Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-60 - Medical Supplies and Durable Medical Equipment › Subsection 144-101-II-60.08 - RESTRICTED SERVICES

Current through 2024-29, July 17, 2024
This section describes coverage restrictions and
						limitations for Medical Supplies and DME. Changes in technology alone do not
						necessitate replacement or upgrades in equipment. If it is medically necessary
						for a member to exceed any of the listed limits, the prescribing provider must
						submit a request for PA and provide supporting medical documentation to
						establish the medical necessity. Unless otherwise specified, limits apply to
						all members twenty-one (21) years and older.
60.08-1
Physician Provided
					 Supplies
Physicians may bill for those medical supplies needed to
						perform office procedures, which are above and beyond what is usually included
						in a normal office visit. Reimbursement is made on the basis of acquisition
						cost only and may not include any additional markup. Physicians must bill under
						Chapter II, Section
						90, "Physician Services" of the
MaineCare Benefits Manual
.
A prescribing provider may not be reimbursed for both
						prescribing and supplying DME to the same member, unless the DME is otherwise
						unobtainable or the DME typically requires no maintenance or replacement during
						the period used by a member. If these circumstances do exist, reimbursement to
						the prescribing provider for also supplying DME shall be on the basis of the
						acquisition cost of the DME. The prescribing provider must maintain a copy of
						the invoice to support such claims. In addition, this policy shall also apply
						to any entity in which the provider has direct or indirect proprietary
						interest. All transactions are subject to State and Federal restrictions
						regarding self-referral.
DME providers may not bill for items delivered to a
						member in a prescribing provider's office.
60.08-2
Orthotics and
					 Prosthetics
The Department requires that orthotic or prosthetic
						services be provided by a licensed occupational therapist, a licensed physical
						therapist, prosthetist (American Board for Certification), or an accredited
						orthotist (Board for Orthotist Certification). PA is required for all custom
						molded orthotics and prosthetics regardless of price using evidence-based
						criteria and/or criteria based on national standards for evaluating what is
						considered medically necessary.
Providers shall warranty prosthetics for a period of one
						(1) year to assure proper fit of products purchased by the Department. The
						warranty will cover adjustments, repairs, and parts replacement associated with
						shrinkage, workmanship, etc.
60.08-3
Augmentative and Alternative
					 Communication Devices
Members must trial augmentative and alternative
						communication devices before the Department will purchase or rent the devices.
						PA requests for augmentative and alternative communication devices shall
						include information documenting the trial period to determine the
						appropriateness and member utilization of the device.
60.08-4
Specially Modified Foods and
					 Formulas
Specially modified foods and formulas are covered when
						the member has inborn errors of metabolism.
60.08-5
Orthopedic Shoes and Other
					 Supportive Devices for Feet
Orthopedic shoes and other supportive devices for the
						feet generally are not covered. However, shoes that are an integral part of a
						leg brace, and therapeutic shoes such as those furnished to diabetics, are
						covered. For members twenty-one (21) and older, these items are subject to the
						following limitations:
A. Items
					 classified with HCPCS Level II codes as foot inserts, foot arch supports, shoe
					 wedges or shoe heels are limited to two (2) units (meaning 2 items or 1 pair)
					 per member per year.
B. Items
					 classified with HCPCS Level II codes as orthotic footwear, including orthopedic
					 shoes or items classified as 'other orthopedic footwear', are limited to two
					 (2) units (meaning 2 shoes or 1 pair) per year.
C. Items classified with HCPCS Level II codes
					 as shoe lifts are limited to eight (8) units per member per year (units are one
					 (1) inch increments).
D. Items
					 classified with HCPCS Level II codes as diabetic footwear including diabetic
					 shoes and fittings are limited to two (2) units per member per year (meaning 1
					 pair or 2 fittings). Modifications and inserts for diabetic shoes are limited
					 to a combined total of six (6) units per member per rolling year.
E. Items classified with HCPCS Level II codes
					 as repositioning foot orthotics, excluding the words "abduction rotation bar"
					 are limited to two (2) units (meaning 2 shoes or 1 pair) per year.