These Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information that MassHealth needs to determine medical necessity for genetic testing for hereditary breast and/ or ovarian cancer, hereinafter referred to as “BRCA-related cancer.” 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, 433.000: Physician Services, 450.000: Administrative and Billing Regulations, and Subchapter 6 of the Independent Clinical Laboratory 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 requires PA for genetic testing for BRCA-related cancer. 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.