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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 a fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, L5724,
L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858) is
covered for beneficiaries whose functional level is 3 or above.

L5859 (ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM,
POWERED AND PROGRAMMABLE FLEXION/EXTENSION ASSIST CONTROL, INCLUDES ANY
TYPE MOTOR(S)) is only covered when the beneficiary meets all of the criteria below:

Has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee

K3 functional level only

Has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps
function that impairs K-3 level function with the use of a microprocessor-controlled knee alone

Is able to make use of a product that requires daily charging

Is able to understand and respond to error alerts and alarms indicating problems with the function of the unit

A microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot
with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot
system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above.

An axial rotation unit (L5982, L5984, L5985, L5986) is covered for beneficiaries whose functional level is 2 or
above. You can find these rules in the Local Coverage Determination (LCD) Lower Limb Prostheses L33787.

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.

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.

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).

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).

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.

L5980 describes a product that can be used for either endoskeletal or exoskeletal lower limb construction. The
Flex Foot has an energy storing J-shaped keel design. Heel component is attached onto the J-shaped keel
section. The Flex Foot System's J-shaped keel design extends proximally as a monolithic composite shank.
Shank height is determined and modified by supplier to utilize the dynamics of the composite shank. L5980
includes foot cover.

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.

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."
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.

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.