13-750 Code Vt. R. 13-170-750-X

Current through April, 2024

Section 13 170 750 - PHARMACEUTICALS, MEDICAL SUPPLIES AND EQUIPMENT (7500)

Section 7508 Prosthetic Devices.

A prosthetic device is a replacement, corrective or supportive device to:

1) artificially replace a missing portion of the body;

2) prevent or correct physical deformity or malfunction; or

3) support a weak or deformed portion of the body. Prosthetics include orthotics. This definition is taken from the federal definition found at 42 CFR § 440.120(c).

7508.1Eligibility for Care. Coverage of a prosthetic device is available for beneficiaries of any age.

7508.2Covered Services. Items and services that have been pre-approved for coverage are limited to:

* artificial limbs;

* artificial larynx;

* breast forms;

* prosthetic shoes;

* ostomy products;

* parenteral and enteral nutrition services;

* prosthetic eyes;

* braces and trusses for the purpose of supporting a weak or malformed body member;

* orthotic shoes as an integral part of a leg brace or affixed to an integral part of a leg brace;

* aircast splints;

* foot abduction rotation bars;

* shoe lifts, elevation heels, wedges; and

* molded orthopedic shoes when prescribed for diabetes, severe rheumatoid arthritis, ischemic, intractable ulcerations, congenital defects, and deformities due to injuries.

The complete policy regarding hearing, vision, vocal, and dental prostheses is contained in M650, M670, M842 and M620-M623, respectively.

7508.3Conditions for Coverage. Prosthetic devices must be prescribed by a physician or podiatrist who is enrolled with Vermont Medicaid.

Devices must be appropriate for beneficiary's age, gross and fine motor skills, developmental status, mental functioning, and physical condition.

Duplicate items are not covered (e.g., two pairs of customized orthotics).

Coverage for Medicaid-approved shoes is limited to two pairs per adult beneficiary per calendar year unless a prior authorization review finds special circumstances that warrant additional pairs.

Custom-made arch supports prescribed by a physician or podiatrist are covered when they meet the definition of an orthotic (i.e., are used as a brace, truss or other similar device for the purpose of supporting a weak or deformed body member).

7508.4Prior Authorization Requirements.

Many items of prosthetic/orthotic equipment are subject to prior authorization review but they are not specified here because they are unusually numerous and they change frequently due to product change, new product availability, and the department's need for utilization management. The Provider Manual contains a detailed list of prosthetic/orthotic equipment, their codes, and fee schedule. It also indicates which prosthetic/orthotic equipment codes require prior authorization.

7508.5Non-Covered Services. Unless authorized for coverage via M108, items that are not covered include:

* orthopedic shoes when prescribed for flat feet; and

* orthotics/prosthetics that primarily serve to address social, recreational, or other factors and do not directly address a medical need.

7508.6Qualified Providers. Providers of prosthetic and orthotic devices must be licensed, registered and/or certified by the state (where required) and be enrolled with Vermont Medicaid.

7508.7Reimbursement. Reimbursement for prosthetic and orthotic devices is described in the Provider Manual.

Prosthetic/orthotic suppliers may not bill Medicaid for items furnished by hospitals to their in- or outpatients. Hospitals cannot bill separately for prosthetic or orthotic supplies.

The cost of modifications made within 60 days of purchase is included in the initial reimbursement of the orthotic or prosthetic.

13-750 Code Vt. R. 13-170-750-X

EFFECTIVE DATE:
October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
AMENDED:
January 15, 2010 Secretary of State Rule Log #09-043 [7501, 7501.4]; February 25, 2012 Secretary of State Rule Log #12-005 [7502]; October 29, 2014 Secretary of State Rule Log #14-037 [7502]; July 30, 2016 Secretary of State Rule Log #16-028 [7503]; June 22, 2017 Secretary of State Rule Log #17-033; January 7, 2019 Secretary of State Rule Log #18-068 [repeal 7505], #18-069 [repeal 7506]; June 2022 Secretary of State Rule Log #19-050 [repeal 7501, 7502, 7503, 7504, 7505, 7506, 7501]

STATUTORY AUTHORITY:

33 V.S.A. §§ 105, 1901