This edition of Guidelines for Medical Necessity Determination (Guidelines) identifies the clinical information MassHealth needs to determine medical necessity for cranial orthoses. Cranial orthoses are used in the treatment of postsurgical cranial molding, brachycephaly, and positional nonsynostotic plagiocephaly. 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.
These guidelines apply to comprehensive services for the preparation, fitting, and subsequent adjustment of cranial orthoses. Providers should consult MassHealth regulations at 130 CMR 442.000 (orthotics services) and 130 CMR 450.000 (administrative and billing regulations), The Orthotics and Prosthetic Payment and Coverage Guidelines Tool, and Subchapter 6 of the Orthotics 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 a 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 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.