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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 exoskeletal prosthetic lower limb codes L5150 and L5160 includes a knee disarticulation 
molded prosthetic socket, external knee joints, and a SACH foot. Endoskeletal prosthetic lower limb codes 
L5312, L5321, L5331, L5341 include molded prosthetic socket, an endoskeletal single axis knee-shin system 
and a SACH foot. L5100, L5105, L5301 includes a below knee molded prosthetic socket, and a SACH foot. 
 
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, etc. For codes L5940, L5950, and L5960, the unit of 
service is per limb. 
 
L5301, L5540, L5321, L5590 should not be used when billing a replacement socket for an existing prosthesis. 
The use of L5301, L5540, L5321, L5590 with a replacement socket is incorrect coding (unbundling). Code 
L5999 (LOWER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIED) must not be used to bill for 
any features or functions included in the socket or addition codes. Use of L5999 is incorrect coding 
(unbundling). 
 
Infinite SocketTM (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 (BK) are L5301 or L5700 with the addition of 
L5629 and L5940. The correct combination of HCPCS codes for the Infinite Socket T/F (AK) are L5321 or 
L5701 with the addition of L5631, L5649, and L5950. 
 
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 knee-
shin 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). 
 
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, L5986 describe separate products which provide either a single motion or a 
combination of motions commonly attributed to the anatomic ankle. 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 device with multiaxial ankle motion along with an active dorsiflexion motion activated for 
swing phase only. 
 
Use of L5968, L5982, L5984 or L5986 is based on the beneficiarys 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 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. 
 
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.