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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 overage is extended only if there is sufficient clinical documentation of functional need for 
the technologic or design feature of a given type of knee. This information must be retained in the treating 
practitioner's or prosthetist's files. Coverage is extended only if there is sufficient clinical documentation of 
functional need for the technologic or design feature of a given type of foot. This information must be retained 
in the treating practitioner's or prosthetist's files. You can find this information in Medicares Local Coverage 
Determination (LCD): Lower Limb Prostheses (L33787). 
 
The rules say that 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. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Lower Limb Prostheses 
(L33787). 
 
The rules say that payment may be made for the replacement of a prosthetic device that is an artificial limb, or 
replacement part of a device if the ordering physician determines that the replacement device or part is 
necessary because of any of the following: 
1. A change in the physiological condition of the patient; 
2. An irreparable change in the condition of the device, or in a part of the device; or 
3. The condition of the device, or the part of the device, requires repairs and the cost of such repairs 
would be more than 60 percent of the cost of a replacement device, or, as the case may be, of the part 
being replaced. You can find this information in the Medicare Benefit Policy Manual: Chapter 15  Covered 
Medical and Other Health Services p.130 of 306: 120  Prosthetic Devices A. General. 
 
The rules say that under the circumstances specified below, payment may be made for repair, maintenance, and 
replacement of medically required DME, including equipment which had been in use before the user enrolled 
in Part B of the program. However, do not pay for repair, maintenance, or replacement of equipment in the 
frequent and substantial servicing or oxygen equipment payment categories. In addition, payments for repair 
and maintenance may not include payment for parts and labor covered under a manufacturers or suppliers 
warranty. You can find this information in the Medicare Benefit Policy Manual: Chapter 15  Covered Medical 
and Other Health Services pp.123-124 of 306: 110.2 - Repairs, Maintenance, Replacement, and Delivery (Rev. 
203, Issued: 02-13-15, Effective: 07-01-15, Implementation: 07-06-15). 
 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.