130 CMR, § 409.414

Current through Register 1533, October 25, 2024

Section 409.414 - Non-covered Services

The MassHealth agency does not pay for the following:

(A) DME that is experimental or investigational in nature;

(B) DME that is determined by the MassHealth agency not to be medically necessary pursuant to 130 CMR 409.000, and 130 CMR 450.204: Medical Necessity. This includes, but is not limited to, items that:

(1) cannot reasonably be expected to make a meaningful contribution to the treatment of a member's illness, disability, or injury;

(2) are more costly than medically appropriate and feasible alternative pieces of equipment; or

(3) serve the same purpose as DME already in use by the member, with the exception of the devices described in 130 CMR 409.413(D);

(C) the repair of any DME that is not identified as a covered service in Subchapter 6 of the Durable Medical Equipment Manual, the DME and Oxygen Payment and Coverage Guideline Tool or any other guidance issued by the MassHealth agency;

(D) the repair of any equipment where the cost of the repair is equal to or more than the cost of purchasing a replacement;

(E) routine periodic maintenance, such as testing, cleaning, regulating, and checking of DME that is owned by the member and does not require the specialized knowledge of a trained technician, and which may be performed by a member or member's designee;

(F) DME that is not of proven quality and dependability, consistent with 130 CMR 409.404(B)(12);

(G) DME furnished through a consignment/stock and bill closet (unless permitted by specific MassHealth guidance, pursuant to 130 CMR 409.405(M));

(H) DME that has not been approved by the federal Food and Drug Administration (FDA) for community use;

(I) evaluation or diagnostic tests conducted by the DME provider to establish the medical need for DME;

(J) home or vehicle modifications including, but not limited to, ramps, elevators, or stair lifts;

(K) common household and personal hygiene items generally used by the public including, but not limited to, washcloths, wet wipes, and non-sterile swabs;

(L) products that are not DME (except for augmentative and alternative communication devices covered pursuant to M.G.L. c. 118E, § 10H under 130 CMR 409.428);

(M) certain DME provided to members in facilities in accordance with 130 CMR 409.415; and

(N) provider claims for non-covered services under 130 CMR 409.414 for MassHealth members with other insurance, except as otherwise required by law.