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
TRANSMITTAL LETTER PRT-16
June 2003
TO:      Prosthetic Providers Participating in MassHealth
FROM:      Douglas S. Brown, Acting Commissioner-
RE:      Prosthetics Manual (Restoration of Certain Prosthetic Services and Revised Subchapter 6)

This letter transmits revised regulations for prosthetic providers. Effective July 1, 2003, the Division is restoring coverage for certain prosthetic services that were previously available to MassHealth members aged 21 and older.
This letter also transmits a revised and reformatted Subchapter 6 for the Prosthetics Manual. Subchapter 6 now lists all covered service codes in alphanumeric order, and no longer includes service descriptions. Providers must refer to the St. Anthony’s National HCPCS 2003 code book for the descriptions of the codes listed in Subchapter 6. Subchapter 6 is now also formatted to indicate service limitations according to the member’s age. The limitations listed in Subchapter 6 are in addition to all other conditions and limitations of payment in the Division’s regulations at 130 CMR 428.000 and 450.000.
Subchapter 6 has also been updated to reflect the Centers for Medicare and Medicaid Services revisions to the Healthcare Common Procedure Coding System (HCPCS) for 2003. To ensure that the Division’s codes are compliant with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, new national service codes have been added and obsolete national service codes and MassHealth local codes have been removed.
The revisions to the regulations were filed as an emergency. The revised regulations and Subchapter 6 are effective for dates of service on and after July 1, 2003.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Prosthetics Manual
Pages iv, vi, 4-1 through 4-4, and 6-1 through 6-10
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Prosthetics Manual
Pages iv, vi, 4-3, 4-4, and 6-1 through 6-16 — transmitted by Transmittal Letter PRT-14
Pages 4-1 and 4-2 — transmitted by Transmittal Letter PRT-15

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

	TRANSMITTAL LETTER
PRT-16	DATE
07/01/03	
4.   PROGRAM REQUIREMENTS
428.401:	Introduction 		4-1
428.402:	Definitions 		4-1
428.403:	Eligible Members 		4-2
428.404:	Provider Eligibility 		4-3
428.405:	Provider Responsibility 		4-3
428.406:	Covered Services 		4-3
428.407:	Service Limitations 		4-4
428.408:	Noncovered Services 		4-4
428.409:	Prescription Requirements 		4-4
428.410:	Prosthetic Equipment Provided to Institutionalized Members 		4-5
428.411:	Repairs of Prosthetic Equipment 		4-5
428.412:	Prior Authorization 		4-5
428.413:	Procedure for Requesting Prior Authorization 		4-6
428.414:	Medicare Coverage 		4-7
(130 CMR 428.415 through 428.419 Reserved)
428.420:	Payment for Prosthetic Services 		4-8
428.421:	Individual Consideration 		4-8
428.422:	Adjusted Acquisition Cost 		4-9
428.423:	Recordkeeping Requirements 		4-9

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

	TRANSMITTAL LETTER
PRT-16	DATE
07/01/03	
6. SERVICE CODES
601	Introduction 		6-1
602	Service Codes and Limitations 		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
PROSTHETICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 428.000)	PAGE
4-1	

