Medicaid coverage determinations are made when all criteria of medical necessity are met. Florida Medicaid must determine if a diagnostic test, therapeutic procedure, or medical device or technology is experimental or investigational, as one of the components of the medical necessity criteria.
The guidelines that Florida Medicaid will use when determining the circumstances under which a health service is consistent with generally accepted professional medical standards (GAPMS) and not experimental or investigational are described in 59G-1.035 F.A.C., “Determining Generally Accepted Professional Medical Standards.” This rule also includes the types of information to be considered in the decision making process and names the person(s) qualified to make the final determination.
In order for the agency to review a health service for coverage under the Florida Medicaid program, please submit a written request to:
Bureau of Medicaid Policy
c/o GAPMS Request
2727 Mahan Drive, MS #20,
Tallahassee, Florida 32308
Or email to:
The request must include the name, a brief description, and any additional information that supports coverage of the health service, including sources of reliable evidence as defined in the Agency for Health Care Administration’s Definitions Policy (August 2017).