Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma

MassHealth

MASSHEALTH
TRANSMITTAL LETTER ORT-17
January 2004
TO:      Orthotic Providers Participating in MassHealth
FROM:      Beth Waldman, Acting Commissioner
RE:      Orthotics Manual (Revisions to Service Codes and Reduction in Shoe Maximum)
Effective February 1, 2004, MassHealth has revised its regulations to limit coverage of medically necessary orthotic shoes to one pair for a member within a 12-month period. The previous limit was two pairs within a 12-month period. The number of allowed service codes for shoe inserts and other accessories has also been reduced to reflect the new shoe maximum effective February 1, 2004.
MassHealth may cover additional orthotic shoes within a 12-month period if a physician or nurse practitioner can show that additional orthotic shoes are needed because the member’s physical condition has changed. See 130 CMR 442.407(C).
In addition, MassHealth has revised Subchapter 6 to reflect this revised limit, add new codes, and update the number of allowed units on certain service codes.
New Service Codes
The following service codes are effective for dates of service on and after February 1, 2004. These new codes are paid on an individual consideration basis.
•	L0112
•	L0861
•	L1831
•	L1907
•	L1951
•	L1971
•	L3917
Revised Units
Effective for dates of service on and after February 01, 2004, MassHealth has adjusted the number of allowed units for Service Code L0999. The limitation of two units per 12 months has been removed.
Providers are reminded that they may submit a request for prior authorization for eligible members for coverage of additional units, if additional units are medically necessary. In particular, for members under age 21, MassHealth regulations at 130 CMR 450.144(A) allow providers to seek coverage of units in excess of service limitations, when medically necessary, by requesting prior authorization. Any request for prior authorization of additional units must be submitted before the additional units are provided and must be supported by medical documentation.
These regulations and revisions to Subchapter 6 are effective February 1, 2004.

MASSHEALTH
TRANSMITTAL LETTER ORT-17 January 2004 Page 2
NEW MATERIAL
(The pages listed here contain new or revised language.)
Orthotics Manual
Pages vi, 4-5, 4-5, and 6-1 through 6-12
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Orthotics Manual
Pages vi, 4-5, 4-5, and 6-1 through 6-12 — transmitted by Transmittal Letter ORT-16

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
TABLE OF CONTENTS	PAGE
vi	

	TRANSMITTAL LETTER
ORT-17	DATE
02/01/04	
6.   SERVICE CODES
601	Introduction 	       6-1
602	Service Codes, Limitations, and Special Requirements 	       6-1
Appendix A. DIRECTORY 		A-1
Appendix B. ENROLLMENT CENTERS 		B-1
Appendix C. THIRD-PARTY-LIABILITY CODES 		C-1
Appendix W. EPSDT SERVICES: MEDICAL PROTOCOL AND
PERIODICITY SCHEDULE 		W-1
Appendix X. FAMILY ASSISTANCE COPAYMENTS AND DEDUCTIBLES 		X-1
Appendix Y. REVS/CODES MESSAGES 		Y-1
Appendix Z. EPSDT SERVICES LABORATORY CODES 		Z-1

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 442.000)	PAGE
4-5	

	TRANSMITTAL LETTER
ORT-17	DATE
02/01/04	
(C)	Shoe Maximum. A member is not entitled to more than one pair of shoes during a 12-month
period, unless the attending physician or nurse practitioner submits documentation that the
member's physical condition has changed. The shoe provider must make diligent efforts to ensure
that the member has not already received a pair of shoes from another provider within the previous
12 months. Diligent efforts include but are not limited to:
(1)	asking the member and the prescriber if the member has received shoes from another shoe provider within the previous 12 months; and
(2)	reviewing the provider’s own records to determine whether the member has already received a pair of shoes within the previous 12 months.
(D)	Closure Modification. When a manufacturer offers an off-the-shelf shoe that comes standard
with either lace or velcro closures, the provider must choose the appropriate shoe to meet the
member’s needs, and not bill separately for closure modification.
(E)	Custom-Shoe Inserts. When a manufacturer offers a customized shoe that includes the insert,
the provider must not bill separately for the insert.
(F)	Other Service Limitations. The service limitations set forth in Subchapter 6 of the Orthotics
Manual apply, subject to the Early and Periodic Screening, Diagnosis, and Treatment provisions
set forth in 130 CMR 450.144(A).
442.408: Noncovered Services
MassHealth does not pay for any of the following:
(A)	any orthotic or pedorthic services for which, under comparable circumstances, the provider does not customarily bill private patients who do not have health insurance;
(B)	nonmedical orthotic or pedorthic services. 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;
(C)	storage of orthotic or pedorthic equipment or associated items;
(D)	sneakers or athletic shoes;
(E)	an additional charge for nonstandard size (width or length) in custom-molded shoes;
(F)	shoes when there is no diagnosis of associated foot deformities; and
(G)	orthotic or pedorthic services that are not both medically necessary in accordance with
130 CMR 450.204 and reasonable for the treatment of a member's condition. This includes
services that:
(1)	cannot reasonably be expected to make a meaningful contribution to the treatment of a member's condition or the performance of the member's activities of daily living; and
(2)	are more costly than a medically comparable and suitable alternative or that serve essentially the same purpose as equipment already available to the member.
(1)	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 442.000)	PAGE
4-6	

