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 Breast Reconstruction
Table of Contents
Guidelines for Medical Necessity Determination for Breast Reconstruction
These Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information that MassHealth needs to determine medical necessity for breast reconstruction and breast implant removal surgeries. These Guidelines are based on generally accepted standards of practice, review of the medical literature, and federal and/or state policies and laws applicable to Medicaid programs. Other breast surgeries are covered in other MassHealth Guidelines.
Providers should consult MassHealth regulations at 130 CMR 415.000: Acute Inpatient Hospital Services, 130 CMR 433.000: Physician Services, 130 CMR 410.000: Outpatient Hospital Services, 130 CMR 450.000: Administrative and Billing Regulations, Subchapter 6 of the Physician Manual, and Subchapter 6 of the Acute Outpatient Hospital Manual for information about coverage, limitations, service conditions, and other prior-authorization (PA) requirements.
Providers serving members enrolled in a MassHealth-contracted accountable care partnership plan (ACPP), managed care organization (MCO), One Care Organization, Senior Care Organization (SCO), or Program of All-inclusive Care for the Elderly (PACE) should refer to the ACPP’s, MCO’s, One Care Organization’s, SCO’s, or PACE’s medical policies for covered services.
MassHealth requires PA for breast reconstruction and breast implant removal. MassHealth reviews requests for PA on the basis of medical necessity. If MassHealth approves the request, payment is still subject to all general conditions of MassHealth, including member eligibility, other insurance, and program restrictions.