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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 (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 
 
 
 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. No more than two of the same socket inserts (L5654, L5655, L5656, L5658, L5661, 
L5665, L5673, L5679, L5681, L5683) are allowed per individual prosthesis at the same time. You can find 
these rules in the Local Coverage Determination (LCD) Lower Limb Prostheses L33787. 
 
The rules 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 HCPCS 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. 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. 
 
Infinite SocketTM (LIM Innovations) is an open-socket design that has distinct below knee and above knee 
products. These sockets are custom fabricated from a model of the patient's residual limb and utilize struts that 
extend from a base to an adjustable brim enclosing an inner shell to form the primary structure of the socket. 
The LIM Innovations socket is functionally equivalent to design features of current HCPCS codes. The correct 
combination of HCPCS codes for the Infinite Socket TT-S (BK) are L5301 or L5700 with the addition of 
L5629 and L5940. The correct combination of HCPCS codes for the Infinite Socket T/F (AK) are L5321 or 
L5701 with the addition of L5631, L5649, and L5950. 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. 
 
Codes L5647 and L5652 describe a modification to a prosthetic socket that incorporates a suction valve in the 
design. The items described by these codes are not components of a suspension locking mechanism (L5671). 
 
Codes L5940, L5950, and L5960 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. They are not used for ultralight materials used in other components of a 
prosthesis  e.g., knee/shin system, pylon, ankle, foot, etc. For codes L5940, L5950, and L5960, the unit of 
service is per limb. 
 
L5301, L5540, L5321, L5590 should not be used when billing a replacement socket for an existing prosthesis. 
The use of L5301, L5540, L5321, L5590 with a replacement socket is incorrect coding (unbundling). Code 
L5999 (lower extremity prosthesis, not otherwise specified) must not be used to bill for any features or 
functions included in the socket or addition codes. Use of L5999 is incorrect coding (unbundling). Codes 
L5681 and L5683 are for use only with the initial issue of a custom fabricated socket insert. Additional inserts 
(either custom fabricated or prefabricated) provided at the time of initial issue or replacement socket inserts are 
coded L5673 and L5679, whichever is applicable. 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.