Nonreimbursable Services

The Division does not pay for the following equipment and services: (A) any equipment or services that are investigative or experimental in nature; (B) any equipment or services for which, under comparable circumstances, the provider does not customarily bill private patients who do not have health insurance; (C) nonmedical equipment or supplies. Equipment that is used primarily and customarily for a nonmedical purpose is not considered medical equipment, even if such equipment has a medically related use. For example, equipment whose primary function is environmental control, comfort, or convenience is not reimbursable; (D) any equipment or services that are not both necessary and reasonable for the treatment of a recipient’s pulmonary condition. This includes but is not limited to: (1) equipment or services that cannot, based on medical standards as determined by the Division, reasonably be expected to make a meaningful contribution to the treatment of a recipient’s pulmonary condition; (2) equipment or services that are substantially more costly than a medically appropriate and feasible alternative; and (3) equipment or services that serve essentially the same purpose as equipment already available to the recipient; (E) accessory equipment (except when the item it accessorizes is reimbursable); (F) the repair of equipment that is not reimbursable under these regulations; (G) routine periodic testing, cleaning, regulating, and checking of equipment. This limitation does not apply to extensive maintenance that, based on the manufacturer’s recommendations, must be performed by authorized technicians. Such extensive maintenance is a repair service reimbursable under 130 CMR 427.426; (H) equipment and supplies that are not of proven quality and dependability; (I) equipment that does not conform to all applicable federal and state product standards; and (J) diagnostic tests used to determine the medical need for oxygen or respiratory therapy equipment, or associated medical supplies.