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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 lower limb prosthesis is covered when the beneficiary: 
 
Will reach or maintain a defined functional state within a reasonable period of time; and 
 
Is motivated to ambulate. 
 
FUNCTIONAL LEVELS: 
 
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: 
 
The beneficiarys past history (including prior prosthetic use if applicable); and 
 
The beneficiarys current condition including the status of the residual limb and the nature of other medical 
problems; and 
 
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. 
 
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. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Lower Limb Prostheses 
(L33787). 
 
The rules say 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. 
 
L5858 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 stance phase of gait. 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. 
 
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. 
 
You can find this information in Medicare's Local Coverage Article: Lower Limb Prostheses (A52496). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.