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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 state that 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. 
 
    A determination of the type of foot for the prosthesis will be made by the treating practitioner and/or the 
prosthetist based upon the functional needs of the beneficiary. Basic lower extremity prostheses include a 
SACH foot. Other prosthetic feet are considered for coverage based upon functional classification. 
 
    An external keel SACH foot (L5970) or single axis ankle/foot (L5974) is covered for beneficiaries whose 
functional level is 1 or above. 
 
    A flexible-keel foot (L5972) or multiaxial ankle/foot (L5978) is covered for beneficiaries whose functional 
level is 2 or above. 
 
    A microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot 
with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot 
system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above. 
 
    The microprocessor foot or ankle system addition with power assist which includes any type motor (L5969) 
is not covered because there is insufficient information to demonstrate that the item meets the Medicare 
standard to be considered reasonable and necessary as per PIM Chapter 13. Claims for L5969 will be denied as 
not reasonable and necessary. 
 
    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.  
    A user-adjustable heel height feature (L5990) will be denied as not reasonable and necessary. 
 
    KNEES: 
 
    A determination of the type of knee for the prosthesis will be made by the treating practitioner and/or the 
prosthetist based upon the functional needs of the beneficiary. Basic lower extremity prostheses include a 
single axis, constant friction knee. Other prosthetic knees are considered for coverage based upon functional 
classification. 
 
    A high activity knee control frame (L5930) is covered for beneficiaries whose functional level is 4. 
 
    A fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, L5724, L5726, L5728, 
L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858) is covered for 
beneficiaries whose functional level is 3 or above. 
 
    L5859 (ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN 
SYSTEM, POWERED AND PROGRAMMABLE FLEXION/EXTENSION ASSIST CONTROL, 
INCLUDES ANY TYPE MOTOR(S)) is only covered when the beneficiary meets all of the criteria below: 
 
    Has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee 
 
    K3 functional level only 
 
 
    If these coverage criteria for the knee component are not met, L5859 will be denied as not reasonable and 
necessary. 
 
    Other knee systems (L5611, L5616, L5710, L5711, L5712, L5714, L5716, L5718, L5810, L5811, L5812, 
L5816, L5818) are covered for beneficiaries whose functional level is 1 or above. 
 
    Coverage 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. 
 
    ANKLES: 
 
    An axial rotation unit (L5982, L5984, L5985, L5986) is covered for beneficiaries whose functional level is 2 
or above. 
 
You can find this information in the Local Coverage Determination (LCD) Lower Limb Prostheses L33787. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.