	TRANSMITTAL LETTER
PRT-16	DATE
07/01/03	
428.401: Introduction
130 CMR 428.000 states the requirements and procedures for the purchase and repair of prosthetic devices, customized equipment, and supplies under MassHealth. All providers of prosthetic services participating in MassHealth must comply with the regulations of the Division governing MassHealth, including, but not limited to, Division regulations set forth in 130 CMR 428.000 and in 130 CMR 450.000.
428.402: Definitions
The following terms used in 130 CMR 428.000 have the meanings given in 130 CMR 428.402 unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 428.000 is not determined by these definitions, but by application of regulations elsewhere in 130 CMR 428.000 and in 130 CMR 450.000.
Accessory Equipment — equipment that is fabricated primarily and customarily to modify or enhance the usefulness or functional capability of another piece of prosthetic equipment and that is generally not useful in the absence of such prosthetic equipment.
Adjusted Acquisition Cost — except where the manufacturer is the provider, the price paid by the provider to the manufacturer or any other supplier for prosthetic devices, customized equipment, or supplies, excluding all associated costs such as shipping, handling, and insurance costs in accordance with 130 CMR 428.422. Where the manufacturer is the provider, the adjusted acquisition cost is the actual cost of manufacturing such prosthetic devices, customized equipment, or supplies.
Date of Service — the date the prosthesis is delivered and fitted to the MassHealth member. If the prosthetic service involves a series of fittings and adjustments, the date of service is the date on which the final adjustment is made. If the prosthetic service involves only the provision of a service (for example, a repair), then the date of service is the date on which the service was completed.
Discount — any remuneration or reduction of payment of any kind, whether direct or indirect, received by the provider.
Nursing Facility — a licensed facility that meets the provider-eligibility and certification requirements of 130 CMR 456.404 or 456.405 and whose members meet the medical eligibility criteria under 130 CMR 456.409. Nursing facilities do not include facilities such as rest homes, state schools, and state hospitals.
Nursing Facility Visit — a visit by a provider to a nursing facility for the purpose of providing prosthetic services.
Prosthesis (or Prosthetic Equipment) — an artificial replacement for a missing body part, such as an artificial limb or total joint replacement.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PROSTHETICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 428.000)	PAGE
4-2	

	TRANSMITTAL LETTER
PRT-16	DATE
07/01/03	
Prosthetic Service — the purchase, customization, fitting, repair, replacement, or adjustment of a prosthesis or component part, or other activity performed or equipment provided in accordance with 130 CMR 428.000.
Prosthetic Supplies — products that are:
(1)	fabricated primarily and customarily to fulfill a medical purpose;
(2)	used in conjunction with a prosthesis or prosthetic equipment;
(3)	generally not useful in the absence of a prosthesis; and
(4)	non-reusable and disposable.
Prosthetics — the design, fitting, and attachment of an artificial replacement of a missing body part.
Service Facility — the place of business, physically accessible to MassHealth members, where prosthetic services, especially those involving fitting, adjustment, repair, and replacement of prostheses, are performed. A service facility does not include a MassHealth member’s place of residence.
428.403: Eligible Members
(A)	(1) MassHealth Members. The Division covers prosthetic services only when provided to
eligible MassHealth members, subject to the restrictions and limitations in130 CMR 428.000
and 450.000. 130 CMR 450.105 specifically states, for each coverage type, which services
are covered and which members are eligible to receive those services.
(2)	Age Limitations. In addition to any other restrictions and limitations set forth in 130 CMR 428.000 and 450.000, the Division covers prosthetic services only when provided to eligible MassHealth members, subject to the age limitations set forth in Subchapter 6 of the Prosthetics Manual.
(3)	Recipients of the Emergency Aid to the Elderly, Disabled and Children Program. For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106.
(B)	For information on verifying member eligibility and coverage type, see 130 CMR 450.107.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PROSTHETICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 428.000)	PAGE
4-3	

	TRANSMITTAL LETTER
PRT-16	DATE
07/01/03	
428.404: Provider Eligibility
For services described in 130 CMR 428.000, the Division pays only those providers of prosthetic services who are participating in MassHealth as of the date of service.
(A)	In State. To participate in MassHealth, a provider with a service facility in Massachusetts
must:
(1)	primarily engage in the business of providing prosthetic and repair services to the public;
(2)	meet all state and local requirements for engaging in such business;
(3)	be or employ a prosthetist currently certified by the American Board for Certification in Orthotics and Prosthetics, Inc. or the Board for Orthotics/Prosthetics Certification.
(4)	be a Medicare provider;
(5)	have a service facility that is physically accessible to MassHealth members during reasonable business hours;
(6)	maintain a visible sign identifying the business and hours of operation; and
(7)	maintain a primary business telephone listed under the name of the business in a local directory. The exclusive use of a pager, answering machine, or cell phone is prohibited.
(B)	Out of State. A provider with no service facility in Massachusetts may participate in
MassHealth only if the provider participates in the medical assistance program of the state in
which the provider primarily conducts business and otherwise meets the requirements of
130 CMR 428.404(A). Such a provider may receive payment for MassHealth services only as set
forth in 130 CMR 450.109.
428.405: Provider Responsibility
(A)	The provider must ensure that all prosthetic equipment and supplies are:
(1)	clean (sterilized when appropriate);
(2)	in proper working condition;
(3)	functional;
(4)	free from defects; and
(5)	new and unused at the time of purchase. .

