Medical Necessity Criteria

(A) All orthotics covered by MassHealth must meet the medical necessity requirements set forth in 130 CMR 442.000, and 450.204: Medical Necessity, in the Orthotics and Prosthetics Payment and Coverage Guidelines Tool, and in any other medical necessity guidelines for specific orthotics issued by MassHealth or its designee. (B) For items covered by MassHealth, for which there is no MassHealth item-specific medical necessity guideline and for which there is a Medicare LCD policy developed by CMS indicating Medicare coverage of the item under at least some circumstances, the provider must demonstrate medical necessity of the item consistent with the Medicare LCD. However, if the provider believes the orthotic is medically necessary even though it does not meet the criteria established by the LCD, the provider must demonstrate medical necessity under 130 CMR 450.204: Medical Necessity. (C) For an item covered by MassHealth, for which there is no MassHealth item-specific medical necessity guideline and for which there is a Medicare LCD indicating that the item is not covered by Medicare, the provider must demonstrate medical necessity under 130 CMR 450.204: Medical Necessity.