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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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say a determination of the medical necessity for certain components/additions to the prosthesis is 
based on the beneficiarys potential functional abilities. Potential functional ability is based on the reasonable 
expectations of the prosthetist, and treating practitioner, considering factors including, but not limited to: 
 
    The beneficiarys past history (including prior prosthetic use if applicable); and 
    The beneficiarys current condition including the status of the residual limb and the nature of other medical 
problems; and 
    The beneficiarys desire to ambulate. 
 
Clinical assessments of beneficiary rehabilitation potential must be based on the following classification levels: 
 
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. 
 
GENERAL: 
 
If a prosthesis is denied as not reasonable and necessary, related additions will also be denied as not reasonable 
and necessary. 
 
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. 
 
FEET: 
 
A determination of the type of foot for the prosthesis will be made by the treating practitioner and/or the 
prosthetist based upon the functional needs of the beneficiary. Basic lower extremity prostheses include a 
SACH foot. Other prosthetic feet are considered for coverage based upon functional classification. 
 
A flex-walk system or equal (L5981) is covered for beneficiaries whose functional level is 3 or above. 
 
Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or 
design feature of a given type of foot. This information must be retained in the treating practitioner's or 
prosthetist's files. 
 
KNEES:  
A fluid, pneumatic, or electronic/microprocessor knee (L5828, L5848, L5856) is covered for beneficiaries 
whose functional level is 3 or above. 
 
Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or 
design feature of a given type of knee. This information must be retained in the treating practitioner's or 
prosthetist's files. 
 
SOCKETS: 
 
No more than two of the same socket inserts (L5679) are allowed per individual prosthesis at the same time. 
 
Socket replacements are considered reasonable and necessary if there is adequate documentation of functional 
and/or physiological need. It is recognized that there are situations where the explanation includes but is not 
limited to: changes in the residual limb; functional need changes; or irreparable damage or wear/tear due to 
excessive beneficiary weight or prosthetic demands of very active amputees. 
 
You can find this information in the Local Coverage Determination (LCD) for Lower Limb Prostheses 
(L33787). 
 
The rules say that the socket inserts used in conjunction with a suspension locking mechanism are billed with 
codes L5673, L5679, L5681, or L5683, as appropriate. These codes include socket inserts with or without a 
distal umbrella adapter for attaching the pin or lanyard of the locking mechanism. 
 
Codes L5681 and L5683 are for use only with the initial issue of a custom fabricated socket insert. Additional 
inserts (either custom fabricated or prefabricated) provided at the time of initial issue or replacement socket 
inserts are coded L5673 and L5679, whichever is applicable. 
 
Code L5652 describes a modification to a prosthetic socket that incorporates a suction valve in the design. The 
items described by this code is not a component of a suspension locking mechanism (L5671). 
  
PROSTHETIC SYSTEMS 
 
Endoskeletal prosthetic lower limb code L5321 includes molded prosthetic socket, an endoskeletal single axis 
knee-shin system and a SACH foot. 
 
SOCKETS 
 
Codes L5940, L5950, and L5960 for ultra-light materials may only be used when materials such as carbon 
fiber, fiberglass, Kevlar, or other advanced composite lamination materials are used in the fabrication of a 
socket for an endoskeletal prosthesis. They are not used for ultralight materials used in other components of a 
prosthesis  e.g., knee/shin system, pylon, ankle, foot. For codes L5940, L5950, and L5960, the unit of service 
is per limb. 
 
L5321 should not be used when billing a replacement socket for an existing prosthesis. The use of L5321 with 
a replacement socket is incorrect coding (unbundling). 
 
Infinite Socket (LIM Innovations) is an open-socket design that has distinct below knee and above knee 
products. These sockets are custom-fabricated from a model of the patient's residual limb and utilize struts that 
extend from a base to an adjustable brim enclosing an inner shell to form the primary structure of the socket. 
The LIM Innovations socket is functionally equivalent to design features of current HCPCS codes. The correct 
combination of HCPCS codes for the Infinite Socket TT-S (below-knee socket) are L5301 or L5700 with the addition of L5629, L5637, and L5940. The correct combination of HCPCS codes for the Infinite Socket T/F 
(above-knee socket) are L5321 or L5701 with the addition of L5631, L5649, and L5950. 
  
 
KNEES 
 
With the exception of items described by specific HCPCS codes, there should be no separate billing and there 
is no separate payment for a component or feature of a microprocessor controlled knee, including but not 
limited to real time gait analysis, continuous gait assessment, or electronically controlled static stance regulator. 
 
Addition codes for endoskeletal knee-shin systems L5828 is considered an upgrade to the knee-shin system. 
 
L5845, L5848, L5856 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 (L5828). 
 
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. 
 
ANKLE AND LOWER EXTREMITY MOTION UNITS 
 
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). 
 
FEET 
 
Addition codes for lower extremity prostheses, L5981, is considered an upgrade to the SACH foot. 
 
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 this information 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.