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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 lower limb prosthesis is covered when the beneficiary: 
 
1. Will reach or maintain a defined functional state within a reasonable period of time; and 
 
2. Is motivated to ambulate. 
 
 
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: 
 
1. The beneficiarys past history (including prior prosthetic use if applicable); and 
 
2. The beneficiarys current condition including the status of the residual limb and the nature of other medical 
problems; and 
 
3. The beneficiarys desire to ambulate. 
 
Clinical assessments of beneficiary rehabilitation potential must be based on the following classification levels: 
 
Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a 
prosthesis does not enhance their quality of life or mobility. 
Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed 
cadence. Typical of the limited and unlimited household ambulator. 
Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers 
such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. 
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. Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting 
high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete. 
 
The records must document the beneficiarys current functional capabilities and his/her expected functional 
potential, including an explanation for the difference, if that is the case. It is recognized, within the functional 
classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level 
classifications. 
 
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. 
 
You can find this information in the Local Coverage Determination (LCD): Lower Limb Prostheses (L33787). 
 
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. The predicate product is the Rincoe R-Hab Ankle manufactured by R.G. 
Rincoe & Associates, Inc. 
 
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: Lower Limb Prostheses - Policy Article 
(A52496). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.