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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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment. You can find
this rule at 42 CFR 424.5.

The rules say for Medicare to consider coverage and payment for any item or service, the information
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity
Manual, Chapter 3, Section 3.3.2.1.

The rules say that coverage is extended only if there is sufficient clinical documentation of functional need for
the technologic or design feature of a given type of foot. This information must be retained in the treating
practitioner's or prosthetist's files. You can find this rule in the Local Coverage Determination (LCD) - Lower
Limb Prostheses (L33787) - Effective January 1, 2020.

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 could maneuver 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 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 an axial rotation unit (L5982, L5984, L5985, L5986) is covered for beneficiaries whose
functional level is 2 or above. You can find this rule in Local Coverage Determination (LCD): Lower Limb
Prostheses (L33787) - Effective January 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.