Non-covered Services

The MassHealth agency does not pay for the following: (A) DME that is experimental or investigational in nature; (B) DME that is determined by the MassHealth agency not to be medically necessary pursuant to 130 CMR 409.000 and 130 CMR 450.204: Medical Necessity. This includes, but is not limited to items that: (1) cannot reasonably be expected to make a meaningful contribution to the treatment of a member’s illness, disability, or injury; (2) are more costly than medically appropriate and feasible alternative pieces of equipment; or (3) serve the same purpose as DME already in use by the member with the exception of the devices described in 130 CMR 409.413(D); (C) the repair of any DME that is not identified as a covered service in Subchapter 6 of the Durable Medical Equipment Manual, the DME and Oxygen Payment and Coverage Guideline Tool or any other guidance issued by the MassHealth agency; (D) the repair of any equipment where the cost of the repair is equal to or more than the cost of purchasing a replacement; (E) routine periodic maintenance, such as testing, cleaning, regulating, and checking of DME that is owned by the member and does not require the specialized knowledge of a trained technician, and which may be performed by a member or member’s designee; (F) DME that is not of proven quality and dependability, consistent with 130 CMR 409.404(B)(12); (G) DME furnished through a consignment/stock and bill closet (unless permitted by specific MassHealth guidance, pursuant to 130 CMR 409.405(M)); (H) DME that has not been approved by the federal Food and Drug Administration (FDA) for community use; (I) evaluation or diagnostic tests conducted by the DME provider to establish the medical need for DME; (J) home or vehicle modifications, including but not limited to, ramps, elevators, or stair lifts; (K) common household and personal hygiene items generally used by the public, including but not limited to washcloths, wet wipes, and non-sterile swabs; (L) products that are not DME (except for augmentative and alternative communication devices covered pursuant to M.G.L. c. 118E § 10H under 130 CMR 409.428); (M) certain DME provided to members in facilities in accordance with 130 CMR 409.415; and (N) provider claims for noncovered services under 130 CMR 409.414 for MassHealth members with other insurance, except as otherwise required by law.