The MassHealth Guidelines for Medical Necessity Determination (Guidelines) are used by MassHealth's reviewing clinicians to determine the medical necessity of prior-authorization requests submitted by providers.
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MassHealth Guidelines for Medical Necessity Determination for Bariatric Surgery
Table of Contents
Guidelines for Medical Necessity Determination for Bariatric Surgery
These Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information MassHealth needs to determine medical necessity for bariatric surgery. These Guidelines are based on generally accepted standards of practice, review of the medical literature, and federal and state policies and laws applicable to Medicaid programs. Providers should consult MassHealth regulations at 130 CMR 415.000 (acute inpatient hospital services), 433.000 (physician services), and 450.000 (administrative and billing regulations), and Subchapter 6 of the Physician Manual for information about coverage, limitations, service conditions, and other priorauthorization requirements.
Providers serving members enrolled in a MassHealth-contracted accountable care partnership plan (ACPP), managed care organization (MCO), integrated care organization (ICO), senior care organization (SCO), or program of all-inclusive care for the elderly (PACE) should refer to the ACPP’s, MCO’s, ICO’s, SCO’s or PACE’s medical policies for covered services.