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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 equipment which the beneficiary owns or is a capped rental item may be replaced in cases 
of loss or irreparable damage. 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. The reasonable useful lifetime of durable 
medical equipment is determined through program instructions, but in no case can it be less than 5 years. 
Replacement due to wear is not covered during the reasonable useful lifetime of the equipment. You can find 
this rule in Medicare Benefit Policy Manual Chapter 15, Section 110.2(C). 
 
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. 
 
An axial rotation unit (L5982, L5984, L5985, L5986) 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. Socket replacements are considered reasonable and necessary if there is adequate documentation of 
functional and/or physiological need. It is recognized that there are situations where the explanation includes 
but is not limited to: changes in the residual limb; functional need changes; or irreparable damage or wear/tear 
due to excessive beneficiary weight or prosthetic demands of very active amputees. You can find these rules in 
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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.