	TRANSMITTAL LETTER
ORT-17	DATE
02/01/04	
442.409:  Prescription and Other Documentation Requirements
(A)	The purchase of orthotic or pedorthic equipment requires a written prescription signed by a
licensed physician, a licensed podiatrist, or an independent nurse practitioner.
(1)	For orthotic equipment other than shoes, the prescriber must write the prescription on the
prescriber’s prescription form and must include the following information:
(a)	the member's name and address;
(b)	the member’s MassHealth identification number;
(c)	specific identification of the prescribed item;
(d)	medical justification for the use of the item, including the member’s diagnosis;
(e)	the prescriber's address and telephone number; and
(f)	the date on which the prescription was signed by the prescriber.
(2)	For shoes, the provider must complete the shoe prescription form designated by
MassHealth. A copy of the shoe prescription form must be submitted to MassHealth to
support the provider’s claim.
(B)	MassHealth pays for podiatry services only when the member’s primary care physician certifies on letterhead that such services are medically necessary for the life and safety of the member. Prescriptions from podiatrists for any orthotic or pedorthic equipment must be accompanied by a copy of such a letter from the member’s primary care physician.
(C)	The provider must keep the shoe prescription form and any accompanying letters, if required, on file for the period of time required by 130 CMR 450.205.
442.410: Orthotic and Pedorthic Services and Equipment Provided to Institutionalized Members
(A)	Nursing Facilities. MassHealth pays orthotic and pedorthic providers for:
(1)	nursing facility visits;
(2)	the purchase and repair of orthotic and pedorthic equipment; and
(3)	orthotic and pedorthic supplies provided for the personal full-time use of a member residing in a nursing facility.

(B)	Institutions Licensed as Hospitals, Chronic Disease Hospitals, and Rehabilitation Hospitals. MassHealth does not pay orthotic or pedorthic providers for the purchase or repair of orthotic or pedorthic equipment or for supplies provided to a hospitalized member, except for orthotic or pedorthic equipment that is prescribed for home use after discharge. The hospital record must document the member’s discharge plan and that the date of discharge was before the purchase or repair of the prescribed item.
(C)	Intermediate Care Facilities for the Mentally Retarded with 16 Beds or More (State Schools).

(1)	MassHealth pays orthotic and pedorthic providers for the purchase and repair of customized orthotic and pedorthic equipment provided for the personal full-time use of a member residing in an ICF/MR with 16 beds or more (a state school) only if the customization precludes the use of the equipment by subsequent residents in that institution.
(2)	MassHealth does not pay orthotic or pedorthic providers for noncustomized equipment or supplies provided to a member residing in a state school.
(1)	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-1	

	TRANSMITTAL LETTER
ORT-17	DATE
02/01/04	
601 Introduction
MassHealth pays for all codes listed in Section 602 in effect at the time of service, subject to all the conditions and limitations in Subchapter 6 and MassHealth regulations at 130 CMR 442.000 and 450.000.
For full service descriptions of the service codes listed in Section 602, MassHealth providers should refer to the official list of HCPCS codes and descriptions, as posted on the Centers for Medicare and Medicaid Web site at www.cms.gov/medicare/hcpcs.
Providers may request prior authorization (PA) for eligible members, if additional units are medically necessary. In particular, for members under age 21, MassHealth regulations at 130 CMR 450.144(A) allow providers to seek coverage of units in excess of service limitations, when medically necessary, by requesting prior authorization.
When the rate of payment has not been established by the Division of Health Care Finance and Policy, MassHealth pays for the service based on individual consideration, subject to all other conditions of payment. Service codes that require individual consideration are identified with the abbreviation “I.C.” located in the “Service Limitations (PA required for units in excess of limitations)/Special Requirements” column in Section 602.
602 Service Codes, Limitations, and Special Requirements
			Service Limitations (PA re	
HCPCS	Covered	Covered	for units in excess of limita	
Code	Under Age 21?	Age 21 and older?	and Special Requirements	
A5500	Yes	Yes	1 per 12 months; I.C.	
A5501	Yes	Yes	1 per 12 months; I.C.	
A5503	Yes	Yes	2 per 12 months; I.C.	
A5504	Yes	Yes	2 per 12 months; I.C.	
A5505	Yes	Yes	2 per 12 months; I.C.	
A5506	Yes	Yes	2 per 12 months; I.C.	
A5507	Yes	Yes	2 per 12 months; I.C.	
A5508	Yes	Yes	2 per 12 months; I.C.	
A5509	Yes	Yes	6 per 12 months; I.C.	
A5511	Yes	Yes	2 per 12 months; I.C.	
L0100	Yes	Yes	1 per 12 months	
L0110	Yes	No	1 per 12 months	
L0112	Yes	Yes	2 per 12 months; I.C.	
L0120	Yes	No	2 per 12 months	
L0130	Yes	No	2 per 12 months	
L0140	Yes	No	1 per 12 months	
L0150	Yes	No	1 per 12 months	
L0160	Yes	Yes	1 per 12 months	
L0170	Yes	Yes	1 per 12 months	
L0172	Yes	Yes	2 per 12 months	
L0174	Yes	Yes	2 per 12 months	

