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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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment. You can find
this rule at 42 CFR 424.5.

The rules say for Medicare to consider coverage and payment for any item or service, the information
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity
Manual, Chapter 3, Section 3.3.2.1.

The rules state that a K3 ambulator is defined as a patient who 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. You can find these rules in the Local Coverage Determination (LCD) for Lower Limb
Prostheses, L33787.

The rules state 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 beneficiary's history and
current condition which supports the designation of the functional level by the prosthetist. The rules also say
that 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. The rules say that 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. You can find these
rules in the Local Coverage Article for 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.