These Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information MassHealth needs to determine medical necessity for skin substitutes. 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), and 450.000 (administrative and billing regulations); Subchapter 6 of the Physician Manual; and Subchapter 6 of the Acute Outpatient Hospital Manual for information about coverage, limitations, service conditions, and other prior-authorization 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 for covered services.