Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 442.000 - Orthotics Services
Section 442.406 - Covered Services

Universal Citation: 130 MA Code of Regs 130.442

Current through Register 1531, September 27, 2024

(A) The MassHealth agency pays for medically necessary orthotics and orthotic services pursuant to the governing of the Orthotics Manual, Subchapter 6; the Prosthetics Payment and Coverage Guidelines Tool; and any other guidance issued by the MassHealth agency or its designee. MassHealth covers orthotics that are appropriate for use in the member's home or any setting in which normal life activities take place in the community, subject to the requirements of 130 CMR 442.000, and 130 CMR 450.000: Administrative and Billing Regulations, including 130 CMR 450.204: Medical Necessity.

(B) Therapeutic Shoes for Diabetics, Inserts and Modifications. MassHealth covers therapeutic shoes for diabetics, inserts and modifications under the following conditions, subject to compliance with 130 CMR 442.000 and 130 CMR 450.000: Administrative and Billing Regulations.

(1) MassHealth covers therapeutic shoes for diabetics only when prescribed by a DO or MD.

(2) In all cases, the member must have a documented diagnosis of diabetes mellitus and meet one or more of the following conditions:
(a) previous amputation of the other foot, or part of either foot;

(b) history of previous foot ulceration of either foot;

(c) history of pre-ulcerative calluses of either foot;

(d) peripheral neuropathy with evidence of callus formation of either foot;

(e) foot deformity of either foot (must clearly indicate the foot deformity); or

(f) poor circulation in either foot.

(3) For non-custom therapeutic shoes for diabetics, the shoe must meet all of the following guidelines in addition to the member meeting the requirements of 130 CMR 442.406(B)(2):
(a) contain a full length, heel-to-toe filler that when removed provides a minimum of 3/16" of additional depth used to accommodate custom molded or customized inserts;

(b) be made from leather or suitable material of equal quality;

(c) have some form of shoe closure; and

(d) be available in full and half sized with a minimum of three widths so that the shoe is graded to the size and width of the upper portion of the shoe according to the American Standard last sizing schedule or its equivalent. This includes a shoe with or without an internally seamless toe.

(4) For custom-molded therapeutic shoes for diabetics, the shoe must meet all of the following guidelines, in addition to the member meeting the requirements of 130 CMR 442.406(B)(2):
(a) be constructed over a positive model of the member's foot;

(b) be made from leather or suitable material of equal quality;

(c) have removable inserts that can be altered or replaced as the member's condition warrants; and

(d) have some form of shoe closure.

(C) Orthotics Other than Therapeutic Shoes for Diabetics, Inserts and Modifications. MassHealth covers orthotics and orthotic services other than therapeutic shoes for diabetics, inserts and modifications, in accordance with the guidelines described in the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool, subject to compliance with 130 CMR 442.000 and 130 CMR 450.000: Administrative and Billing Regulations.

(D) Custom Fabricated Items Ordered but Not Furnished. 130 CMR 450.231: Conditions of Payment, governs payment for custom fabricated, fitted or altered items ordered for, but not furnished to, a member who ceases to be eligible for such items on a date prior to the final delivery. 130 CMR 450.231(C) and (D). Payment will be made based on materials used. Providers must maintain documentation demonstrating compliance with 130 CMR 450.231(C) and (D) including, but not limited to:

(1) the date of the member's last visit;

(2) the date that the provider fabricated the item, as defined in 130 CMR 450.231(C); and

(3) the first substantial step taken to initiate the production process after the conclusion of all necessary member visits.

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