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 state that 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 beneficiary's 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. 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. 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. 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 Local Coverage Determination (LCD) Lower Limb Prostheses (L33787).
The rules state that protective outer surface covering systems (L5962, L5964, and L5966) are specialized
covers intended to be worn over an existing prosthesis. They are used by a beneficiary who has special needs
for protection against unusually harsh environmental situations where it is necessary to protect the lower limb
prosthesis beyond the level of protection that is afforded by L5704, L5705, L5706, and L5707. They are not for
cosmetic or convenience reasons, or for everyday usage in a typical environment. Protective outer surface
coverings are different from the covering that is already reimbursed as part of L5704, L5705, L5706, and
L5707. You can find these rules in Local Coverage Article (LCA) Lower Limb Prostheses Policy Article
(A52496).
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.