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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 clinical assessments of beneficiary rehabilitation potential must be based on the following 
classification levels: 
- Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance 
and a prosthesis does not enhance their quality of life or mobility. 
- Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at 
fixed cadence. Typical of the limited and unlimited household ambulator. 
- Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental 
barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. 
- Level 3: 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. 
- Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, 
exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active 
adult, or athlete. 
 
The records must document the beneficiarys current functional capabilities and his/her expected functional 
potential, including an explanation for the difference, if that is the case. It is recognized, within the functional classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level 
classifications. 
 
When an above knee initial prosthesis (L5505) or an above knee preparatory (L5560, L5570, L5580, L5590, 
L5595, L5600) prosthesis is provided, prosthetic substitution and/or additions of procedures and components 
are covered in accordance with the functional level assessment except for codes L5610, L5631, L5640, L5642, 
L5644, L5648, L5705, L5706, L5964, L5980, and L5710, L5711, L5712, L5714, L5716, L5718, L5722, 
L5724, L5726, L5728, L5780, L5790, L5795 which will be denied as not reasonable and necessary. When an 
above knee preparatory prefabricated prosthesis (L5585) is provided, prosthetic substitution and/or additions of 
procedures and components are covered in accordance with the functional level assessment except for codes 
L5624, L5631, L5648, L5651, L5652, L5705, L5706, L5964, and L5966 which will be denied as not 
reasonable and necessary. 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. 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. You can find these rules in Local 
Coverage Determination (LCD) Lower Limb Prostheses (L33787). 
 
The rules state that protective outer surface covering systems (L5962, L5964, and L5966) are specialized 
covers intended to be worn over an existing prosthesis. They are used by a beneficiary who has special needs 
for protection against unusually harsh environmental situations where it is necessary to protect the lower limb 
prosthesis beyond the level of protection that is afforded by L5704, L5705, L5706, and L5707. They are not for 
cosmetic or convenience reasons, or for everyday usage in a typical environment. Protective outer surface 
coverings are different from the covering that is already reimbursed as part of L5704, L5705, L5706, and 
L5707. You can find these rules in Local Coverage Article (LCA) Lower Limb Prostheses Policy Article 
(A52496). 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
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.