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 a lower limb prosthesis is covered when the beneficiary: 1. Will reach or maintain a defined functional state within a reasonable period of time; and2.Is motivated to ambulate. FUNCTIONAL LEVELS: 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. Clinical assessments of beneficiary rehabilitation potential must be based on the following classification levels: Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility. Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulatory. Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. Level 3: 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. Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete. The records must document the beneficiary's current functional capabilities and his/her expected functional potential, including an explanation for the difference, if that is the case. It is recognized, within the functional classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level classifications. 
 
GENERAL: If a prosthesis is denied as not reasonable and necessary, related additions will also be denied as not reasonable and necessary. 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. In the following sections, the determination of coverage for selected prostheses and components with respect to potential functional levels represents the usual case. Exceptions will be considered in an individual case if additional documentation is included which justifies the medical necessity. Prostheses will be denied as not reasonable and necessary if the beneficiary's potential functional level is 0.GENERAL:If a prosthesis is denied as not reasonable and necessary, related additions will also be denied as not reasonable and necessary. 
 
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 codesL5629, 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. In the following sections, the determination of coverage for selected prostheses and components with respect to potential functional levels represents the usual case. Exceptions will be considered in an individual case if additional documentation is included which justifies the medical necessity. Prostheses will be denied as not reasonable and necessary if the beneficiary's potential functional level is 0. KNEES: 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 is4.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-SHINSYSTEM, 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) knee2.K3 functional level only3.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 alone4.Is able to make use of a product that requires daily charging5.Is able to understand and respond to error alerts and alarms indicating problems with the function of the unit. If these coverage criteria for the knee component are not met, L5859 will be denied as not reasonable and necessary. Other knee systems (L5611, L5616, L5710, L5711, L5712, L5714, L5716, L5718, L5810, L5811, L5812, L5816, L5818) are covered for beneficiaries whose functional level is 1 or above. Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of knee. This information must be retained in the treating practitioner's or prosthetist's files. Sign feature of a given type of knee. This information must be retained in the treating practitioner's or prosthetist's files. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Lower Limb Prostheses (L33787).