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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 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 a fluid, pneumatic, or electronic/microprocessor knee (L5828, L5848, L5856) 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 L5968 describes a product that is used as an addition to L-code foot systems for lower limb
prosthesis construction. The product provides multiaxial motion in the coronal and sagittal plane from
articulating components. At transition of stance phase to swing phase, the product will increase the ankle's
dorsiflexion angle and maintain it throughout swing phase.
The product provides an accommodation of changing heel heights without the user's input. The predicate
product is the Rincoe R-Hab Ankle. 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 L5850 is an additional feature/function that does not describe a complete endoskeletal kneeshin
system and must be used in combination with an L-code for a knee-shin system. The use of additional
feature L-codes may also depend on the assigned K-Level modifier (K0-K4). You can find this rule in the
Local Coverage Article (LCA) - Lower Limb Prostheses - Policy Article (A52496) - Effective August 1, 2020.
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