Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 442.000 - Orthotics Services
Section 442.408 - Non-covered Services

(A) any orthotics for which, under comparable circumstances, the provider of orthotics does not customarily bill private patients who do not have health insurance;

(B) nonmedical items: items that are used primarily and customarily for a nonmedical purpose are not considered orthotics, even if the item has a medically related use;

(C) therapeutic shoes for diabetics that are not listed on the PDAC Product Classification List, with an associated HCPCS code;

(D) an additional charge for nonstandard size (width or length) in custom-molded shoes;

(E) orthotics that are not provided in accordance with the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines tool, or other guidance issued by the MassHealth agency or its designee;

(F) orthotics that are not reasonably expected to make a meaningful contribution to the treatment of a member's condition or the performance of the member's activities of daily living;

(G) orthotics that are not listed as covered services in Subchapter 6 of the Orthotics Manual and the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool or any other guidance issued by the MassHealth agency or its designee, unless prior authorization has been issued by the MassHealth agency or its designee;

(H) orthotics provided to members in facilities that are not permissible under 130 CMR 442.410;

(I) repairs that do not meet the requirements of 130 CMR 442.411 and 130 CMR 442.410 (if applicable);

(J) orthotics that are experimental or investigational in nature as described in 130 CMR 450.204(E): Medical Necessity; and

(K) orthotics furnished through a consignment/stock and bill closet (unless permitted by specific MassHealth guidance).