13-002 Code Vt. R. 13-174-002-X - PROSTHETIC AND ORTHOTIC DEVICES

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.

Notes

13-002 Code Vt. R. 13-174-002-X

EFFECTIVE DATE:
October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
AMENDED:
January 15, 2010 Secretary of State Rule Log #09-043 [7501, 7501.4]; February 25, 2012 Secretary of State Rule Log #12-005 [7502]; October 29, 2014 Secretary of State Rule Log #14-037 [7502]; July 30, 2016 Secretary of State Rule Log #16-028 [7503]; June 22, 2017 Secretary of State Rule Log #17-033; January 7, 2019 Secretary of State Rule Log #18-068 [repeal 7505], #18-069 [repeal 7506]; June 2022 Secretary of State Rule Log #19-050 [repeal 7501, 7502, 7503, 7504, 7505, 7506, 7501]; 5/1/2023 Secretary of State Rule Log #23-006 [repeal 7508]

STATUTORY AUTHORITY:

33 V.S.A. §§ 105, 1901