TMPPM 2011 > Children's Services Handbook > Medicaid Children's Services Comprehensive Care Program (CCP) > Orthotic and Prosthetic Services (CCP) > Orthotics Services > Services/Benefits and Limitations

2.7.2 Orthotics Services

2.7.2.1 Services/Benefits and Limitations

Orthoses, including orthopedic shoes, wedges, and lifts, are a benefit of Texas Medicaid when provided by a licensed orthotist or a licensed prosthetist/orthotist through CCP for clients who are birth through 20 years of age.

The following orthoses and related services may be reimbursed when medical necessity criteria are met:

•Spinal orthoses and additions to spinal orthoses, including those for scoliosis

•Lower-limb orthoses and additions to lower-limb orthoses, including fracture orthoses

•Foot orthoses, including inserts, orthopedic shoes, surgical boots, heel lifts, and wedges

•Upper-limb orthoses and additions to upper-limb orthoses, including fracture orthoses

•Other orthopedic devices, including protective helmets and dynamic splints

•Repairs, replacements, and modifications

•Orthotic device training

Note: Training in the use of an orthotic device for a client who has not worn one previously, has not worn one for a prolonged period, or is receiving a different type is a benefit when the training is provided by a physical or occupational therapist.

Refer to: Subsection 2.10, "Therapy Services (CCP)" in this handbook for more information on physical and occupational therapy services.

To be considered for reimbursement, orthoses must be dispensed, fabricated, or modified by a licensed orthotist or licensed prosthetist/orthotist enrolled with Medicare and CCP.

•Upper extremity customized splints made with low-temperature materials and inhibitive casting may be provided by occupational or physical therapists.

•Other orthopedic devices addressed in the orthotic section may be provided by a Medicaid-enrolled DME vendor.

•Orthopedic shoes must be provided by a shoe vendor enrolled as a DME provider.

The date of service for a custom-made or custom-fitted orthosis is the date the supplier places an order for the equipment and incurs liability for the equipment. The custom-made or custom-fitted orthosis will be eligible for reimbursement as long as the service is provided during a month the client is eligible for Medicaid.

The following items and services are included in the reimbursement for an orthotic device and not reimbursed separately:

•Client evaluation, measurement, casting, or fitting of the orthosis.

•Repairs due to normal wear and tear during the 90 days following delivery.

•Adjustments or modifications of the orthotic device made when fitting the orthosis and for 90 days from the date of delivery (adjustments and modifications during the first 90 days are considered part of the purchase of the initial device).

Orthopedic shoes that are attached to a brace must be billed by the vendor that bills for the brace.

Reimbursement for lifts and wedges may include the cost of the prescription shoe.