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 say that repairs to a prosthesis are covered when necessary to make the prosthesis functional. If the 
expense for repairs exceeds the estimated expense of purchasing another entire prosthesis, no payments can be 
made for the amount of the excess. Maintenance which may be necessitated by manufacturer's 
recommendations or the construction of the prosthesis and must be performed by the prosthetist is covered as a 
repair. 
 
Replacement of a prosthesis or prosthetic component is covered if the treating practitioner orders a replacement 
device or part because of any of the following: 
 
    1. A change in the physiological condition of the beneficiary; or 
 
    2. Irreparable wear of the device or a part of the device; or 
 
    3. The condition of the device, or part of the device, requires repairs and the cost of such repairs would be 
more than 60% of the cost of a replacement device, or of the part being replaced. 
 
Replacement of a prosthesis or prosthetic components required because of loss or irreparable damage may be 
reimbursed without a practitioner's order when it is determined that the prosthesis as originally ordered still fills 
the beneficiary's medical needs. 
 
Adjustments and repairs of prostheses and prosthetic components are covered under the original order for the 
prosthetic device. 
 
Medicare payment may be made for the replacement of prosthetic devices which are artificial limbs, or for the 
replacement of any part of such devices, without regard to continuous use or useful lifetime restrictions if a 
treating practitioner determines that the replacement device, or replacement part of such a device, is reasonable 
and necessary. Claims involving the replacement of a prosthesis or major component (foot, ankle, knee, socket) 
must be supported by a new treating practitioner's order and documentation supporting the reason for the 
replacement. The reason for replacement must be documented by the treating practitioner, either on the order or 
in the medical record, and must fall under one of the following: 
 
    1. A change in the physiological condition of the patient resulting in the need for a replacement. Examples 
include but are not limited to, changes in beneficiary weight, changes in the residual limb, beneficiary 
functional need changes; or, 
 
    2. An irreparable change in the condition of the device, or in a part of the device resulting in the need for a 
replacement; or, 
 
    3. The condition of the device, or the part of the device, requires repairs and the cost of such repairs would 
be more than 60 percent of the cost of a replacement device, or, as the case may be, of the part being replaced. 
 
 
 
The prosthetist must retain documentation of the prosthesis or prosthetic component replaced, the reason for 
replacement, and a description of the labor involved irrespective of the time since the prosthesis was provided 
to the beneficiary. This information must be available upon request. It is recognized that there are situations 
where the reason for replacement 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 Article: Lower Limb Prostheses - Policy Article 
(A52496). 
 
The rules say that when an initial below knee prosthesis (L5500) or a preparatory below knee prosthesis 
(L5510, L5520,L5530, L5540) is provided, prosthetic substitutions and/or additions of procedures and 
components are covered in accordance with the functional level assessment except for codes L5629, L5638, 
L5639, L5646, L5647, L5704, L5785, L5962, and L5980 which will be denied as not reasonable and 
necessary. When a below knee preparatory prefabricated prosthesis (L5535) is provided, prosthetic 
substitutions and/or additions of procedures are covered in accordance with the functional level assessment 
except for codes L5620, L5629, L5645, L5646, L5670, L5676, L5704, and L5962 which will be denied as not 
reasonable and necessary. 
 
When an above knee initial prosthesis (L5505) or an above knee preparatory (L5560, L5570, L5580, L5590, 
L5595, L5600) prosthesis is provided, prosthetic substitution and/or additions of procedures and components 
are covered in accordance with the functional level assessment except for codes L5610, L5631, L5640, L5642, 
L5644, L5648, L5705, L5706, L5964, L5980, and L5710, L5711, L5712, L5714, L5716, L5718, L5722, 
L5724, L5726, L5728, L5780, L5790, L5795 which will be denied as not reasonable and necessary. When an 
above knee preparatory prefabricated prosthesis (L5585) is provided, prosthetic substitution and/or additions of 
procedures and components are covered in accordance with the functional level assessment except for codes 
L5624, L5631, L5648, L5651, L5652, L5705, L5706, L5964, and L5966 which will be denied as not 
reasonable and necessary. 
 
An axial rotation unit (L5982, L5984, L5985, L5986) is covered for beneficiaries whose functional level is 2 or 
above. 
 
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.