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Update for All Clinical Laboratory and Ordering or Prescribing Providers

May 31, 2022

Medical Necessity Guidelines for CPT code 81420 with Prior Authorization (PA) requirement: https://www.mass.gov/doc/guidelines-for-maternal-cell-free-fetal-dna-testing/download

To avoid delays in obtaining PA for CPT code 81420, physicians and all other authorized prescribers have a responsibility to ensure that the member is an eligible candidate and meets the criteria and risk factors associated with medically necessary coverage of this laboratory service.

Ordering providers must supply the appropriate diagnosis and all supporting documentation to the clinical laboratory receiving referrals for this scope of testing. 

Please note the following common PA denial/cancellation reasons:

  • Laboratory entering incorrect diagnosis code on the request
  • Lack of documentation to support risk factors
  • Member not meeting coverage criteria listed on P3 of Medical Necessity guidelines

If you have questions, please contact the MassHealth Customer Service Center at providersupport@mahealth.net or (800) 841-2900.