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Massachusetts CT/CTA/MRI/MRA Prior Authorization Form

Massachusetts health plans accept a standard form for prior authorization of outpatient CT, CTA, MRI and MRA studies. Ordering clinicians meet it when a plan or its radiology benefit manager requires approval before advanced imaging. Developed by the Massachusetts Collaborative and adopted through Division of Insurance Bulletin 2016-08, it organizes clinical reasons by body region and asks for conservative treatment history, prior imaging and exam findings.

Who completes it

The ordering clinician's office completes all six sections: member, ordering provider, facility, exam request with CPT and ICD codes, body region and reasons, and documented findings. The patient completes nothing.

Submitting and payment

How to submit it
Send the form to the patient's health plan or its radiology benefit manager, attaching any additional data relevant to the plan's medical necessity criteria.

Good to know

  • Spine and extremity requests ask which conservative treatments were tried, such as NSAIDs, physical therapy, injections, chiropractic care or home exercise, and for 3 to 5 or 6 or more weeks.
  • Breast MRI screening requests list qualifying reasons, including a lifetime risk of 20% or more, a BRCA1 or BRCA2 mutation, or chest radiation between ages 10 and 30.
  • Chest and extremity sections ask for plain x-ray results, including whether one was not performed in the past 2 months.
  • Section 6 holds exam findings, prior tests with results and dates, conservative therapy duration, prior imaging and any trauma history. The posted version is April 2019 (version 1.0).

Get the official form

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

CT/CTA/MRI/MRA Prior Authorization Form

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.

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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

Does the Massachusetts CT/MRI form cover breast MRI?

Yes. Section 5 includes diagnostic and screening breast MRI. Screening requests check reasons such as a lifetime risk of 20% or greater, a BRCA1 or BRCA2 mutation, prior lobular or ductal carcinoma in situ, certain genetic syndromes, or chest radiation between ages 10 and 30.

Do Massachusetts plans have to accept the standard CT/MRI form?

Carriers must accept the standard imaging forms under Division of Insurance Bulletin 2016-08, which implements M.G.L. c.176O s.25(c). The form, developed by the Massachusetts Collaborative, tells providers to check the plan's coverage policies and medical necessity guidelines while completing it.