These guidelines for medical necessity determination (guidelines) identify the clinical information that MassHealth needs to determine medical necessity for screening for maternal Fragile X carrier status.
Fragile X syndrome is transmitted as an X-linked disorder. However, the molecular genetics of the syndrome are complex. 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 401.000: Independent Clinical Laboratory Services, 130 CMR 433.000: Physician Services, and 130 CMR 450.000: Administrative and Billing Regulations; Subchapter 6 of the Independent Clinical Laboratory Manual; and Subchapter 6 of the Physician 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, respectively, for covered services.
MassHealth requires PA for Fragile X carrier screening. 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.