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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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules state that Prefabricated Knee Orthoses (L1810, L1812, L1820, L1830, L1831, L1832, L1833, L1836, 
L1843, L1845, L1847, L1848, L1850, L1851, L1852): 
 
A knee flexion contracture is a condition in which there is shortening of the muscles and/or tendons with the 
resulting inability to bring the knee to 0 degrees extension or greater (i.e., hyperextension) by passive range of 
motion. (0 degrees knee extension is when the femur and tibia are in alignment in a horizontal plane). A knee 
extension contracture is a condition in which there is shortening of the muscles and/or tendons with the 
resulting inability to bring the knee to 80 degrees flexion or greater by passive range of motion. A contracture 
is distinguished from the temporary loss of range of motion of a joint following injury, surgery, casting, or 
other immobilization. 
 
A knee orthosis with joints (L1810, L1812) or knee orthosis with condylar pads and joints with or without 
patellar control (L1820) are covered for ambulatory beneficiaries who have weakness or deformity of the knee 
and require stabilization. A knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints (L1832, L1833), or a 
knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation 
control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury to or a surgical 
procedure on the knee(s). Refer to the diagnoses listed in the Groups 2 or 4 ICD-10 Codes in the LCD-related 
Policy Article. 
 
Knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a beneficiary who is 
ambulatory and has knee instability due to a condition specified in the Group 4 ICD-10 Codes in the LCD-
related Policy Article. 
 
Claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and 
necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied 
if only pain or a subjective description of joint instability is documented. 
 
Addition codes will be denied as not reasonable and necessary if the base orthosis is not reasonable and 
necessary or the addition is not reasonable and necessary. You can find this information in the Local Coverage 
Determination (LCD): Knee Orthoses (L33318). 
 
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.