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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 fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, L5724, 
L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858) is 
covered for beneficiaries whose functional level is 3 or above. 
 
L5859 (addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable 
flexion/extension assist control, includes any type motor(s)) is only covered when the beneficiary meets all of 
the criteria below: 
Has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee 
K3 functional level only 
Has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps 
function that impairs K-3 level function with the use of a microprocessor-controlled knee alone 
Is able to make use of a product that requires daily charging 
Is able to understand and respond to error alerts and alarms indicating problems with the function of the unit 
 
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 these rules in the Local Coverage Determination (LCD) Lower Limb Prostheses L33787. 
 
The rules also say 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. 
 
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. 
 
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, 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). 
 
Addition codes for lower extremity prostheses, L5970, L5971, L5972, L5974, L5975, L5976, L5978, L5979, 
L5980, L5981, L5987 are considered an upgrade to the solid ankle cushion heel (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. 
 L5980 describes a product that can be used for either endoskeletal or exoskeletal lower limb construction. The 
Flex Foot has an energy storing J-shaped keel design. Heel component is attached onto the J-shaped keel 
section. The Flex Foot Systems J-shaped keel design extends proximally as a monolithic composite shank. 
Shank height is determined and modified by supplier to utilize the dynamics of the composite shank. L5980 
includes foot cover. 
 
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. 
 
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). 
 
Powered base items are those that contain the power source (battery). At the time that a base item is billed, all 
necessary batteries and/or battery chargers are considered as included in the payment for the powered base 
item. There is no separate payment for batteries (L7360, L7364, and L7367) and/or battery chargers (L7362, 
L7366, and L7368) billed concurrently with a powered base item. 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.