Appeal type: unknown
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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say an ankle-foot orthoses (AFO) described by codes L1900, L1902, L1904, L1906, L1907, L1910, 
L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2106, L2108, 
L2112, L2114, L2116, L4350, L4360, L4361, L4386, L4387 and L4631 are covered for ambulatory 
beneficiaries with weakness or deformity of the foot and ankle, who: 
        1. Require stabilization for medical reasons, and 
        2. Have the potential to benefit functionally. 
 
Knee-ankle-foot orthoses (KAFO) described by codes L2000, L2005, L2010, L2020, L2030, L2034, L2035, 
L2036, L2037, L2038, L2126, L2128, L2132, L2134, L2136, and L4370 are covered for ambulatory 
beneficiaries for whom an ankle-foot orthosis is covered and for whom additional knee stability is required. If 
the basic coverage criteria for an AFO or KAFO are not met, the orthosis will be denied as not reasonable and 
necessary. AFOs and KAFOs that are custom-fabricated are covered for ambulatory beneficiaries when the 
basic coverage criteria listed above and one of the following criteria are met: 
         1. The beneficiary could not be fit with a prefabricated AFO; or 
         2. The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more 
than 6 months); or 
         3. There is a need to control the knee, ankle or foot in more than one plane: or 
         4. The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom 
fabricating over a model to prevent tissue injury; or 
         5. The beneficiary has a healing fracture which lacks normal anatomical integrity or anthropometric 
proportions. If a custom fabricated orthosis is provided but basic coverage criteria above and the additional criteria 1-5 for a 
custom fabricated orthosis are not met, the custom fabricated orthosis will be denied as not reasonable and 
necessary. You can find this in the LCD: Ankle-Foot/Knee-Ankle-Foot Orthosis L33686. 
 
The rules say that shoes are also covered if they are an integral part of a covered leg brace described by codes 
L1900, L1920, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2050, L2060, L2080, or L2090. Oxford 
shoes (L3224, L3225) are covered in these situations. Other shoes, e.g., high top, depth inlay or custom for 
non-diabetics, etc. (L3649), are also covered if they are an integral part of a covered brace and if they are 
medically necessary for the proper functioning of the brace. Heel replacements (L3455, L3460), sole 
replacements (L3530, L3540), and shoe transfers (L3600, L3610, L3620, L3630 and L3640) involving shoes 
on a covered brace are also covered. Inserts and other shoe modifications (L3000, L3001, L3002, L3003, 
L3010, L3020, L3030, L3031, L3040, L3050, L3060, L3070, L3080, L3090, L3100, L3140, L3150, L3160, 
L3170, L3300, L3310, L3320, L3330, L3332, L3334, L3340, L3350, L3360, L3370, L3380, L3390, L3400, 
L3410, L3420, L3430, L3440, L3450, L3465, L3470, L3480, L3485, L3500, L3510, L3520, L3550, L3560, 
L3570, L3580, L3590 and L3595) are covered if they are on a shoe that is an integral part of a covered brace 
and if they are medically necessary for the proper functioning of the brace. Shoes and related modifications, 
inserts, heel/sole replacements or shoe transfers billed without a KX modifier will be denied as noncovered 
because coverage is statutorily excluded. You can find this information in the Local Coverage Article A52481. 
 
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.