Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street
Boston, MA  02111
www.mass.gov/masshealth	
	MassHealth
	Acute Inpatient Hospital Bulletin 130 
	August 2005

TO:	Acute Inpatient Hospitals Participating in MassHealth 

	FROM:	Beth Waldman, Medicaid Director

	RE:	Guideline for Medical Necessity Determination for Breast Reduction

Background	In December 2004, MassHealth issued All Provider Bulletin 142, informing you that MassHealth would be posting on its Web site a targeted series of Guidelines for Medical Necessity Determination (Guidelines) and their associated forms for certain medical products and services.  MassHealth has since posted several Guidelines on its Web site, including a Guideline for Medical Necessity Determination for Breast Reduction (Breast Reduction Guideline).  This bulletin provides additional guidance about the implementation of the Breast Reduction Guideline.  

Breast Reduction	The Breast Reduction Guideline identifies the clinical information 
Guideline 	MassHealth needs to determine medical necessity for breast reduction and is based on generally accepted standards of practice, review of the medical literature, and federal and /or state policies and laws applicable to Medicaid programs.  

	Breast reduction continues to require prior authorization.  Subject to all applicable requirements, prior authorization will be granted if the clinical information provided to MassHealth supports a determination that breast reduction is medically necessary in accordance with 130 CMR 450.204.   

	To support such a determination, a provider must, among other things, certify and document that he or she reasonably has considered all potential causes of the member’s symptoms, including comorbid conditions and, taking such causes and conditions into account, has evaluated the relative risks and benefits of surgery compared to alternative courses of treatment.  

	MassHealth will base its decision on all clinical information presented, and will not presume that a member has failed to demonstrate medical necessity based solely on his or her height and weight or body mass index.  Information about a member’s height and weight or body mass index is no longer required to be provided in the prior-authorization request.  

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Requesting Prior 	The requesting surgeon must submit the request for prior authorization 
Authorization for Breast 	and include the following:
Reduction Surgery
1.	Comprehensive medical history, including: 
•	primary diagnosis name and ICD-9-CM code(s) pertinent to clinical symptoms;
•	secondary diagnosis name(s) and ICD-9-CM code(s) pertinent 
to comorbid condition(s);
•	the most recent medical evaluation, including:
o	a summary of the medical history and last physical exam;
o	the member’s age at the onset of the condition;
o	the duration of the condition;
o	the date the member was diagnosed with the condition;
o	the member’s current age;
o	comorbid condition(s); and 
o	all previous surgeries and hospitalizations;
•	prior treatments that have been tried and have not been effective in managing medical symptoms;
•	results from diagnostic or laboratory tests pertinent to the diagnosis taken within the last six months, if any; 
•	photo documentation (front and lateral shoulder to waist) taken within the last six months; and
•	evidence of consideration and rule-out of comorbid etiologies of the symptoms.

2.	The surgical treatment plan that outlines the amount of tissue to be removed from each breast and the prognosis for improvement of clinical signs/symptoms pertinent to the diagnosis.  

Providers may submit requests for prior authorization for eligible members at any time.  If the facts or circumstances have changed from the time a request has been denied, providers may submit a new request for prior authorization, which will be individually evaluated on the basis of medical necessity.  Previous denials will not be considered in evaluating the prior-authorization request.  

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Accessing Guidelines	The Guidelines are posted on the MassHealth Web site at: 
and Regulations	 www.mass.gov/masshealth/guidelines. 

MassHealth regulations, including 130 CMR 450.204, can be accessed from the MassHealth Web site at:  www.mass.gov/masshealthpubs.

Prior-authorization forms can be found on the APAS Web site at: 
www.masshealth-apas.com.  To obtain paper copies and associated forms, send a written request to the following address or fax number:

	MassHealth Forms Distribution
	P.O. Box 9118
	Hingham, MA 02043
	Fax: 617-988-8973

When requesting forms, providers must include their provider number, street address (no post-office boxes), a contact name, the exact name of the form, and the quantity desired.  

E-mail Alerts	MassHealth may update the Breast Reduction Guideline and other Guidelines from time to time.  Providers should check the Web site frequently, or sign up for e-mail alerts to receive notice of updates to the Guidelines and the availability of related forms.  To sign up for e-mail alerts, go to the Guidelines for Medical Necessity Determination Web page and click on the link for e-mail alerts. 

Questions	If you have questions about the Guidelines, contact MassHealth Customer Service at 1‑800‑841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974.  
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