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
ORTHOTICS MANUAL		6 SERVICE CODES	6-2	

		TRANSMITTAL LETTER	DATE	
			ORT-17	02/01/04	
602 Service Codes and Limitations (cont.)			
			Service Limitations (PA required	
HCPCS	Covered                    Covered	for units in excess of limitations)	
Code	Under Age 21?         Age 21 and older?      and Special Requirements	
L0180	Yes	No	1 per 12 months	
L0190	Yes	Yes	1 per 12 months	
L0200	Yes	No	1 per 12 months	
L0210	Yes	No	1 per 12 months	
L0220	Yes	No	1 per 12 months	
L0450	Yes	No	1 per 12 months; I.C.	
L0452	Yes	No	1 per 12 months; I.C.	
L0454	Yes	No	1 per 12 months; I.C.	
L0456	Yes	No	1 per 12 months; I.C.	
L0458	Yes	Yes	1 per 12 months; I.C.	
L0460	Yes	Yes	1 per 12 months; I.C.	
L0462	Yes	Yes	1 per 12 months; I.C.	
L0464	Yes	Yes	1 per 12 months; I.C.	
L0466	Yes	No	1 per 12 months; I.C.	
L0468	Yes	No	1 per 12 months; I.C.	
L0470	Yes	No	1 per 12 months; I.C.	
L0472	Yes	Yes	1 per 12 months; I.C.	
L0474	Yes	No	1 per 12 months; I.C.	
L0476	Yes	No	1 per 12 months; I.C.	
L0478	Yes	No	1 per 12 months; I.C.	
L0480	Yes	Yes	1 per 12 months; I.C.	
L0482	Yes	Yes	1 per 12 months; I.C.	
L0484	Yes	Yes	1 per 12 months; I.C.	
L0486	Yes	Yes	1 per 12 months; I.C.	
L0488	Yes	Yes	1 per 12 months; I.C.	
L0490	Yes	Yes	1 per 12 months; I.C.	
L0500	Yes	No	1 per 12 months	
L0510	Yes	No	1 per 12 months	
L0515	Yes	Yes	1 per 12 months	
L0520	Yes	No	1 per 12 months	
L0530	Yes	No	1 per 12 months	
L0540	Yes	No	1 per 12 months	
L0550	Yes	Yes	1 per 12 months	
L0560	Yes	Yes	1 per 12 months	
L0561	Yes	No	1 per 12 months	
L0565	Yes	Yes	1 per 12 months	
L0600	Yes	No	1 per 12 months	
L0610	Yes	No	1 per 12 months	
L0620	Yes	No	1 per 12 months	
L0700	Yes	Yes	1 per 12 months	
L0710	Yes	Yes	1 per 12 months	
L0810	Yes	No	1 per 12 months		

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-3	

	TRANSMITTAL LETTER
ORT-17	DATE
02/01/04	
602 Service Codes and Limitations (cont.)

HCPCS	Covered	Covered	
Code	Under Age 21?	Age 21 and older?	
L0820	Yes	No	
L0830	Yes	No	
L0860	Yes	No	
L0861	Yes	Yes	
L0960	Yes	No	
L0970	Yes	No	
L0972	Yes	No	
L0974	Yes	No	
L0976	Yes	No	
L0978	Yes	No	
L0980	Yes	No	
L0982	Yes	No	
L0984	Yes	No	
L0999	Yes	Yes	
L1000	Yes	No	
L1005	Yes	No	
L1010	Yes	No	
LI 020	Yes	No	
LI 025	Yes	No	
L1030	Yes	No	
LI 040	Yes	No	
L1050	Yes	No	
L1060	Yes	No	
L1070	Yes	No	
L1080	Yes	No	
L1085	Yes	No	
L1090	Yes	No	
L1100	Yes	No	
L1110	Yes	No	
L1120	Yes	No	
L1200	Yes	No	
L1210	Yes	No	
L1220	Yes	No	
L1230	Yes	No	
L1240	Yes	No	
L1250	Yes	No	
L1260	Yes	No	
L1270	Yes	No	
L1280	Yes	No	
L1290	Yes	No	
L1300	Yes	No	

