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 a determination of the medical necessity for certain components/additions to the prosthesis is based on the beneficiary's 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:  1. The beneficiary's past history (including prior prosthetic use if applicable); and 2. The beneficiary's current condition including the status of the residual limb and the nature of other medical problems; and 3. The beneficiary's desire to ambulate. You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective January 1, 2020.  The rules say that a level 3 ambulator 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. You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective January 1, 2020.  The rules say that a flex-walk system or equal (L5981) is covered for beneficiaries whose functional level is 3 or above. You can find this rule in Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) - Effective January 1, 2020.  The rules say that the use of L5301 with a replacement socket is incorrect coding (unbundling). You can find this rule in the Local Coverage Article (LCA) - Lower Limb Prostheses - Policy Article (A52496) - Effective August 1, 2020.  The rules say that L5968 describes a separate product which provides 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. You can find this rule in the Local Coverage Article (LCA) - Lower Limb Prostheses - Policy Article (A52496) - Effective August 1, 2020.  The rules say that code L5940 for ultra-light materials may only be used when materials such as carbon fiber, fiberglass, Kevlar, or other advanced composite lamination materials are used in the fabrication of a socket for an endoskeletal prosthesis.  They are not used for ultralight materials used in other components of a prosthesis - e.g., knee/shin system, pylon, ankle, foot. For codes L5940, L5950, and L5960, the unit of service is per limb. You can find this rule in the Local Coverage Article (LCA) - Lower Limb Prostheses - Policy Article (A52496) - Effective August 1, 2020.  The rules say that replacement refers to the provision of an identical or nearly identical item. Equipment which the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood).  A physician's order and/or new Certificate of Medical Necessity (CMN), when required, is needed to reaffirm the medical necessity of the item. Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot be identified.  Replacement of equipment due to irreparable wear takes into consideration the reasonable useful lifetime of the equipment. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 100.2.   The rules say that the reasonable useful lifetime of durable medical equipment is determined through program instructions. In the absence of program instructions, A/B MACs may determine the reasonable useful lifetime of equipment, but in no case can it be less than five years. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 100.2.  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.