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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 Healthcare 
Common Procedure Coding System (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 beneficiarys history and current condition which supports the designation of the 
functional level by the prosthetist. 
 
Codes L5968, L5982, L5984, L5985, L5986 and L5988 describe separate products which provide either a 
single motion or a combination of motions generally attributed to functional movement of the lower limb 
during ambulation. The use of these codes can be used to fully describe additional features or functions not 
found in the prosthetic foot system (L5969, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, 
L5979 L5980, L5981 and L5987). 
 
L5986 describes a product that is used as an addition to L-code foot systems for lower limb prosthesis 
construction. The product provides multiaxial motion in all three planes of motion, sagittal, coronal, and 
transverse. This code does not describe the multiaxial motion achieved from the inherent flexibility of the 
prosthetic keel or a split keel/heel prosthetic foot design. The predicate product is a device that was 
manufactured by Medical Center Prosthetic, which is represented in the coding narrative by MCP. 
 
Use of L5968, L5982, L5984 or L5986 is based on the beneficiarys K-level modifier (K0-K4), as referenced 
in the LCD. 
 
L5968, L5982, L5984, L5985, L5986, L5988, L5990 are additional features and/or functions that do not 
describe a complete prosthetic foot and may be used in combination with L5970, L5971, L5972, L5974, 
L5975, L5976, L5978, L5979, L5980, L5981, and L5987. The use of additional feature L-codes may also 
depend on the assigned K-Level modifier (K0-K4) as referenced in the LCD. 
 
Addition codes for lower extremity prostheses, L5970, L5971, L5972, L5974, L5975, L5976, L5978, L5979, 
L5980, L5981, L5987 are considered an upgrade to the solid ankle cushioned heel (SACH) foot. The 
beneficiary may qualify for an upgraded prosthetic foot based on their assigned K-level modifier (K0-K4) as 
referenced in the LCD. A single addition code (L5970, L5971, L5972, L5974, L5975, L5976, L5978, L5979, 
L5980, L5981, L5987) can fully describe a complete foot and thus the use of more than one code would be 
considered incorrect coding (unbundling). 
 
L5968, L5982, L5984, L5985, L5986, L5988, L5990 are additional features and/or functions that do not 
describe a complete prosthetic foot and may be used in combination with L5970, L5971, L5972, L5974, 
L5975, L5976, L5978, L5979, L5980, L5981, and L5987. The use of additional feature L-codes may also 
depend on the assigned K-Level modifier (K0-K4) as referenced in the LCD. 
 
L5987 describes a product that can be used for either endoskeletal or exoskeletal lower limb construction. All 
components are integrated as a single product, i.e., not an assembly of separate products or components. The 
product has an energy storing J-shaped keel design. Heel component is attached onto the J-shaped keel section. 
Vertical loading pylon allows controlled motion for shock absorption. This code does not describe vertical 
loading or shock absorption achieved from the inherent flexibility of the J-shaped keel section. L5987 includes 
foot cover. 
 
You can find these rules in the Local Coverage Article 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.