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 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. Addition codes for
endoskeletal knee-shin systems are L5610, L5611, L5613, L5616, L5810, L5811, L5812, L5814, L5816,
L5818, L5822, L5824, L5826, L5828, L5830, L5840 are considered an upgrade to the kneeshin system. The
beneficiary may qualify for an upgraded knee-shin system based on their assigned K-Level modifier (K0-K4),
as referenced in the LCD. These HCPCS codes can fully describe a complete prosthetic knee-shin system
commonly referred to as a "base knee code". A single addition code can fully describe a complete knee-shin
system and thus the use of two codes (L5610, L5611, L5613, L5616, L5810, L5811, L5812, L5814, L5816,
L5818, L5822, L5824, L5826, L5828, L5830, L5840) would be considered incorrect coding (unbundling).
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. 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 Lower Limb Prostheses - Policy Article
A52496
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.
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.