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MassHealth Guidelines for Medical Necessity Determination for Organ Transplant Procedures

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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Guidelines for Medical Necessity Determination for Organ Transplant Procedures

These Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information MassHealth needs to determine medical necessity for the transplant procedures identified in Section I of these Guidelines. 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 433.000 and 450.000 and Subchapter 6 of the Physician Manual for information about coverage, limitations, service conditions, and other priorauthorization 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.

If MassHealth approves the request, payment is still subject to all general conditions of MassHealth, including member eligibility, other insurance, and program restrictions. Site-of-service providers must be enrolled in MassHealth pursuant to 130 CMR 433.403 and 450.212, and the institution must be enrolled in MassHealth pursuant to 130 CMR 415.404 and 450.212.

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