Calendar Year 2025 Prior Authorization Metrics

For a list of all items and services that require a Prior Authorization, please review Subchapter 6 of the MassHealth provider manuals. A comprehensive list of Subchapter 6 of each provider manual can be found on MassHealth Service Codes and Descriptions.

Please note the following for Calendar Year 2025 (CY25) PA metrics: 

1. PA request metrics represent aggregated Fee-For-Service PA request data from CY25. 
2. PA requests that were cancelled or voided are not included in the data. 
3. “PA requests that were approved” metrics include PA requests for which MassHealth determined that the requested service was medically necessary and does not include the PA requests described in item IV below.  
4. “PA requests that were approved after appeal” metrics include PA requests for which the result of the appeal of a PA request denial was that the requested service was determined to be medically necessary. 
5. “PA requests that were denied” metrics include PA requests denied due to lack of medical necessity and/or administrative reasons (e.g., member’s coverage does not include the requested service). 
6. As the Final Rule was not effective in CY25, the CY25 “Expedited” metrics reflect CY25 PAs that were identified as expedited in MassHealth systems in CY25.