Service Limitations (PA required for units in excess of limitations) and Special Requirements
1 per 12 months 1 per 12 months 1 per 12 months 1 per 12 months; I.C. 4 per 12 months 1 per 12 months 1 per 12 months 1 per 12 months 1 per 12 months 1 per 12 months
1	per 12 months
2	per 12 months
3	per 6 months I.C. 1 per 12 months

1	per 12 months
2	per 12 months 2 per 12 months 2 per 12 months 2 per 12 months 2 per 12 months 2 per 12 months 2 per 12 months 2 per 12 months 2 per 12 months 2 per 12 months 2 per 12 months 2 per 12 months 2 per 12 months
4	per 12 months
1 per 12 months
1 per 12 months
1 per 12 months
1	per 12 months
2	per 12 months 2 per 12 months 2 per 12 months 2 per 12 months 2 per 12 months 2 per 12 months 1 per 12 months
1	
Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
ORTHOTICS MANUAL		6 SERVICE CODES	6-4	

		TRANSMITTAL LETTER	DATE	
			ORT-17	02/01/04	
602 Service Codes and Limitations (cont.)			
			Service Limitations (PA required	
HCPCS	Covered                    Covered	for units in excess of limitations)	
Code	Under Age 21?         Age 21 and older?      and Special Requirements	
L1310	Yes	No	1 per 12 months	
L1499	Yes	Yes	i.e.	
L1500	Yes	No	1 per 12 months	
L1510	Yes	No	1 per 12 months	
L1520	Yes	No	1 per 12 months	
L1600	Yes	No	2 per 12 months	
L1610	Yes	No	2 per 12 months	
LI 620	Yes	No	2 per 12 months	
L1630	Yes	No	2 per 12 months	
LI 640	Yes	No	2 per 12 months	
L1650	Yes	No	2 per 12 months	
L1652	Yes	Yes	1 per 12 months; I.C.	
L1660	Yes	No	2 per 12 months	
L1680	Yes	Yes	1 per 12 months	
L1685	Yes	Yes	1 per 12 months	
L1686	Yes	Yes	1 per 12 months	
L1690	Yes	No	2 per 12 months	
L1700	Yes	No	2 per 12 months	
L1710	Yes	No	2 per 12 months	
LI 720	Yes	No	2 per 12 months	
L1730	Yes	No	2 per 12 months	
L1750	Yes	No	2 per 12 months	
L1755	Yes	No	2 per 12 months	
L1800	Yes	No	2 per 12 months	
L1810	Yes	No	2 per 12 months	
L1815	Yes	No	2 per 12 months	
L1820	Yes	No	2 per 12 months	
L1825	Yes	No	2 per 12 months	
L1830	Yes	No	2 per 12 months	
L1831	Yes	Yes	2 per 12 months; I.C.	
L1832	Yes	Yes	2 per 12 months	
L1834	Yes	Yes	2 per 12 months	
L1836	Yes	Yes	2 per 12 months; I.C.	
L1840	Yes	Yes	2 per 12 months	
L1843	Yes	Yes	2 per 12 months	
LI 844	Yes	Yes	2 per 12 months	
L1845	Yes	No	2 per 12 months	
L1846	Yes	Yes	2 per 12 months	
L1847	Yes	Yes	2 per 12 months	
L1850	Yes	No	2 per 12 months	
L1855	Yes	Yes	2 per 12 months		

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
ORTHOTICS MANUAL		6 SERVICE CODES	6-5	

