Massachusetts Executive Office Of Health And Human Services Prior Authorization Lookup
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- All Massachusetts Executive Office Of Health And Human Services policy updates
Latest Massachusetts Executive Office Of Health And Human Services prior authorization updates25
- Prior AuthClinical/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
- Prior AuthClinical/Medical PolicyEff. 2025-06-25Guidelines for Medical Necessity Determination for Genetic Testing for BRCA-related Breast and/or Ovarian CancerThis policy governs MassHealth medical-necessity review and prior authorization for germline BRCA1, BRCA2, and PALB2 testing for hereditary breast, ovarian, pancreatic, and prostate cancer risk. It applies to MassHealth members and providers, with coverage determined case by case and generally limited to one test episode per lifetime.All Massachusetts Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyEff. 2025-02-10Guidelines for Medical Necessity Determination for Orthognathic SurgeryThis guideline describes the clinical information MassHealth uses to determine medical necessity and prior authorization for orthognathic surgery. It applies to MassHealth members and providers requesting surgery for functional skeletal, airway, temporomandibular joint, speech, or related craniofacial conditions; cosmetic surgery is not covered.All Massachusetts Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyEff. 2025-01-17Guidelines for Medical Necessity Determination for Rhinoplasty and SeptoplastyThis MassHealth guideline governs prior authorization and medical-necessity review for reconstructive rhinoplasty, septoplasty, and related procedures. It applies to MassHealth members and instructs enrolled surgeons on covered indications and required clinical documentation.All Massachusetts Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyEff. 2025-01-17Guidelines for Medical Necessity Determination for the Treatment of Erectile DysfunctionDefines medical-necessity criteria, clinical documentation, and prior-authorization requirements for erectile dysfunction treatment, including external devices, penile prostheses, and penile revascularization for MassHealth fee-for-service members.All Massachusetts Executive Office of Health and Human Services updates
- Prior AuthClinical/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
- Prior AuthClinical/Medical PolicyEff. 2024-05-09Guidelines for Medical Necessity Determination for Hair RemovalThis policy governs MassHealth prior authorization and medical-necessity review for non-presurgical hair removal, particularly laser hair removal and electrolysis, when used to treat gender dysphoria. It also addresses case-by-case review for other diagnoses and applies to providers submitting requests for MassHealth members.All Massachusetts Executive Office of Health and Human Services updates
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthReimbursement/Payment PolicyEff. 2024-02-01Durable Medical Equipment Bulletin 36: New Rates for Durable Medical EquipmentThis bulletin governs reimbursement rates, product quality specifications, and prior authorization procedures for absorbent durable medical equipment supplied to MassHealth members and applies to participating MassHealth DME providers.All Massachusetts Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyEff. 2023-05-26Guidelines for Medical Necessity Determination for Reduction MammoplastyThis guideline explains the clinical information and medical-necessity criteria MassHealth uses to review prior-authorization requests for reduction mammoplasty, including requests for adults, adolescents ages 15 through 17, and case-by-case requests for members under age 15.All Massachusetts Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyEff. 2023-05-26Guidelines for Medical Necessity Determination for Reduction MammoplastyThis guideline identifies the clinical information MassHealth needs to determine medical necessity and prior-authorization eligibility for reduction mammoplasty in members with symptomatic breast hypertrophy, macromastia, or gigantomastia. It applies to MassHealth providers and requires case-by-case review, subject to general MassHealth eligibility, insurance, program, and service conditions.All Massachusetts Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyEff. 2022-12-12Guidelines for Medical Necessity Determination for Rhinoplasty and SeptoplastyThis policy governs MassHealth medical-necessity determinations and prior authorization for rhinoplasty, septoplasty, and extracorporeal septoplasty for MassHealth members and enrolled surgeons.All Massachusetts Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyEff. 2022-10-04Guidelines for Medical Necessity Determination for Orthognathic SurgeryThese guidelines describe the clinical information MassHealth requires to determine medical necessity and prior authorization for orthognathic surgery. They apply to providers requesting surgery for skeletal deformities, masticatory dysfunction, temporomandibular conditions, airway disorders including obstructive sleep apnea, congenital anomalies, and selected speech impairments.All Massachusetts Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyEff. 2022-07-22Guidelines for Medical Necessity Determination for High Frequency Chest Wall Oscillation Air-Pulse Generator System (Vest)This guideline governs MassHealth medical-necessity determinations and prior authorization for a high frequency chest wall oscillation air-pulse generator system used for airway-clearance therapy. It applies to MassHealth providers, including Oxygen and Respiratory Therapy Equipment providers, submitting requests for eligible members.All Massachusetts Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyEff. 2021-09-01Guidelines for Medical Necessity Determination for Hair RemovalThis policy governs MassHealth medical-necessity and prior-authorization requirements for non-presurgical hair removal, particularly laser hair removal and electrolysis, when used to treat gender dysphoria. Hair removal for other diagnoses is evaluated case by case, while cosmetic hair removal is not considered medically necessary.All Massachusetts Executive Office of Health and Human Services updates
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/Medical PolicyEff. 2018-04-24Guidelines for Medical Necessity Determination for Physical TherapyIdentifies the clinical information MassHealth needs to determine medical necessity for skilled physical therapy services provided in outpatient and home settings, including coverage and prior authorization requirements.All Massachusetts Executive Office of Health and Human Services updates
- Prior AuthClinical/Medical PolicyEff. 2016-03-15Guidelines for Medical Necessity Determination for Gene Expression Profiling Tests for Breast CancerThis policy establishes MassHealth medical-necessity and prior-authorization requirements for gene expression profiling, primarily Oncotype DX, in patients with newly diagnosed early-stage breast cancer. It specifies eligible clinical characteristics, documentation, ordering and laboratory requirements, and circumstances in which testing is not medically necessary.All Massachusetts Executive Office of Health and Human Services updates
- Prior AuthClinical/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
- Prior AuthClinical/Medical PolicyEff. 2004-12-01Guidelines for Medical Necessity Determination for Support SurfacesThese guidelines describe the clinical information MassHealth uses to determine medical necessity for support surfaces requiring prior authorization. They apply to providers requesting support surfaces for MassHealth members, with approval determined individually and subject to applicable MassHealth and managed-care requirements.All Massachusetts Executive Office of Health and Human Services updates
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Tool Description
Search Massachusetts Executive Office Of Health And Human Servicesprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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