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 Codes L5968, L5982, L5984, L5986 describe separate products which provide either a single 
motion or a combination of motions commonly attributed to the anatomic ankle. 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 device with multiaxial ankle motion along with an active dorsiflexion motion activated for 
swing phase only. Use of L5968, L5982, L5984 or L5986 is based on the beneficiarys 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). 
 
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. 
 
When submitting a prosthetic claim, the billed code for knee, foot, ankle and hip (HCPCS 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 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 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.