Code of Vermont Rules
Agency 13 - AGENCY OF HUMAN SERVICES
Sub-Agency 174 - HEALTH CARE ADMINISTRATIVE RULES (HCAR)
Chapter 002 - PROSTHETIC AND ORTHOTIC DEVICES
Section 13 174 002 - PROSTHETIC AND ORTHOTIC DEVICES
Universal Citation: VT Code of Rules 13 174 002
Current through August, 2024
4.212 Prosthetic and Orthotic Devices.
(5/1/2023, GCR 22-099)
4.212.1 Definitions
(a) "Prosthetic devices" means replacement,
corrective, or supportive devices to: artificially replace a missing portion of
the body, prevent or correct physical deformity or malfunction, or support a
weak or deformed portion of the body.
This definition is in accordance with the federal definition found at 42 CFR § 440.120(c).
(b) "Orthotic devices" means devices
fashioned to support, correct, or improve the function of a body
part.
4.212.2 Covered
Services
(a) Prosthetic and orthotic devices
are covered when medically necessary.
(b) Vermont Medicaid publishes and maintains
a list of pre-approved prosthetic and orthotic devices and any prior
authorization requirements. This information is publicly available on the
Department of Vermont Health Access website.
4.212.3 Qualified Providers
(a) Prosthetic and orthotic devices must be
ordered by a physician or other licensed provider working within the scope of
their practice and enrolled with Vermont Medicaid.
4.212.4 Conditions for Coverage
(a) Prosthetic and orthotic devices must be
necessary to address a beneficiary's medical condition as ordered by a
qualified provider.
(b) The
face-to-face requirements in Health Care Administrative Rule
4.209 Durable Medical Equipment apply to
prosthetic and orthotic devices that are also subject to the face-to-face
requirement under Medicare.
(c)
Coverage for Medicaid-approved shoes is limited to two pairs per adult
beneficiary per calendar year unless additional pairs are medically
necessary.
(d) Custom-made arch
supports prescribed by a qualified provider are covered when they meet the
definition of an orthotic.
(e)
Custom devices are covered only when prefabricated devices cannot meet the
medical need.
(f) These conditions
for coverage do not apply to prosthetics and orthotics reimbursed as a
component of an institutional payment.
4.212.5 Non-Covered Services
(a) Orthotics or prosthetics that primarily
serve to address social, recreational, or other factors and do not directly
address a medical need.
(b)
Duplicate items are not covered.
STATUTORY AUTHORITY:
33 V.S.A. §§ 105, 1901
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