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.
Guide MassHealth Guidelines for Medical Necessity Determination for Diabetes Management
Table of Contents
Guidelines for Medical Necessity Determination for Diabetes Management
These Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information that MassHealth needs to determine medical necessity for Continuous Glucose Monitoring Systems (CGMS) and insulin pumps. 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 409.000 and 450.000, Subchapter 6 of the Durable Medical Equipment Manual, and the online MassHealth DME and Oxygen Payment and Coverage Guidelines Tool for information about coverage, limitations, service conditions, and other prior-authorization (PA) requirements. The links for these resources are provided in the Appendix to these guidelines.
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.
MassHealth requires PA for continuous glucose monitoring and insulin pump devices. MassHealth reviews requests for prior authorization 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.
MassHealth considers approval for coverage of the insulin pump and CGM devices on an individual, case-by-case basis, in accordance with 130 CMR 450.204. MassHealth covers both insulin pumps and CGMs under Durable Medical Equipment (DME) services. Note that members may obtain insulin pumps only from DME providers under MassHealth’s Medicaid Management Information System (MMIS). However, the CGM device and parts may be obtained from DME pharmacy providers who bill through MMIS, or pharmacy providers who bill through the Pharmacy Online Processing System (POPS).
This Guideline addresses the MMIS-based PA process administered through the Long Term Services and Supports Management System (LTMS) or Provider Online Service Center (POSC) for insulin pumps or CGM supplied by either a MassHealth-enrolled DME provider or pharmacy that uses MMIS. For pharmacies that are only using POPS, submission criteria can be found in the MassHealth Drug List, Therapeutic Class Table 78: Diabetes Medical Supplies and Emergency Treatments (non-drug formulary).