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 fluid pneumatic, or electronic/microprocessor knee 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 billed 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 Local 
Coverage Article: Lower Limb Prostheses - Policy Article (A52496) - Effective August 1, 2020. 
 
The rules when an above knee initial prosthesis or an above 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 Local Coverage Determination (LCD): Lower 
Limb Prostheses (L33787) - Effective January 1, 2020. 
 
The rules say that when an above knee 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, L5631, L5651, L5652. You can find this rule in Local Coverage Determination (LCD): 
Lower Limb Prostheses (L33787) - Effective January 1, 2020. 
 
The rules say more than two test/diagnostic sockets (L5624) for an individual prosthesis are not reasonable and 
necessary unless there is documentation in the medical record which justifies the need. You can find this rule in 
Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective January 1, 2020. 
 
The rules say that no more than two of the same socket inserts (L5679) are allowed per individual prosthesis at 
the same time. You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses 
(L33787) - Effective January 1, 2020. 
 
The rules say that L5925 and L5845 are additional features and/or functions that do not describe 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 Local Coverage Article: Lower Limb Prostheses - Policy Article (A52496) - 
Effective August 1, 2020. 
 
The rules say that L5950 are used for ultralight materials. This code may be 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. They are not used for ultralight materials used in other 
components of a prosthesis e.g., knee/shin system, pylon, ankle, foot, etc. You can find this rule in Local 
Coverage Article: Lower Limb Prostheses - Policy Article (A52496) - Effective August 1, 2020. 

The rules say that L5981 are considered an upgrade to the SACH foot. The beneficiary may qualify for an 
upgraded prosthetic foot based on their assigned K-level modifier (K0-K4). You can find this rule in Local 
Coverage Article: Lower Limb Prostheses - Policy Article (A52496) - Effective August 1, 2020. 
 
The rules say that a flex-walk system or equal (L5981) 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 an axial rotation unit is covered for beneficiaries whose functional level is 2 or above. You 
can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective 
January 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.