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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 protective outer surface covering systems (L5962, L5964, and L5966) are specialized covers 
intended to be worn over an existing prosthesis. They are used by a beneficiary who has special needs for 
protection against unusually harsh environmental situations where it is necessary to protect the lower limb 
prosthesis beyond the level of protection that is afforded by L5704, L5705, L5706, and L5707. They are not for 
cosmetic or convenience reasons, or for everyday usage in a typical environment. Protective outer surface 
coverings are different from the covering that is already reimbursed as part of L5704, L5705, L5706, 
and L5707. 
 
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. 
 
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). 
 
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. 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. 
 
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.