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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 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-shin system, powered and programmable 
flexion/extension assist control, includes any type motor(s)) is only covered when the beneficiary meets all of 
the criteria below: 
 
Has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee 
K3 functional level only 
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 alone 
Is able to make use of a product that requires daily charging 
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. 
 
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 these rules in the Local Coverage Determination (LCD) Lower Limb Prostheses L33787. 
 
The rules also say that when submitting a prosthetic claim, the billed code for knee, foot, ankle and hip 
(HCPCS codes L5610, L5611, L5613, L5614, L5616, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, 
L5830, L5840, L5848, L5856, L5857, L5858, L5859, L5930, L5961, L5970, L5971, L5972, L5973, L5974, 
L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987) components must be 
submitted with modifiers K0 - K4, indicating the expected beneficiary functional level. This expectation of 
functional ability information must be clearly documented and retained in the prosthetist's records. The simple 
entry of a K modifier in those records is not sufficient. There must be information about the beneficiarys 
history and current condition which supports the designation of the functional level by the prosthetist. 
 
Addition codes for endoskeletal knee-shin systems are L5610, L5611, L5613, L5616, L5810, L5811, L5812, 
L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840 are considered an upgrade to the knee-
shin system. The beneficiary may qualify for an upgraded knee-shin system based on their assigned K-Level 
modifier (K0-K4), as referenced in the LCD. These codes can fully describe a complete prosthetic knee-shin 
system commonly referred to as a base knee code. A single addition code can fully describe a complete knee-
shin system and thus the use of two codes (L5610, L5611, L5613, L5616, L5810, L5811, L5812, L5814, 
L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840) would be considered incorrect coding 
(unbundling). 
 
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. 
 
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. 
 
L5856 refers to a feature of an endoskeletal knee component which is incorporated into the entire knee-shin 
system. The microprocessor componentry with sensors, any type, provide automated adjustment for controlling 
the swing and stance phase of gait. This feature would be discernable from schematic drawings and user 
manual documentation. The documentation would provide details for all of the adjustments for the dynamic 
properties of this sub-system within the knee component. Adjustments could factor user characteristics such as 
the activity level, body weight, or gait preferences, among others. This adjustment feature is energized by an 
on-board rechargeable battery source. The code would include any external components needed to access the 
microprocessor for modification of the settings. 
 
Codes L5968, L5982, L5984, L5985, L5986 and L5988 describe separate products which provide either a 
single motion or a combination of motions generally attributed to functional movement of the lower limb 
during ambulation. 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). 
 
L5973 describes an endoskeletal device with integrated energy storage and release foot and microprocessor 
ankle system. The integrated microprocessor is programmable along with sensors to optimize plantar and 
dorsiflexion angles for stance and swing phase. L5973 includes foot cover, power source(s) and charger. 
 
A microprocessor ankle-foot system with power assist (BiOM Ankle-Foot System by iWalk, Inc) is coded as 
the combination of L5969 (addition, endoskeletal ankle-foot or ankle system, power assist, includes any type of 
motor(s)) and l5973 (endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source). You can find these rules 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.