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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 state that 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 beneficiarys potential functional level is 0. 
 
FEET: 
 
A determination of the type of foot 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 
SACH foot. Other prosthetic feet are considered for coverage based upon functional classification. 
 
An external keel SACH foot (L5970) or single axis ankle/foot (L5974) is covered for beneficiaries whose 
functional level is 1 or above. 
 
A flexible-keel foot (L5972) or multiaxial ankle/foot (L5978) is covered for beneficiaries whose functional level is 2 or above. 
 
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. 
 
The microprocessor foot or ankle system addition with power assist which includes any type motor (L5969) is 
not covered because there is insufficient information to demonstrate that the item meets the Medicare standard 
to be considered reasonable and necessary as per PIM Chapter 13. Claims for L5969 will be denied as not 
reasonable and necessary. 
 
Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or 
design feature of a given type of foot. This information must be retained in the treating practitioner's or 
prosthetist's files. 
 
A user-adjustable heel height feature (L5990) will be denied as not reasonable and necessary. 
 
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 is 4. 
 
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. 
 
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. 
 
ANKLES: 
 
An axial rotation unit (L5982, L5984, L5985, L5986) is covered for beneficiaries whose functional level is 2 or 
above. 
 
You can find this information in the Local Coverage Determination (LCD) Lower Limb Prostheses L33787. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.