		TRANSMITTAL LETTER	DATE	
			ORT-17	02/01/04	
602 Service Codes and Limitations (cont.)			
			Service Limitations (PA required	
HCPCS	Covered                    Covered	for units in excess of limitations)	
Code	Under Age 21?         Age 21 and older?      and Special Requirements	
L1858	Yes	Yes	2 per 12 months	
L1860	Yes	No	2 per 12 months	
L1870	Yes	Yes	2 per 12 months	
L1880	Yes	Yes	2 per 12 months	
L1885	Yes	Yes	2 per 12 months	
L1900	Yes	Yes	2 per 12 months	
L1901	Yes	No	2 per 12 months; I.C.	
LI 902	Yes	No	2 per 12 months	
LI 904	Yes	Yes	2 per 12 months	
L1906	Yes	No	2 per 12 months	
L1907	Yes	Yes	2 per 12 months; I.C.	
L1910	Yes	Yes	2 per 12 months	
LI 920	Yes	Yes	2 per 12 months	
L1930	Yes	Yes	2 per 12 months	
LI 940	Yes	Yes	2 per 12 months	
LI 945	Yes	Yes	2 per 12 months	
L1950	Yes	Yes	2 per 12 months	
L1951	Yes	Yes	2 per 12 months; I.C.	
L1960	Yes	Yes	2 per 12 months	
L1970	Yes	Yes	2 per 12 months	
L1971	Yes	Yes	2 per 12 months; I.C.	
L1980	Yes	Yes	2 per 12 months	
L1990	Yes	Yes	2 per 12 months	
L2000	Yes	Yes	2 per 12 months	
L2010	Yes	Yes	2 per 12 months	
L2020	Yes	Yes	2 per 12 months	
L2030	Yes	Yes	2 per 12 months	
L2035	Yes	No	2 per 12 months	
L2036	Yes	Yes	2 per 12 months	
L2037	Yes	Yes	2 per 12 months	
L2038	Yes	Yes	2 per 12 months	
L2039	Yes	Yes	2 per 12 months	
L2040	Yes	Yes	1 per 12 months	
L2050	Yes	Yes	1 per 12 months	
L2060	Yes	Yes	1 per 12 months	
L2070	Yes	Yes	1 per 12 months	
L2080	Yes	Yes	2 per 12 months	
L2090	Yes	Yes	2 per 12 months	
L2106	Yes	Yes	2 per 12 months	
L2108	Yes	Yes	2 per 12 months	
L2112	Yes	Yes	2 per 12 months		

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
ORTHOTICS MANUAL		6 SERVICE CODES	6-6	

		TRANSMITTAL LETTER	DATE	
			ORT-17	02/01/04	
602 Service Codes and Limitations (cont.)			
			Service Limitations (PA required	
HCPCS	Covered                    Covered	for units in excess of limitations)	
Code	Under Age 21?         Age 21 and older?      and Special Requirements	
L2114	Yes	Yes	2 per 12 months	
L2116	Yes	Yes	2 per 12 months	
L2126	Yes	Yes	2 per 12 months	
L2128	Yes	Yes	2 per 12 months	
L2132	Yes	Yes	2 per 12 months	
L2134	Yes	Yes	2 per 12 months	
L2136	Yes	Yes	2 per 12 months	
L2180	Yes	Yes	2 per 12 months	
L2182	Yes	Yes	2 per 12 months	
L2184	Yes	Yes	2 per 12 months	
L2186	Yes	Yes	2 per 12 months	
L2188	Yes	Yes	2 per 12 months	
L2190	Yes	Yes	1 per 12 months	
L2192	Yes	Yes	2 per 12 months	
L2200	Yes	Yes	4 per 12 months	
L2210	Yes	Yes	4 per 12 months	
L2220	Yes	Yes	4 per 12 months	
L2230	Yes	Yes	2 per 12 months	
L2240	Yes	Yes	2 per 12 months	
L2250	Yes	Yes	2 per 12 months	
L2260	Yes	Yes	2 per 12 months	
L2265	Yes	Yes	2 per 12 months	
L2270	Yes	Yes	4 per 12 months	
L2275	Yes	Yes	2 per 12 months	
L2280	Yes	Yes	2 per 12 months	
L2300	Yes	Yes	2 per 12 months	
L2310	Yes	Yes	2 per 12 months	
L2320	Yes	Yes	2 per 12 months	
L2330	Yes	Yes	2 per 12 months	
L2335	Yes	Yes	2 per 12 months	
L2340	Yes	Yes	2 per 12 months	
L2350	Yes	Yes	2 per 12 months	
L2360	Yes	No	2 per 12 months	
L2370	Yes	Yes	2 per 12 months	
L2375	Yes	Yes	4 per 12 months	
L2380	Yes	Yes	4 per 12 months	
L2385	Yes	Yes	4 per 12 months	
L2390	Yes	Yes	4 per 12 months	
L2395	Yes	Yes	4 per 12 months	
L2397	Yes	No	2 per 12 months	
L2405	Yes	Yes	4 per 12 months		

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
ORTHOTICS MANUAL		6 SERVICE CODES	6-7	

