require stabilization for medical reasons, and, 
2. Have the potential to benefit functionally. 
Knee-ankle-foot orthoses (KAFO) described by codes L2000, L2005, L2010, L2020, L2030, L2034, L2035, 
L2036, L2037, L2038, L2126, L2128, L2132, L2134, L2136, and L4370 are covered for ambulatory 
beneficiaries for whom an ankle-foot orthosis is covered and for whom additional knee stability is required. 
 
If the basic coverage criteria for an AFO or KAFO are not met, the orthosis will be denied as not reasonable 
and necessary. 
 
AFOs and KAFOs that are custom-fabricated are covered for ambulatory beneficiaries when the basic coverage 
criteria listed above and one of the following criteria are met: 
1. The beneficiary could not be fit with a prefabricated AFO; or,  
2. The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more 
than 6 months); or,  
3. There is a need to control the knee, ankle or foot in more than one plane; or, 
4. The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom 
fabricating over a model to prevent tissue injury; or,  
5. The beneficiary has a healing fracture which lacks normal anatomical integrity or anthropometric 
proportions. 
If a custom fabricated orthosis is provided but basic coverage criteria above and the additional criteria 1-5 for a 
custom fabricated orthosis are not met, the custom fabricated orthosis will be denied as not reasonable and 
necessary. 
 
L coded additions to AFOs and KAFOs (L2180, L2182, L2184, L2186, L2188, L2190, L2192, L2200, L2210, 
L2220, L2230, L2232, L2240, L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, 
L2335, L2340, L2350, L2360, L2370, L2375, L2380, L2385, L2387, L2390, L2395, L2397, L2405, L2415, 
L2425, L2430, L2492, L2500, L2510, L2520, L2525, L2526, L2530, L2540, L2550, L2750, L2755, L2760, 
L2768, L2780, L2785, L2795, L2800, L2810, L2820, L2830) will be denied as not reasonable and necessary if 
either the base orthosis is not reasonable and necessary or the specific addition is not reasonable and necessary. 
 
 
You can find this rule in the Local Coverage Determination (LCD): Ankle-Foot/Knee-Ankle-Foot Orthosis 
(L33686) effective January 1, 2020. 
 
For custom fabricated orthoses (L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, 
L2000, L2005, L2006, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2106, L2108, L2126, L2128, 
L4631), there must be detailed documentation in the treating practitioner's records to support the medical 
necessity of custom fabricated rather than a prefabricated orthosis as described in the Coverage Indications, 
Limitations and/or Medical Necessity section of the related LCD. This information will be corroborated by the 
functional evaluation in the orthotist or prosthetist?s records. This information must be available upon request. 
 
You can find this rule in the Local Coverage Article: Ankle-Foot/Knee-Ankle-Foot Orthoses-Policy Article 
(A52457) effective October 1, 2020. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.