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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 an L4396 or L4397 (Static or dynamic positioning ankle-foot orthosis) is covered if either all 
of criteria 1 - 4 or criterion 5 is met: 
1.  Plantar flexion contracture of the ankle (refer to the Group 1 Codes in the ICD-10 code list in the LCD- 
     related Policy Article for applicable diagnoses) with dorsiflexion on passive range of motion testing of at 
     least 10 degrees (i.e., a nonfixed contracture); and, 
2.  Reasonable expectation of the ability to correct the contracture; and, 
3.  Contracture is interfering or expected to interfere significantly with the beneficiary's functional abilities;  
     and, 
4.  Used as a component of a therapy program which includes active stretching of the involved muscles and/or  
     tendons. 
5.  The beneficiary has plantar fasciitis (refer to the Group 1 Codes in the ICD-10 code list in the LCD-related  
     Policy Article for applicable diagnoses). 
 
If an L4396 or L4397 is used for the treatment of a plantar flexion contracture, the pre-treatment passive range 
of motion must be measured with a goniometer and documented in the medical record. There must be 
documentation of an appropriate stretching program carried out by professional staff (in a nursing facility) or 
caregiver (at home). 
 
An L4396 or L4397 and replacement interface (L4392) will be denied as not reasonable and necessary if the 
contracture is fixed. Codes L4396, L4397 and L4392 will be denied as not reasonable and necessary for a 
beneficiary with a foot drop but without an ankle flexion contracture. A component of a static/dynamic AFO 
that is used to address positioning of the knee or hip will be denied as not reasonable and necessary because the 
effectiveness of this type of component is not established. 
 
  
If code L4396 or L4397 is covered, a replacement interface (L4392) is covered as long as the beneficiary 
continues to meet indications and other coverage rules for the splint. Coverage of a replacement interface is 
limited to a maximum of one (1) per 6 months. Additional interfaces will be denied as not reasonable and 
necessary. 
 
Medicare does not reimburse for a foot drop splint/recumbent positioning device (L4398) or replacement 
interface (L4394). A foot drop splint/recumbent positioning device and replacement interface will be denied as 
not reasonable and necessary in a beneficiary with foot drop who is non-ambulatory because there are other 
more appropriate treatment modalities. 
 
AFOs AND KAFOs USED DURING AMBULATION: 
Ankle-foot orthoses (AFO) described by codes L1900, L1902, L1904, L1906, L1907, 
L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, 
L1980, L1990, L2106, L2108, L2112, L2114, L2116, L4350, L4360, L4361, L4386, 
L4387 and L4631 are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle, 
who:  
Require stabilization for medical reasons and have the potential to benefit functionally. 
 
You can find this information in Local Coverage Article: Ankle-Foot/Knee-Ankle-Foot Orthosis (A55426). 
 
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.