		TRANSMITTAL LETTER	DATE	
			ORT-17	02/01/04	
602 Service Codes and Limitations (cont.)			
			Service Limitations (PA required	
HCPCS	Covered                    Covered	for units in excess of limitations)	
Code	Under Age 21?         Age 21 and older?      and Special Requirements	
L2415	Yes	Yes	4 per 12 months	
L2425	Yes	Yes	4 per 12 months	
L2430	Yes	Yes	4 per 12 months	
L2435	Yes	Yes	4 per 12 months	
L2492	Yes	Yes	4 per 12 months	
L2500	Yes	Yes	2 per 12 months	
L2510	Yes	Yes	2 per 12 months	
L2520	Yes	Yes	2 per 12 months	
L2525	Yes	Yes	2 per 12 months	
L2526	Yes	Yes	2 per 12 months	
L2530	Yes	Yes	2 per 12 months	
L2540	Yes	Yes	2 per 12 months	
L2550	Yes	Yes	2 per 12 months	
L2570	Yes	Yes	2 per 12 months	
L2580	Yes	Yes	2 per 12 months	
L2600	Yes	Yes	2 per 12 months	
L2610	Yes	Yes	2 per 12 months	
L2620	Yes	Yes	2 per 12 months	
L2622	Yes	Yes	2 per 12 months	
L2624	Yes	Yes	2 per 12 months	
L2627	Yes	Yes	2 per 12 months	
L2628	Yes	Yes	2 per 12 months	
L2630	Yes	Yes	2 per 12 months	
L2640	Yes	Yes	2 per 12 months	
L2650	Yes	Yes	2 per 12 months	
L2660	Yes	Yes	2 per 12 months	
L2670	Yes	Yes	2 per 12 months	
L2680	Yes	Yes	2 per 12 months	
L2750	Yes	Yes	4 per 12 months	
L2755	Yes	Yes	4 per 12 months	
L2760	Yes	Yes	4 per 12 months	
L2768	Yes	Yes	4 per 12 months	
L2770	Yes	Yes	8 per 12 months	
L2780	Yes	Yes	8 per 12 months	
L2785	Yes	Yes	4 per 12 months	
L2795	Yes	Yes	2 per 12 months	
L2800	Yes	Yes	2 per 12 months	
L2810	Yes	Yes	2 per 12 months	
L2820	Yes	Yes	4 per 12 months	
L2830	Yes	Yes	4 per 12 months	
L2840	Yes	Yes	6 per 12 months		

Commonwealth of Massachusetts		SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
ORTHOTICS MANUAL		6 SERVICE CODES	6-8	

		TRANSMITTAL LETTER	DATE	
			ORT-17	02/01/04	
602 Service Codes and Limitations (cont.)			
			Service Limitations (PA required	
HCPCS	Covered                    Covered	for units in excess of limitations)	
Code	Under Age 21?         Age 21 and older?      and Special Requirements	
L2850	Yes	Yes	6 per 12 months	
L2860	Yes	Yes	2 per 12 months	
L2999	Yes	Yes	~	
L3000	Yes	No	2 per 12 months	
L3001	Yes	No	2 per 12 months	
L3002	Yes	No	2 per 12 months	
L3003	Yes	No	2 per 12 months	
L3010	Yes	No	2 per 12 months	
L3020	Yes	No	2 per 12 months	
L3030	Yes	No	2 per 12 months	
L3040	Yes	No	2 per 12 months	
L3050	Yes	No	2 per 12 months	
L3060	Yes	No	2 per 12 months	
L3070	Yes	No	2 per 12 months	
L3080	Yes	No	2 per 12 months	
L3090	Yes	No	2 per 12 months	
L3100	Yes	No	2 per 12 months	
L3140	Yes	No	1 per 12 months	
L3150	Yes	No	1 per 12 months	
L3160	Yes	No	1 per 12 months	
L3170	Yes	No	1 per 12 months	
L3201	Yes	No	2 per 12 months; I.C.	
L3202	Yes	No	2 per 12 months; I.C.	
L3203	Yes	No	2 per 12 months; I.C.	
L3204	Yes	No	2 per 12 months; I.C.	
L3206	Yes	No	2 per 12 months; I.C.	
L3207	Yes	No	2 per 12 months; I.C.	
L3208	Yes	No	2 per 12 months; I.C.	
L3209	Yes	No	2 per 12 months; I.C.	
L3211	Yes	No	2 per 12 months; I.C.	
L3212	Yes	No	1 per 12 months; I.C.	
L3213	Yes	No	1 per 12 months; I.C.	
L3214	Yes	No	1 per 12 months; I.C.	
L3215	Yes	No	1 per 12 months; I.C.	
L3216	Yes	No	1 per 12 months; I.C.	
L3217	Yes	No	1 per 12 months; I.C.	
L3219	Yes	No	1 per 12 months; I.C.	
L3221	Yes	No	1 per 12 months; I.C.	
L3222	Yes	No	1 per 12 months; I.C.	
L3224	Yes	No	2 per 12 months; I.C.	
L3225	Yes	No	2 per 12 months; I.C.		

