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.
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MassHealth Guidelines for Medical Necessity Determination for Gender Affirming Surgery
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Guidelines for Medical Necessity Determination for Gender Affirming Surgery
This edition of the Guidelines for Medical Necessity Determination (Guidelines) identifies the clinical information that MassHealth needs to determine medical necessity for gender-affirming surgery (GAS). 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 415.000: Acute Inpatient Hospital Services, 433.000: Physician Services, 410.000: Outpatient Hospital Services, 450.000: Administrative and Billing Regulations 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), 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 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.