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Massachusetts Cardiac Imaging Prior Authorization Form

Myocardial perfusion imaging (MPI), stress echocardiograms, MUGA scans, transthoracic and transesophageal echocardiograms, and fetal echo share one standard prior authorization form in Massachusetts. Ordering clinicians meet it when a health plan requires approval before one of these studies. Developed by the Massachusetts Collaborative and adopted through Division of Insurance Bulletin 2016-08, it asks for codes, symptoms, risk factors and prior test results.

Who completes it

The ordering clinician's office completes all sections: member demographics, ordering provider, performing facility, the exam request with CPT and ICD codes, and the clinical reasons for the study. The patient does not complete any part.

Submitting and payment

How to submit it
Send the completed form to the patient's health plan or to the radiology benefit manager that reviews the plan's imaging. Additional data relevant to the plan's medical necessity criteria can be attached.

Good to know

  • Section 4 asks for the dates of the first and most recent office visits for the condition with any provider, so have the visit history ready.
  • For MPI or stress echo, check chest pain features, associated conditions such as atrial fibrillation or known CAD, and coronary risk factors like diabetes, smoking or family history.
  • Page 2 records previous cardiac tests with dates and results, from exercise stress tests and SPECT to cardiac catheterization and coronary CTA.
  • The posted version is April 2019 (version 1.0). Separate Massachusetts standard forms cover CT/CTA/MRI/MRA, PET/PET CT and non-OB ultrasound.

Get the official form

Download the current version from the source each time; forms change without notice.

Cardiac Imaging Prior Authorization Form to be used with Myocardial Perfusion Imaging (MPI); Stress Echocardiogram; Multiple Gated Acquisition Scan (MUGA); Transthoracic Echocardiogram (TTE); Transesophageal Echocardiogram (TEE)

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

See how Vero Documents works

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Which tests does the Massachusetts cardiac imaging PA form cover?

Section 4 lists myocardial perfusion imaging, stress echocardiogram, MUGA, transthoracic echo, transesophageal echo and fetal echo. CT, CTA, MRI, MRA, PET and non-obstetric ultrasound studies use the other Massachusetts standard imaging forms developed by the same Massachusetts Collaborative.

Do Massachusetts insurers have to accept the standard cardiac imaging form?

Carriers must accept the standard imaging forms adopted under Division of Insurance Bulletin 2016-08, which implements M.G.L. c.176O s.25(c). The form tells providers to consult the plan's coverage policies and medical necessity guidelines when completing it, and plans often route imaging reviews through a radiology benefit manager.