(B)	The provider must ensure that all prosthetic services are the most cost effective, given the medical need for which they are prescribed and the member's physical limitations.
(C)	The provider must make a reasonable effort to purchase the item from the least costly reliable source by comparing prices charged by different suppliers for comparable items.
428.406: Covered Services
The Division pays for only those prosthetic services listed in, and subject to the service limitations set forth in, Subchapter 6 of the Prosthetics Manual.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PROSTHETICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 428.000)	PAGE
4-4	

	TRANSMITTAL LETTER
PRT-16	DATE
07/01/03	
428.407: Service Limitations
The service limitations set forth in Subchapter 6 of the Prosthetics Manual apply, subject to the Early and Periodic Screening, Diagnosis, and Treatment provisions set forth in 130 CMR 450.144(A).
428.408: Noncovered Services
The Division does not pay for any of the following:
(A)	any prosthetic services for which, under comparable circumstances, the provider does not customarily bill private patients who do not have health insurance;
(B)	nonmedical prosthetic 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 prosthetic equipment or associated items; and
(D)	prosthetic 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.
428.409: Prescription Requirements
(A)	The purchase of prosthetic equipment requires a written prescription signed by a licensed
physician or an independent nurse practitioner. The prescription must be written on the
prescriber's prescription form and must include the following information:
(1)	the member's name and address;
(2)	the member’s MassHealth identification number;
(3)	specific identification of the prescribed item;
(4)	medical justification for the use of the item, including the member’s diagnosis;
(5)	the prescriber's address and telephone number; and
(6)	the date on which the prescription was signed by the prescriber.
(B)	The provider must keep the prescription on file for the period of time required by 130 CMR
450.205.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PROSTHETICS MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-1	

	TRANSMITTAL LETTER
PRT-16	DATE
07/01/03	
601 Introduction
MassHealth providers must refer to the St. Anthony’s National HCPCS 2003 code book for the descriptions of the service codes listed in Section 602.
The Division pays for all codes listed in Section 602 in effect at the time of service, subject to all conditions and limitations in Subchapter 6 and in the Division’s regulations at 130 CMR 428.000 and 450.000
602 Service Codes and Limitations
HCPCS	Covered	Covered	Service	
Code	Under Age 21?	Age 21 and older?	Limitations	
L5000	Yes	No	1 per 36 months	
L5010	Yes	Yes	2 per 12 months	
L5020	Yes	Yes	2 per 12 months	
L5050	Yes	Yes	2 per 12 months	
L5060	Yes	Yes	2 per 12 months	
L5100	Yes	No	2 per 12 months	
L5105	Yes	Yes	2 per 12 months	
L5150	Yes	Yes	2 per 12 months	
L5160	Yes	Yes	2 per 12 months	
L5200	Yes	No	2 per 12 months	
L5210	Yes	Yes	2 per 12 months	
L5220	Yes	No	2 per 12 months	
L5230	Yes	Yes	2 per 12 months	
L5250	Yes	No	2 per 12 months	
L5270	Yes	No	2 per 12 months	
L5280	Yes	No	2 per 12 months	
L5301	Yes	Yes	2 per 12 months	
L5311	Yes	Yes	2 per 12 months	
L5321	Yes	Yes	2 per 12 months	
L5331	Yes	Yes	2 per 12 months	
L5341	Yes	Yes	2 per 12 months	
L5400	Yes	No	2 per 12 months	
L5410	Yes	No	2 per 12 months	
L5420	Yes	No	2 per 12 months	
L5430	Yes	No	2 per 12 months	
L5450	Yes	No	2 per 12 months	
L5460	Yes	No	2 per 12 months	
L5500	Yes	No	2 per 12 months	
L5505	Yes	No	2 per 12 months	
L5510	Yes	Yes	2 per 12 months	
L5520	Yes	Yes	2 per 12 months	
L5530	Yes	Yes	2 per 12 months	
L5535	Yes	Yes	2 per 12 months	