Commonwealth of Massachusetts		SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
ORTHOTICS MANUAL		6 SERVICE CODES	6-9	

		TRANSMITTAL LETTER	DATE	
			ORT-17	02/01/04	
602 Service Codes and Limitations (cont.)			
			Service Limitations (PA required	
HCPCS	Covered                    Covered	for units in excess of limitations)	
Code	Under Age 21?         Age 21 and older?      and Special Requirements	
L3230	Yes	No	2 per 12 months; I.C.	
L3250	Yes	No	2 per 12 months; I.C.	
L3251	Yes	No	2 per 12 months; I.C.	
L3252	Yes	No	2 per 12 months; I.C.	
L3253	Yes	No	2 per 12 months; I.C.	
L3254	Yes	No	1 per 12 months; I.C.	
L3255	Yes	No	1 per 12 months; I.C.	
L3257	Yes	No	1 per 12 months; I.C.	
L3260	Yes	No	2 per 12 months; I.C.	
L3265	Yes	No	2 per 12 months; I.C.	
L3300	Yes	No	2 per 12 months	
L3310	Yes	No	2 per 12 months	
L3320	Yes	No	2 per 12 months	
L3332	Yes	No	1 per 12 months	
L3334	Yes	No	2 per 12 months	
L3350	Yes	No	2 per 12 months	
L3360	Yes	No	2 per 12 months	
L3370	Yes	No	2 per 12 months	
L3390	Yes	No	2 per 12 months	
L3400	Yes	No	2 per 12 months	
L3420	Yes	No	2 per 12 months	
L3450	Yes	No	2 per 12 months	
L3455	Yes	No	2 per 12 months	
L3460	Yes	No	2 per 12 months	
L3465	Yes	No	2 per 12 months	
L3470	Yes	No	2 per 12 months	
L3480	Yes	No	2 per 12 months	
L3485	Yes	No	2 per 12 months	
L3500	Yes	No	2 per 12 months	
L3510	Yes	No	2 per 12 months	
L3530	Yes	No	2 per 12 months	
L3540	Yes	No	2 per 12 months	
L3570	Yes	No	2 per 12 months	
L3580	Yes	No	2 per 12 months	
L3590	Yes	No	2 per 12 months	
L3595	Yes	No	2 per 12 months	
L3600	Yes	Yes	2 per 12 months	
L3610	Yes	Yes	2 per 12 months	
L3620	Yes	Yes	2 per 12 months	
L3630	Yes	Yes	2 per 12 months	
L3640	Yes	No	2 per 12 months		

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
ORTHOTICS MANUAL		6 SERVICE CODES	6-10	

		TRANSMITTAL LETTER	DATE	
			ORT-17	02/01/04	
602 Service Codes and Limitations (cont.)			
			Service Limitations (PA required	
HCPCS	Covered                    Covered	for units in excess of limitations)	
Code	Under Age 21?         Age 21 and older?      and Special Requirements	
L3649	Yes	No	1 per 12 months; I.C.	
L3650	Yes	Yes	2 per 12 months	
L3651	Yes	No	2 per 12 months; I.C.	
L3652	Yes	No	1 per 12 months; I.C.	
L3660	Yes	No	2 per 12 months	
L3670	Yes	Yes	2 per 12 months	
L3675	Yes	Yes	2 per 12 months	
L3700	Yes	No	2 per 12 months	
L3701	Yes	No	2 per 12 months; I.C.	
L3710	Yes	No	2 per 12 months	
L3720	Yes	Yes	2 per 12 months	
L3730	Yes	Yes	2 per 12 months	
L3740	Yes	Yes	2 per 12 months	
L3760	Yes	Yes	2 per 12 months	
L3762	Yes	Yes	2 per 12 months; I.C.	
L3800	Yes	Yes	2 per 12 months	
L3805	Yes	Yes	2 per 12 months	
L3807	Yes	Yes	2 per 12 months	
L3810	Yes	Yes	2 per 12 months	
L3815	Yes	Yes	2 per 12 months	
L3820	Yes	Yes	2 per 12 months	
L3825	Yes	Yes	2 per 12 months	
L3830	Yes	Yes	2 per 12 months	
L3835	Yes	Yes	2 per 12 months	
L3840	Yes	Yes	2 per 12 months	
L3845	Yes	Yes	2 per 12 months	
L3850	Yes	Yes	2 per 12 months	
L3855	Yes	Yes	2 per 12 months	
L3860	Yes	Yes	2 per 12 months	
L3890	Yes	Yes	2 per 12 months	
L3900	Yes	Yes	2 per 12 months	
L3901	Yes	Yes	2 per 12 months	
L3902	Yes	No	2 per 12 months	
L3904	Yes	No	2 per 12 months	
L3906	Yes	Yes	2 per 12 months	
L3907	Yes	Yes	2 per 12 months	
L3908	Yes	No	2 per 12 months	
L3909	Yes	No	2 per 12 months; I.C.	
L3910	Yes	Yes	2 per 12 months	
L3911	Yes	Yes	2 per 12 months; I.C.	
L3912	Yes	Yes	2 per 12 months		

