This edition of Guidelines for Medical Necessity Determination (Guidelines) identifies the clinical information that MassHealth needs to determine medical necessity for enteral nutrition and special medical formulas. 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 (130 CMR 409.000: Durable Medical Equipment Services) and (130 CMR 450.000: Administrative and Billing Regulations), Subchapter 6 of the Durable Medical Equipment Manual, and the MassHealth DME and Oxygen Payment and Coverage Guidelines Tool for information about coverage, limitations, service conditions, and other prior-authorization (PA) requirements. The links to the regulations, subchapter 6, and the tool can be found in the reference section.
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 all enteral nutrition and special medical formulas. 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.