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

		TRANSMITTAL LETTER	DATE	
			PRT-16		07/01/03	
602 Service Codes and Limitations (cont.)				
HCPCS	Covered                    Covered	Service	
Code	Under Age 21?         Age 21 and older?      Limitations	
L5540	Yes	Yes	2 per	12 months	
L5560	Yes	Yes	2 per	12 months	
L5570	Yes	Yes	2 per	12 months	
L5580	Yes	Yes	2 per	12 months	
L5585	Yes	Yes	2 per	12 months	
L5590	Yes	Yes	2 per	12 months	
L5595	Yes	Yes	2 per	12 months	
L5600	Yes	Yes	2 per	12 months	
L5610	Yes	No	2 per	12 months	
L5611	Yes	Yes	2 per	12 months	
L5613	Yes	Yes	2 per	12 months	
L5614	Yes	Yes	2 per	12 months	
L5616	Yes	Yes	2 per	12 months	
L5617	Yes	No	2 per	12 months	
L5618	Yes	Yes	2 per	12 months	
L5620	Yes	Yes	2 per	12 months	
L5622	Yes	Yes	2 per	12 months	
L5624	Yes	Yes	2 per	12 months	
L5626	Yes	Yes	2 per	12 months	
L5628	Yes	Yes	2 per	12 months	
L5629	Yes	Yes	2 per	12 months	
L5630	Yes	No	2 per	12 months	
L5631	Yes	Yes	2 per	12 months	
L5632	Yes	Yes	2 per	12 months	
L5634	Yes	Yes	2 per	12 months	
L5636	Yes	Yes	2 per	12 months	
L5637	Yes	Yes	2 per	12 months	
L5638	Yes	No	2 per	12 months	
L5639	Yes	No	2 per	12 months	
L5640	Yes	No	2 per	12 months	
L5642	Yes	No	2 per	12 months	
L5643	Yes	Yes	2 per	12 months	
L5644	Yes	No	2 per	12 months	
L5645	Yes	Yes	2 per	12 months	
L5646	Yes	No	2 per	12 months	
L5647	Yes	Yes	2 per	12 months	
L5648	Yes	No	2 per	12 months	
L5649	Yes	Yes	2 per	12 months	
L5650	Yes	Yes	2 per	12 months	
L5651	Yes	Yes	2 per	12 months	
L5652	Yes	Yes	2 per	12 months	
L5653	Yes	No	2 per	12 months			

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

		TRANSMITTAL LETTER	DATE	
			PRT-16		07/01/03	
602 Service Codes and Limitations (cont.)				
HCPCS	Covered                    Covered	Service	
Code	Under Age 21?         Age 21 and older?      Limitations	
L5654	Yes	No	4 per	12 months	
L5655	Yes	Yes	4 per	12 months	
L5656	Yes	Yes	4 per	12 months	
L5658	Yes	Yes	4 per	12 months	
L5661	Yes	Yes	4 per	12 months	
L5665	Yes	Yes	4 per	12 months	
L5666	Yes	Yes	2 per	12 months	
L5668	Yes	Yes	2 per	12 months	
L5670	Yes	Yes	2 per	12 months	
L5671	Yes	Yes	2 per	12 months	
L5672	Yes	No	2 per	12 months	
L5674	Yes	Yes	2 per	12 months	
L5675	Yes	Yes	2 per	12 months	
L5676	Yes	Yes	2 per	12 months	
L5677	Yes	Yes	2 per	12 months	
L5678	Yes	Yes	2 per	12 months	
L5680	Yes	Yes	2 per	12 months	
L5682	Yes	Yes	2 per	12 months	
L5684	Yes	Yes	2 per	12 months	
L5686	Yes	Yes	2 per	12 months	
L5688	Yes	Yes	2 per	12 months	
L5690	Yes	Yes	2 per	12 months	
L5692	Yes	Yes	2 per	12 months	
L5694	Yes	Yes	2 per	12 months	
L5695	Yes	Yes	2 per	12 months	
L5696	Yes	Yes	2 per	12 months	
L5697	Yes	Yes	2 per	12 months	
L5698	Yes	Yes	2 per	12 months	
L5699	Yes	Yes	2 per	12 months	
L5700	Yes	Yes	2 per	12 months	
L5701	Yes	Yes	2 per	12 months	
L5702	Yes	Yes	2 per	12 months	
L5704	Yes	Yes	2 per	12 months	
L5705	Yes	Yes	2 per	12 months	
L5706	Yes	Yes	2 per	12 months	
L5707	Yes	Yes	2 per	12 months	
L5710	Yes	No	2 per	12 months	
L5711	Yes	No	2 per	12 months	
L5712	Yes	No	2 per	12 months	
L5714	Yes	No	2 per	12 months	
L5716	Yes	No	2 per	12 months	
L5718	Yes	No	2 per	12 months			

