These Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information that MassHealth needs to determine medical necessity for a High Frequency Chest Wall Oscillation Air-Pulse Generator System (Vest). 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 427.000 and 130 CMR 450.000: Administrative and Billing Regulations, Subchapter 6 of the Oxygen and Respiratory Therapy Equipment (OXY) Manual and the online MassHealth Durable Medical Equipment and Oxygen Payment and Coverage Guideline Tool for information about coverage, limitations, service conditions, and other prior authorization (PA) requirements.
Links to the regulations, subchapter 6, the tool, and the referenced prior authorization form can be found in the appendix.
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 a 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 for covered services.
MassHealth requires PA for a High Frequency Chest Wall Oscillation Air-Pulse Generator System (Vest). MassHealth reviews requests for PA on the basis of medical necessity. Prior authorization determines only the medical necessity of the authorized item or service. Payment is still subject to all general conditions of MassHealth, including member eligibility, other insurance, and program limitations.