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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 beneficiarys 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 beneficiarys past history (including prior prosthetic use if applicable); and 
2. The beneficiarys current condition including the status of the residual limb and the nature of other 
medical problems; and 
3. The beneficiarys 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 ambulator. 
 
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 beneficiarys 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. KNEES: 
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. 
 
FEET: 
A microprocessor-controlled ankle foot system (L5973), energy storing foot (L5976), dynamic 
response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal 
(L5981), or shank foot system with vertical loading pylon (L5987) is covered for beneficiaries 
whose functional level is 3 or above. 
 
You can find this information in the Local Coverage Determination (LCD) Lower Limb Prostheses L33787. 
 
KNEES 
L5925, L5930, L5845, L5848, L5850, L5856, L5857, L5858, L5859 are additional features and/or 
functions 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 (L5610, L5611, L5613, L5616, L5810, L5811, 
L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840). The use of additional 
feature L-codes may also depend on the assigned K-Level modifier (K0-K4), as referenced in the 
LCD. 
 
ANKLES 
Codes L5968, L5982, L5984, L5986 describe separate products which provide either a single 
motion or a combination of motions commonly attributed to the anatomic ankle. The use of 
these codes can be used to fully describe additional features or functions not found in the 
prosthetic foot system (L5969, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979 
L5980, L5981 and L5987). 
 
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. 
 
You can find this information in the Local Coverage Article Lower Limb Prostheses - Policy Article A52496 
 
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.