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
PROSTHETICS MANUAL		6 SERVICE CODES	6-4	

		TRANSMITTAL LETTER	DATE	
			PRT-16		07/01/03	
602 Service Codes and Limitations (cont.)				
HCPCS	Covered                    Covered	Service	
Code	Under Age 21?         Age 21 and older?      Limitations	
L5722	Yes	No	2 per	12 months	
L5724	Yes	No	2 per	12 months	
L5726	Yes	No	2 per	12 months	
L5728	Yes	No	2 per	12 months	
L5780	Yes	No	2 per	12 months	
L5781	Yes	Yes	2 per	12 months	
L5782	Yes	Yes	2 per	12 months	
L5785	Yes	No	2 per	12 months	
L5790	Yes	No	2 per	12 months	
L5795	Yes	No	2 per	12 months	
L5810	Yes	Yes	2 per	12 months	
L5811	Yes	Yes	2 per	12 months	
L5812	Yes	Yes	2 per	12 months	
L5814	Yes	Yes	2 per	12 months	
L5816	Yes	Yes	2 per	12 months	
L5818	Yes	Yes	2 per	12 months	
L5822	Yes	Yes	2 per	12 months	
L5824	Yes	Yes	2 per	12 months	
L5826	Yes	Yes	2 per	12 months	
L5828	Yes	Yes	2 per	12 months	
L5830	Yes	No	2 per	12 months	
L5840	Yes	Yes	2 per	12 months	
L5845	Yes	Yes	2 per	12 months	
L5846	Yes	No	2 per	12 months	
L5847	Yes	No	2 per	12 months	
L5848	Yes	Yes	2 per	12 months	
L5850	Yes	Yes	2 per	12 months	
L5855	Yes	Yes	2 per	12 months	
L5910	Yes	Yes	2 per	12 months	
L5920	Yes	Yes	2 per	12 months	
L5925	Yes	Yes	2 per	12 months	
L5930	Yes	Yes	2 per	12 months	
L5940	Yes	Yes	2 per	12 months	
L5950	Yes	Yes	2 per	12 months	
L5960	Yes	Yes	2 per	12 months	
L5962	Yes	No	2 per	12 months	
L5964	Yes	No	2 per	12 months	
L5966	Yes	No	2 per	12 months	
L5968	Yes	No	2 per	12 months	
L5970	Yes	No	2 per	12 months	
L5972	Yes	Yes	2 per	12 months	
L5974	Yes	Yes	2 per	12 months			