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
ORTHOTICS MANUAL		6 SERVICE CODES	6-11	

		TRANSMITTAL LETTER	DATE	
			ORT-17	02/01/04	
602 Service Codes and Limitations (cont.)			
			Service Limitations (PA required	
HCPCS	Covered                    Covered	for units in excess of limitations)	
Code	Under Age 21?         Age 21 and older?      and Special Requirements	
L3914	Yes	No	2 per 12 months	
L3916	Yes	Yes	2 per 12 months	
L3917	Yes	Yes	2 per 12 months; I.C.	
L3918	Yes	Yes	2 per 12 months	
L3920	Yes	Yes	2 per 12 months	
L3922	Yes	Yes	2 per 12 months	
L3923	Yes	No	2 per 12 months	
L3924	Yes	Yes	2 per 12 months	
L3926	Yes	Yes	2 per 12 months	
L3928	Yes	No	2 per 12 months	
L3930	Yes	Yes	2 per 12 months	
L3932	Yes	Yes	2 per 12 months	
L3934	Yes	Yes	2 per 12 months	
L3936	Yes	Yes	2 per 12 months	
L3938	Yes	No	2 per 12 months	
L3940	Yes	Yes	2 per 12 months	
L3942	Yes	Yes	2 per 12 months	
L3944	Yes	Yes	2 per 12 months	
L3946	Yes	Yes	2 per 12 months	
L3948	Yes	Yes	2 per 12 months	
L3950	Yes	Yes	2 per 12 months	
L3952	Yes	Yes	2 per 12 months	
L3954	Yes	Yes	2 per 12 months	
L3956	Yes	Yes	2 per 12 months; I.C.	
L3960	Yes	Yes	2 per 12 months	
L3962	Yes	Yes	2 per 12 months	
L3963	Yes	Yes	2 per 12 months	
L3964	Yes	No	2 per 12 months	
L3965	Yes	No	2 per 12 months	
L3966	Yes	No	2 per 12 months	
L3968	Yes	No	2 per 12 months	
L3969	Yes	No	2 per 12 months	
L3970	Yes	No	2 per 12 months	
L3972	Yes	No	2 per 12 months	
L3974	Yes	No	2 per 12 months	
L3980	Yes	Yes	2 per 12 months	
L3982	Yes	Yes	2 per 12 months	
L3984	Yes	Yes	2 per 12 months	
L3985	Yes	Yes	2 per 12 months	
L3986	Yes	Yes	2 per 12 months	
L3995	Yes	No	2 per 12 months		

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
ORTHOTICS MANUAL		6 SERVICE CODES	6-12	

		TRANSMITTAL LETTER	DATE	
			ORT-17	02/01/04	
602 Service Codes and Limitations (cont.)			
			Service Limitations (PA required	
HCPCS	Covered                    Covered	for units in excess of limitations)	
Code	Under Age 21?         Age 21 and older?      and Special Requirements	
L3999	Yes	Yes	i.e.	
L4000	Yes	No	1 per 12 months	
L4010	Yes	No	1 per 12 months	
L4020	Yes	Yes	2 per 12 months	
L4030	Yes	Yes	2 per 12 months	
L4040	Yes	Yes	2 per 12 months	
L4045	Yes	Yes	2 per 12 months	
L4050	Yes	Yes	2 per 12 months	
L4055	Yes	Yes	2 per 12 months	
L4060	Yes	Yes	2 per 12 months	
L4070	Yes	Yes	4 per 12 months	
L4080	Yes	Yes	2 per 12 months	
L4090	Yes	Yes	2 per 12 months	
L4100	Yes	Yes	2 per 12 months	
L4110	Yes	Yes	2 per 12 months	
L4130	Yes	Yes	2 per 12 months	
L4205	Yes	Yes	~	
L4210	Yes	Yes	i.e.	
L4350	Yes	No	2 per 12 months	
L4360	Yes	No	2 per 12 months	
L4370	Yes	No	2 per 12 months	
L4380	Yes	No	2 per 12 months	
L4386	Yes	Yes	2 per 12 months; I.C.	
L4392	Yes	Yes	2 per 12 months	
L4394	Yes	Yes	2 per 12 months	
L4396	Yes	Yes	2 per 12 months	
L4398	Yes	Yes	2 per 12 months	
T2003	
Yes	Yes	—