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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 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 rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective January 1, 2020. 

The rules say that a level 3 ambulator 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. You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective January 1, 2020. 

The rules say that an axial rotation unit (L5986) is covered for beneficiaries whose functional level is 3 or above. You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective January 1, 2020. 

The rules say that a fluid, pneumatic, or electronic/microprocessor knee (L5828, L5848, L5856) is covered for beneficiaries whose functional level is 3 or above. You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective January 1, 2020. 

The rules say that L5321 should not be used when billing a replacement socket for an existing prosthesis. The use of L5321 with a replacement socket is incorrect coding (unbundling). You can find this rule in the Local Coverage Article (LCA) - Lower Limb Prostheses - Policy Article (A52496) - Effective August 1, 2020.

The rules say that when an above knee initial prosthesis or an above knee preparatory prosthesis is provided, prosthetic substitution and/or additions of procedures and components are covered in accordance with the functional level assessment except for codes L5631. You can find this rule in the Local Coverage Article (LCA) - Lower Limb Prostheses - Policy Article (A52496) - Effective August 1, 2020. 

The rules say that when an above knee preparatory prefabricated prosthesis is provided prosthetic substitution and/or additions of procedures and components are covered in accordance with the functional level assessment except for codes L5624, L5651. You can find this rule in the Local Coverage Article (LCA) - Lower Limb Prostheses - Policy Article (A52496) - Effective August 1, 2020. 

The rules say that code L5671 includes both the part of the suspension locking mechanism that is integrated into the prosthesis socket and the pin(s), lanyard, or other component which is attached to the socket insert. L5671 does not include the socket insert itself. The socket inserts used in conjunction with a suspension locking mechanism are billed with codes L5673, L5679, L5681, or L5683, as appropriate. These codes include socket inserts with or without a distal umbrella adapter for attaching the pin or lanyard of the locking mechanism. You can find this rule in the Local Coverage Article (LCA) - Lower Limb Prostheses - Policy Article (A52496) - Effective August 1, 2020. 

The rules say that L5968 describes a product that is used as an addition to L-code foot systems for lower limb prosthesis construction. The product provides multiaxial motion in the coronal and sagittal plane from articulating components. At transition of stance phase to swing phase, the product will increase the ankle's dorsiflexion angle and maintain it throughout swing phase. The product provides an accommodation of changing heel heights without the user's input. The predicate product is the Rincoe R-Hab Ankle. Use of this code is based on the beneficiary's K-level modifier (K0-K4), as referenced in the LCD. You can find this rule in the Local Coverage Article (LCA) - Lower Limb Prostheses - Policy Article (A52496) - Effective August 1, 2020. 

The rules say that lower limb prosthetic covers (L5705) are complete products and afford shape, protection and waterproofing for normal daily usage of the prosthesis. They offer sufficient protection and weatherproofing for beneficiaries who require lower limb prosthetics. You can find this rule in the Local Coverage Article (LCA) - Lower Limb Prostheses - Policy Article (A52496) - Effective August 1, 2020. 

The rules say that code L5950 for ultra-light materials may only be used when materials such as carbon fiber, fiberglass, Kevlar, or other advanced composite lamination materials are used in the fabrication of a socket for an endoskeletal prosthesis. You can find this rule in the Local Coverage Article (LCA) - Lower Limb Prostheses - Policy Article (A52496) - Effective August 1, 2020. 

The rules say that L5845 is an additional feature and/or function that do not describe a complete endoskeletal knee-shin system and must be used in combination with an L-code for a knee-shin system. The use of additional feature L-codes may also depend on the assigned K-Level modifier (K0-K4), as referenced in the LCD. You can find this rule in the Local Coverage Article (LCA) - Lower Limb Prostheses - Policy Article (A52496) - Effective August 1, 2020. 

The rules say that replacement refers to the provision of an identical or nearly identical item. Equipment which the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood). A physician's order and/or new Certificate of Medical Necessity (CMN), when required, is needed to reaffirm the medical necessity of the item. Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot be identified. Replacement of equipment due to irreparable wear takes into consideration the reasonable useful lifetime of the equipment. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 100.2.

The rules say that the reasonable useful lifetime of durable medical equipment is determined through program instructions. In the absence of program instructions, A/B MACs may determine the reasonable useful lifetime of equipment, but in no case can it be less than five years. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 100.2.

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.