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

		TRANSMITTAL LETTER	DATE	
			PRT-16		07/01/03	
602 Service Codes and Limitations (cont.)				
HCPCS	Covered                    Covered	Service	
Code	Under Age 21?         Age 21 and older?      Limitations	
L5975	Yes	Yes	2 per	12 months	
L5976	Yes	Yes	2 per	12 months	
L5978	Yes	Yes	2 per	12 months	
L5979	Yes	Yes	2 per	12 months	
L5980	Yes	No	2 per	12 months	
L5981	Yes	No	2 per	12 months	
L5982	Yes	No	2 per	12 months	
L5984	Yes	Yes	2 per	12 months	
L5985	Yes	Yes	2 per	12 months	
L5986	Yes	Yes	2 per	12 months	
L5987	Yes	No	2 per	12 months	
L5988	Yes	Yes	2 per	12 months	
L5989	Yes	No	2 per	12 months	
L5990	Yes	No	2 per	12 months	
L5995	Yes	Yes	2 per	12 months	
L5999	Yes	Yes	~		
L6000	Yes	Yes	2 per	12 months	
L6010	Yes	Yes	2 per	12 months	
L6020	Yes	Yes	2 per	12 months	
L6025	Yes	Yes	2 per	12 months	
L6050	Yes	Yes	2 per	12 months	
L6055	Yes	Yes	2 per	12 months	
L6100	Yes	Yes	2 per	12 months	
L6110	Yes	Yes	2 per	12 months	
L6120	Yes	Yes	2 per	12 months	
L6130	Yes	Yes	2 per	12 months	
L6200	Yes	Yes	2 per	12 months	
L6205	Yes	Yes	2 per	12 months	
L6250	Yes	Yes	2 per	12 months	
L6300	Yes	Yes	2 per	12 months	
L6310	Yes	Yes	2 per	12 months	
L6320	Yes	Yes	2 per	12 months	
L6350	Yes	Yes	2 per	12 months	
L6360	Yes	Yes	2 per	12 months	
L6370	Yes	Yes	2 per	12 months	
L6380	Yes	No	2 per	12 months	
L6382	Yes	No	2 per	12 months	
L6384	Yes	No	2 per	12 months	
L6386	Yes	No	2 per	12 months	
L6388	Yes	No	2 per	12 months	
L6400	Yes	Yes	2 per	12 months	
L6450	Yes	Yes	2 per	12 months			

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

		TRANSMITTAL LETTER	DATE	
			PRT-16		07/01/03	
602 Service Codes and Limitations (cont.)				
HCPCS	Covered                    Covered	Service	
Code	Under Age 21?         Age 21 and older?      Limitations	
L6500	Yes	Yes	2 per	12 months	
L6550	Yes	Yes	2 per	12 months	
L6570	Yes	No	2 per	12 months	
L6580	Yes	Yes	2 per	12 months	
L6582	Yes	Yes	2 per	12 months	
L6584	Yes	Yes	2 per	12 months	
L6586	Yes	Yes	2 per	12 months	
L6588	Yes	Yes	2 per	12 months	
L6590	Yes	Yes	2 per	12 months	
L6600	Yes	Yes	2 per	12 months	
L6605	Yes	Yes	2 per	12 months	
L6610	Yes	Yes	2 per	12 months	
L6615	Yes	Yes	2 per	12 months	
L6616	Yes	Yes	2 per	12 months	
L6620	Yes	Yes	2 per	12 months	
L6623	Yes	Yes	2 per	12 months	
L6625	Yes	Yes	2 per	12 months	
L6628	Yes	Yes	2 per	12 months	
L6629	Yes	Yes	2 per	12 months	
L6630	Yes	Yes	2 per	12 months	
L6632	Yes	Yes	2 per	12 months	
L6635	Yes	Yes	2 per	12 months	
L6637	Yes	Yes	2 per	12 months	
L6638	Yes	Yes	2 per	12 months	
L6640	Yes	Yes	2 per	12 months	
L6641	Yes	Yes	2 per	12 months	
L6642	Yes	Yes	2 per	12 months	
L6645	Yes	Yes	2 per	12 months	
L6646	Yes	Yes	2 per	12 months	
L6647	Yes	Yes	2 per	12 months	
L6648	Yes	Yes	2 per	12 months	
L6650	Yes	Yes	2 per	12 months	
L6655	Yes	Yes	2 per	12 months	
L6660	Yes	Yes	2 per	12 months	
L6665	Yes	Yes	2 per	12 months	
L6670	Yes	Yes	2 per	12 months	
L6672	Yes	Yes	2 per	12 months	
L6675	Yes	Yes	2 per	12 months	
L6676	Yes	Yes	2 per	12 months	
L6680	Yes	Yes	2 per	12 months	
L6682	Yes	Yes	2 per	12 months	
L6684	Yes	Yes	2 per	12 months			

