Appeal type: unknown
Decision: unknown

 
  
  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 when submitting a prosthetic claim, the billed code for knee, foot, ankle and hip (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. 
 
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 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. 
 
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. 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. 
 
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). 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 ArticleA52496. 
 
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.