This edition of Guidelines for Medical Necessity Determination (Guidelines) identifies the clinical information that MassHealth needs to determine medical necessity for capsule endoscopy. 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 433.000: Physician Services and 130 CMR 450.000: Administrative and Billing Regulations, and Subchapter 6 of the Physician Manual, for information about coverage, limitations, service conditions, and 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 Options (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, respectively, for covered services.
MassHealth requires PA for capsule endoscopy and reviews PA requests 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.