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

		TRANSMITTAL LETTER	DATE	
			PRT-16		07/01/03	
602 Service Codes and Limitations (cont.)				
HCPCS	Covered                    Covered	Service	
Code	Under Age 21?         Age 21 and older?      Limitations	
L6686	Yes	Yes	2 per	12 months	
L6687	Yes	Yes	2 per	12 months	
L6688	Yes	Yes	2 per	12 months	
L6689	Yes	Yes	2 per	12 months	
L6690	Yes	Yes	2 per	12 months	
L6691	Yes	Yes	4 per	12 months	
L6692	Yes	Yes	4 per	12 months	
L6693	Yes	Yes	2 per	12 months	
L6700	Yes	Yes	2 per	12 months	
L6705	Yes	Yes	2 per	12 months	
L6710	Yes	Yes	2 per	12 months	
L6715	Yes	Yes	2 per	12 months	
L6720	Yes	Yes	2 per	12 months	
L6725	Yes	Yes	2 per	12 months	
L6730	Yes	Yes	2 per	12 months	
L6735	Yes	Yes	2 per	12 months	
L6740	Yes	Yes	2 per	12 months	
L6745	Yes	Yes	2 per	12 months	
L6750	Yes	Yes	2 per	12 months	
L6755	Yes	Yes	2 per	12 months	
L6765	Yes	Yes	2 per	12 months	
L6770	Yes	Yes	2 per	12 months	
L6775	Yes	Yes	2 per	12 months	
L6780	Yes	Yes	2 per	12 months	
L6790	Yes	Yes	2 per	12 months	
L6795	Yes	Yes	2 per	12 months	
L6800	Yes	Yes	2 per	12 months	
L6805	Yes	Yes	2 per	12 months	
L6806	Yes	Yes	2 per	12 months	
L6807	Yes	Yes	2 per	12 months	
L6808	Yes	No	2 per	12 months	
L6809	Yes	Yes	2 per	12 months	
L6810	Yes	Yes	2 per	12 months	
L6825	Yes	Yes	2 per	12 months	
L6830	Yes	Yes	2 per	12 months	
L6835	Yes	Yes	2 per	12 months	
L6840	Yes	No	2 per	12 months	
L6845	Yes	Yes	2 per	12 months	
L6850	Yes	Yes	2 per	12 months	
L6855	Yes	Yes	2 per	12 months	
L6860	Yes	Yes	2 per	12 months	
L6865	Yes	Yes	2 per	12 months			

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

		TRANSMITTAL LETTER	DATE	
			PRT-16		07/01/03	
602 Service Codes and Limitations (cont.)				
HCPCS	Covered                    Covered	Service	
Code	Under Age 21?         Age 21 and older?      Limitations	
L6867	Yes	No	2 per	12 months	
L6868	Yes	No	2 per	12 months	
L6870	Yes	No	2 per	12 months	
L6872	Yes	No	2 per	12 months	
L6873	Yes	No	2 per	12 months	
L6875	Yes	Yes	2 per	12 months	
L6880	Yes	Yes	2 per	12 months	
L6881	Yes	Yes	2 per	12 months	
L6882	Yes	Yes	2 per	12 months	
L6890	Yes	Yes	2 per	12 months	
L6895	Yes	Yes	2 per	12 months	
L6900	Yes	Yes	2 per	12 months	
L6905	Yes	Yes	2 per	12 months	
L6910	Yes	Yes	2 per	12 months	
L6915	Yes	Yes	2 per	12 months	
L6920	Yes	Yes	2 per	12 months	
L6925	Yes	Yes	2 per	12 months	
L6930	Yes	Yes	2 per	12 months	
L6935	Yes	Yes	2 per	12 months	
L6940	Yes	Yes	2 per	12 months	
L6945	Yes	Yes	2 per	12 months	
L6950	Yes	Yes	2 per	12 months	
L6955	Yes	Yes	2 per	12 months	
L6960	Yes	Yes	2 per	12 months	
L6965	Yes	Yes	2 per	12 months	
L6970	Yes	Yes	2 per	12 months	
L6975	Yes	Yes	2 per	12 months	
L7010	Yes	Yes	2 per	12 months	
L7015	Yes	Yes	2 per	12 months	
L7020	Yes	Yes	2 per	12 months	
L7025	Yes	Yes	2 per	12 months	
L7030	Yes	Yes	2 per	12 months	
L7035	Yes	Yes	2 per	12 months	
L7040	Yes	Yes	2 per	12 months	
L7045	Yes	Yes	2 per	12 months	
L7170	Yes	Yes	2 per	12 months	
L7180	Yes	No	2 per	12 months	
L7185	Yes	No	2 per	12 months	
L7186	Yes	No	2 per	12 months	
L7190	Yes	No	2 per	12 months	
L7191	Yes	No	2 per	12 months	
L7260	Yes	Yes	2 per	12 months			

