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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 a lower limb prosthesis is covered when the beneficiary: 
 
    Will reach or maintain a defined functional state within a reasonable period of time; and 
    Is motivated to ambulate. 
 
FUNCTIONAL LEVELS: 
 
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 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. 
When an initial below knee prosthesis (L5500) or a preparatory below knee prosthesis (L5510, L5520,L5530, 
L5540) is provided, prosthetic substitutions and/or additions of procedures and components are covered in 
accordance with the functional level assessment except for codes L5629, L5638, L5639, L5646, L5647, L5704, 
L5785, L5962, and L5980 which will be denied as not reasonable and necessary. When a below knee 
preparatory prefabricated prosthesis (L5535) is provided, prosthetic substitutions and/or additions of 
procedures are covered in accordance with the functional level assessment except for codes L5620, L5629, 
L5645, L5646, L5670, L5676, L5704, and L5962 which will be denied as not reasonable and necessary. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Lower Limb Prostheses 
(L33787). 
 
The rules say L5781 describes a complete device that is an addition to a lower limb prosthesis. The primary 
function of the vacuum pump is to suspend the prosthetic limb. Additionally, products coded L5781 provide 
residual limb volume management and moisture evacuation. The pump mechanism evacuates air and 
accumulated moisture between the limb and socket walls. The pump mechanism can be actuated by either 
external power and/or mechanical system(s). 
 
L5782 describes a complete device that is an addition to a lower limb prosthesis. The primary function of the 
vacuum pump is to suspend the prosthetic limb. It also provides residual limb volume management and 
moisture evacuation. The pump mechanism evacuates air and accumulated moisture between the limb and 
socket walls. The pump mechanism can be actuated by either external power and/or mechanical system(s). 
Products described by this code would have components built to withstand higher prosthetic limb forces than 
L5781. 
 
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. You can 
find this information in Medicare's 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.