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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 state that 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 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). 
 
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. 
 
For codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852, knee instability must be documented by 
examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, 
anterior/posterior Drawer test. 
 
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. 
 
A custom fabricated orthosis is covered when there is a documented physical characteristic which requires the 
use of a custom fabricated orthosis instead of a prefabricated orthosis. Examples of situations which meet the 
criterion for a custom fabricated orthosis include, but are not limited to: 
 
    Deformity of the leg or knee; 
 
    Size of thigh and calf; 
 
    Minimal muscle mass upon which to suspend an orthosis. Although these are examples of potential situations where a custom fabricated orthosis may be appropriate, 
suppliers must consider prefabricated alternatives such as pediatric knee orthoses in beneficiaries with small 
limbs, straps with additional length for large limbs, etc. 
 
If a custom fabricated orthosis is provided but the medical record does not document why that item is 
medically necessary instead of a prefabricated orthosis, the custom fabricated orthosis will be denied as 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.