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

	TRANSMITTAL LETTER
PRT-16	DATE
07/01/03	
602 Service Codes and Limitations (cont.)

HCPCS	Covered	Covered	Service	
Code	Under Age 21?	Age 21 and older?	Limitations	
L7261	Yes	Yes	2 per 12 months	
L7266	Yes	Yes	2 per 12 months	
L7272	Yes	Yes	2 per 12 months	
L7274	Yes	Yes	2 per 12 months	
L7360	Yes	Yes	4 per 12 months	
L7362	Yes	Yes	1 per 12 months	
L7364	Yes	Yes	4 per 12 months	
L7366	Yes	Yes	2 per 12 months	
L7367	Yes	Yes	2 per 12 months	
L7368	Yes	Yes	1 per 24 months	
L7499	Yes	Yes	~	
L7510	Yes	Yes	~	
L7520	Yes	Yes	~	
L8000	Yes	Yes	2 per 7 months	
L8001	Yes	Yes	2 per 7 months	
L8002	Yes	Yes	2 per 7 months	
L8010	Yes	Yes	2 per 7 months	
L8015	Yes	Yes	2 per 7 months	
L8020	Yes	Yes	2 per 7 months	
L8030	Yes	Yes	2 per 7 months	
L8100	Yes	No	2 pair per 7 months	
L8120	Yes	No	2 pair per 7 months	
L8130	Yes	No	2 pair per 7 months	
L8140	Yes	No	2 pair per 7 months	
L8150	Yes	No	2 pair per 7 months	
L8160	Yes	No	2 pair per 7 months	
L8170	Yes	No	2 pair per 7 months	
L8180	Yes	No	2 pair per 7 months	
L8190	Yes	No	2 pair per 7 months	
L8195	Yes	No	2 pair per 7 months	
L8200	Yes	No	2 pair per 7 months	
L8210	Yes	No	2 pair per 7 months	
L8220	Yes	No	2 pair per 7 months	
L8239	Yes	No	1 per 12 months	
L8300	Yes	No	2 per 12 months	
L8310	Yes	No	2 per 12 months	
L8320	Yes	No	2 per 12 months	
L8330	Yes	No	2 per 12 months	
L8400	Yes	Yes	12 per 12 months	
L8410	Yes	Yes	12 per 12 months	
L8415	Yes	Yes	12 per 12 months	
L8417	Yes	Yes	12 per 12 months	
L8420	Yes	Yes	12 per 12 months	

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

		TRANSMITTAL LETTER		DATE	
				PRT-16		07/01/03	
602 Service Codes and Limitations (cont.)					
HCPCS	Covered                    Covered		Service		
Code	Under Age 21?         Age 21 and older?	Limitations		
L8430	Yes	Yes		12 per 12 months		
L8435	Yes	Yes		12 per 12 months		
L8440	Yes	Yes		12 per 12 months		
L8460	Yes	Yes		12 per 12 months		
L8465	Yes	Yes		12 per 12 months		
L8470	Yes	Yes		12 per 12 months		
L8480	Yes	Yes		12 per 12 months		
L8485	Yes	Yes		12 per 12 months		
L8490	Yes	Yes		2 per 12 months		
L8499	Yes	Yes		12 per 12 months		
T2003	Yes	Yes		—