Massachusetts Executive Office Of Health And Human Services Coverage Criteria
- Massachusetts Executive Office Of Health And Human Services prior authorization
- All Massachusetts Executive Office Of Health And Human Services policy updates
Latest Massachusetts Executive Office Of Health And Human Services coverage criteria updates12
- Coverage CriteriaClinical/Medical PolicyEff. 2025-06-25Guidelines for Medical Necessity Determination for Genetic Testing for BRCA-related Breast and/or Ovarian CancerThis policy establishes MassHealth medical-necessity criteria, prior-authorization requirements, documentation requirements, and covered testing codes for germline BRCA1, BRCA2, and PALB2 testing for hereditary breast, ovarian, pancreatic, and prostate cancer risk.All Massachusetts Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-06-18Guidelines for Medical Necessity Determination for Gender-Affirming SurgeryClinical criteria and documentation MassHealth uses to determine medical necessity for covered masculinizing, feminizing, and facial gender-affirming surgery through prior authorization.All Massachusetts Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-02-07Guidelines for Medical Necessity Determination for Skin SubstitutesThis guideline explains the clinical information MassHealth uses to determine medical necessity for specified skin-substitute products for adults with diabetic foot ulcers and venous leg ulcers. It identifies products that do and do not require prior authorization, coverage criteria, non-coverage circumstances, documentation requirements, and submission procedures.All Massachusetts Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-02-07Guidelines for Medical Necessity Determination for Skin SubstitutesThis guideline governs MassHealth medical-necessity review and prior authorization requirements for skin-substitute grafts used primarily for adult diabetic foot ulcers and venous leg ulcers. It applies to MassHealth providers and members, with payment also subject to eligibility, other-insurance, program, and managed-care plan requirements.All Massachusetts Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-12-06Guidelines for Medical Necessity Determination for Standers and Power-Assisted (Dynamic) Standing Components for WheelchairsIdentifies the clinical information MassHealth needs to determine medical necessity and prior authorization requirements for static standers, tilt tables, and power-assisted standing components for wheelchairs.All Massachusetts Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-12-06Guidelines for Medical Necessity Determination: Standers and Power-Assisted (Dynamic) Standing Components for WheelchairsThese Guidelines describe the clinical information MassHealth requires to determine medical necessity for static standers, tilt tables, and power-assisted dynamic standing components for wheelchairs. They apply to MassHealth DME providers requesting prior authorization and address clinical criteria, noncoverage circumstances, and supporting documentation.All Massachusetts Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-07-01Guidelines for Medical Necessity Determination for Hospital BedsThese Guidelines identify the clinical information MassHealth uses to determine medical necessity for hospital beds and specialized pediatric beds used in the home. They apply to providers requesting coverage for MassHealth members and require prior authorization for all hospital beds.All Massachusetts Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-07-01Guidelines for Medical Necessity Determination for Hospital BedsGuidelines for providers requesting MassHealth authorization for hospital beds and specialized pediatric beds used in the home.All Massachusetts Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-06-01Guidelines for Medical Necessity Determination for Knee ArthroplastyThis guideline describes the clinical criteria and documentation MassHealth uses to determine medical necessity for total, unicompartmental/partial, and revision knee arthroplasty. It applies to providers requesting prior authorization for MassHealth members; approval remains subject to eligibility, other insurance, and program requirements.All Massachusetts Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-06-01Guidelines for Medical Necessity Determination for Knee ArthroscopyThese guidelines identify the clinical information MassHealth requires to determine medical necessity for knee arthroscopy without arthroplasty, including diagnostic arthroscopy and specified knee repairs, reconstructions, and related procedures. Prior authorization is required, and requests are reviewed case by case.All Massachusetts Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyEff. 2005-07-01Guidelines for Medical Necessity Determination for Speech and Language TherapyThis policy explains the clinical information MassHealth uses to determine medical necessity for speech-language therapy delivered in outpatient and home settings, including coverage criteria, noncoverage circumstances, prior authorization, and required documentation.All Massachusetts Executive Office of Health and Human Services updates
- Coverage CriteriaClinical/Medical PolicyGuidelines for Medical Necessity Determination for Gender-Affirming SurgeryThis guideline explains the clinical criteria and documentation MassHealth uses to determine medical necessity for gender-affirming surgery, including masculinizing, feminizing, and facial procedures. It applies to MassHealth members and providers submitting prior authorization requests; approval remains subject to member eligibility, other insurance, and program restrictions.All Massachusetts Executive Office of Health and Human Services updates
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Tool Description
Search Massachusetts Executive Office Of Health And Human Services coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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