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 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). 
 
L5968 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 the coronal and sagittal plane from articulating 
components. At transition of stance phase to swing phase, the product will increase the ankles dorsiflexion 
angle and maintain it throughout swing phase. The product provides an accommodation of changing heel 
heights without the users input.  
 
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. 
 
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 beneficiarys history and current condition which 
supports the designation of the functional level by the prosthetist. 
 
Addition codes for lower extremity prostheses, L5970, L5971, L5972, L5974, L5975, L5976, L5978, L5979, 
L5980, L5981, L5987 are considered an upgrade to the 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). 
 
L5981 describes a product that can be used for either endoskeletal or exoskeletal lower limb construction. The 
Flex Walk has an energy storing J-shaped keel design. Heel component is attached to the J-shaped keel section. 
The Flex Walk J-shaped keel design proximally terminates at a nonadjustable fixed height determined and 
modified by the prosthetic foot manufacturer. L5981 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.