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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 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 Has a documented
comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps function that impairs K-3
level function with the use of a microprocessor-controlled knee alone Is able to make use of a product that
requires daily charging Is able to understand and respond to error alerts and alarms indicating problems with
the function of the unit. You can find these rules in the Local Coverage Determination (LCD) Lower Limb
Prostheses L33787.

The rules say when submitting a prosthetic claim, the billed code for knee, foot, ankle and hip (HCPCS codes
L5610, L5611, L5613, L5614, L5616, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726,
L5728, L5780, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840,
L5848, L5856, L5857, L5858, L5859, L5930, L5961, L5970, L5971, L5972, L5973, L5974, L5975, L5976,
L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987) components must be submitted with
modifiers K0 - K4, indicating the expected beneficiary functional level. This expectation of functional ability
information must be clearly documented and retained in the prosthetist's records. The simple entry of a K
modifier in those records is not sufficient. There must be information about the beneficiary's history and
current condition which supports the designation of the functional level by the prosthetist. Addition codes for
endoskeletal knee-shin systems are L5610, L5611, L5613, L5616, L5810, L5811, L5812, L5814, L5816,
L5818, L5822, L5824, L5826, L5828, L5830, L5840 are considered an upgrade to the knee-shin system. The
beneficiary may qualify for an upgraded knee-shin system based on their assigned K-Level modifier (K0-K4),
as referenced in the LCD. These codes can fully describe a complete prosthetic knee-shin system commonly
referred to as a "base knee code". A single addition code can fully describe a complete knee-shin system and
thus the use of two codes (L5610, L5611, L5613, L5616, L5810, L5811, L5812, L5814, L5816, L5818, L5822,
L5824, L5826, L5828, L5830, L5840) would be considered incorrect coding (unbundling).

Codes L5925, L5930, L5845, L5848, L5850, L5856, L5857, L5858, L5859 are additional features and/or
functions that do not describe a complete endoskeletal knee-shin system and must be used in combination with
an L-code for a knee-shin system (L5610, L5611, L5613, L5616, L5810, L5811, L5812, L5814, L5816, L5818,
L5822, L5824, L5826, L5828, L5830, L5840). The use of additional feature L-codes may also depend on the
assigned K-Level modifier (K0-K4), as referenced in the LCD. Code L5856 refers to a feature of an
endoskeletal knee component which is incorporated into the entire knee-shin system. The microprocessor
componentry with sensors, any type, provide automated adjustment for controlling the swing and stance phase
of gait. This feature would be discernable from schematic drawings and user manual documentation. The
documentation would provide details for all of the adjustments for the dynamic properties of this sub-system
within the knee component. Adjustments could factor user characteristics such as the activity level, body
weight, or gait preferences, among others. This adjustment feature is energized by an on-board rechargeable
battery source. The code would include any external components needed to access the microprocessor for
modification of the settings. You can find these rules in the Local Coverage Article Lower Limb Prostheses -
Policy Article A52496.

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.