Code of Vermont Rules › Agency 13 - AGENCY OF HUMAN SERVICES › Sub-Agency 170 - DEPARTMENT FOR CHILDREN AND FAMILIES (DCF) › Chapter 750 - PHARMACEUTICALS, MEDICAL SUPPLIES AND EQUIPMENT (7500) › Section 13 170 750 - PHARMACEUTICALS, MEDICAL SUPPLIES AND EQUIPMENT (7500)

Current through June, 2024
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).
7508.1
Eligibility for
				Care.
Coverage of a prosthetic device is available for
				beneficiaries of any age.
7508.2
Covered 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.
7508.3
Conditions 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).
7508.4
Prior 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.
7508.5
Non-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.
7508.6
Qualified 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.
7508.7
Reimbursement.
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.