Prior Authorization

Prior Authorization

HOW TO FILE A PRIOR AUTHORIZATION REQUEST WITH ICARE:
FAX: 414-231-1026
-OR-
CONTACT THE PA DEPARTMENT CALL CENTER AT:
414-299-5539/855-839-1032 (TOLL FREE)
To submit a complaint to CMS click here

In an increasingly complex health care environment, iCare is committed to offering solutions that help health care professionals save time and serve their patients. The prior authorization process is in place to assure iCare members receive the appropriate level of care and to mitigate potential fraud, waste, and abuse.

Services and Procedures Requiring Prior Authorization/Utilization Management Review

Prior authorization is required for:

  • Admission to a subacute facility (Skilled Nursing Facility, Long Term Acute Care Hospital, Inpatient Rehabilitation Facility)
  • Home health care services
  • Hospice
  • Select durable medical equipment
  • Select procedures
  • Outpatient physical, occupational, and speech therapy & cardiac and pulmonary rehabilitation
  • Transplants
  • Referrals for second or third opinions, and out of state providers
  • For Non-Medicaid certified Providers –All Services other than Emergency Services
  • All Category III procedure codes
  • Long term care services covered under iCare’s Family Care Partnership Program also require a service authorization request from the Interdisciplinary Team.
    • Please refer to the Family Care Partnership link under Provider Resources at www.icarehealthplan.org for more information.

Please note that supporting clinical documentation is required for all prior authorization requests in order to determine medical necessity. Incomplete prior authorization requests may delay processing. iCare will not retro authorize services rendered prior to the determination of a prior authorization.

For information about Pharmacy Part D prior authorizations, coverage determinations or formulary exceptions, visit the Drug Coverage Information page.

For detailed procedure code specific information regarding services, procedures and devices that require prior authorization, please reference the Prior Authorization Procedure Specific Listing. Please note that this list is updated on a quarterly basis. Please check the date on the form to ensure you are referencing the most up to date version.

  • Inpatient Notification

    Notification of all inpatient admissions (medical and behavioral) must be faxed to iCare (414-231-1075), using the Inpatient Notification Request Form, within one (1) business day of admission. This allows iCare to initiate discharge planning. Hospitals must ALWAYS notify iCare of all inpatient admissions whether they are elective or emergent.

  • Personal Emergency Response System (PERS) Prior Authorization
    Prior Authorization Requirements: Personal Emergency Response System (PERS)

    In-home Personal Emergency Response System (PERS) is provided by iCare as a supplemental Medicare benefit. PERS is indicated for personal use for members with medical conditions resulting in functional limitations or incapacitation that prevent the member from using other means of summoning assistance in an emergency.

    To request prior authorization for the Personal Emergency Response System , please submit the iiCare Personal Emergency Response System (PERS) Enrollment Form

    Practitioner Requirements to Support PERS Coverage

    The physician or treating practitioner must conduct a face-to-face examination of the beneficiary before writing an order for a PERS. This requirement may be satisfied during an inpatient hospital or subacute facility stay or by an outpatient medical visit within six months of submitting a prior authorization request.

    In instances when the member’s medical or living situation changes such that they may no longer meet the criteria for a PERS, the physician or treating practitioner must renew the prior authorization request, including conducting a face-to-face examination and writing an new order. In lieu of a separate written order, iCare accepts the physician’s signature on the PERS provider requisition form.

    Supportive documentation must be supplied, including portions of the member’s clinical history and recent inpatient hospitalization, as clinically relevant. The documentation is incomplete if it does not support the reasoning used to order the PERS. If requested, suppliers must also submit additional documentation to support medical necessity, which may include physician records, hospital records, nursing home records, home health agency records, records from other health professionals, and/or test reports.

    All PA requests and supporting documentation are received through iCare’s Prior Authorization (PA) fax mailbox (414- 231-1026).The PA staff will process the prior authorization requests according to internal iCare policy, PA-001 (Outpatient Skilled Services, Durable Medical Equipment, and Procedures).

    Member Requirements for PERS Coverage

    The member must:

    1. Have a functioning land line phone to accommodate a PERS or access to wireless cellular connectivity
    2. Live alone or be routinely alone for extended periods of time such that the member’s safety would be compromised without the use of a PERS
    3. Be able to independently use a PERS to summon help or benefit from an assistive device, as determined by the PERS provider at the time of installation;
    4. Understand how to appropriately use the PERS
    5. Be at risk of moving to a more structured residential setting, or be at significant risk for falls or other medical complications that may result in an emergency situation
    Reasons for non-coverage for a PERS:

    In some instances, iCare will deny a member the PERS enhanced benefit; specifically, when the following conditions apply:

    1. Medical necessity documentation is either not provided or is otherwise not available
    2. The PERS duplicates equipment already available to a member in case of an emergency (e.g., emergency call buttons or other electronic means of summoning help)
    3. The member has access to help on a 24-hour, 7-day basis
    4. The member or their guardian refuses this service
    5. The member’s physician (primary care or specialist) submits a medical justification for why the member is at continued risk of harm despite the PERS and recommends a more restrictive environment
    Supplier Requirements for PERS

    The supplier must obtain prior authorization approval before dispensing the PERS and related equipment.

    Claims codes (required for claims processing):

    Claims codes (required for claims processing):

    • S5160 – Installation/Testing/Activation/Education = $0
    • S5161 – (U1) Home Based Landline PERS = $24/mo.
    • S5161 – (U2) Home Based Cellular PERS = $29/mo.
    • S5161 – (U3) Home Based Fall Detection Pendant = $5/mo.
    • S5161 – (U4) Extra Home Based Pendant = $5/mo.
    • S5161 – (U6) Lockbox for Spare Key Upon Request = $0 (complimentary)
    • S5161 – (U7) Smoke Detector (24/7/265 monitored) = $10/mo.
    • S5161 – (U8) Special Adaptive Strobe for Hearing Impaired = $10/mo.
    • S5161 – (U9) Special Adaptive Switch for Physically Impaired = $10/mo.
    • S5161 – (C1) Numera Libris w/ GPS & Fall Detection = $36.95/mo.
    • S5161 – (C6) FreeUs Belle+ w/ GPS & Fall Detection = $36.95/mo.
    • S5161 – (C5) FreeUs Belle w/ WiFi Geo Location Service = $32.95/mo.
    Workflow for benefit authorization:
    1. Member need for PERS service is identified
      1. Care Management

        Care Management teams may identify a member through scheduled assessments and/or at the time of discharge from an inpatient facility and/or through iCare care review meetings (e.g., high risk staffing, chronic disease management staffing, grand rounds, RAP reviews, etc.).

        Prior authorization nursing staff may identify members whom they feel would benefit from the PERS service and will coordinate with the members’ care management staff to discuss.

      2. Members’ provider team

        Providers may recommend members receive this service based on face-to-face office visits or inpatient admissions. Providers may be aware of this benefit provided by iCare as they will have access to iCare’s provider website and those who have email addresses will have access to blast emails. iCare’s provider newsletters feature the enhanced benefits in occasional quarterly publications.

    2. Initiation of prior authorization process for member’s who would benefit from PERS:
      1. Care management staff will fax or email the PERS referral form to the member’s provider, completing all fields, if possible (Life-threatening medical conditions and allergies fields may be left blank for the member’s physician to complete, if this information is unknown at the plan level).
      2. Providers will submit a prior authorization request, including PERS referral form and all requisite clinical documentation, as well as a physician’s order, directly to iCare’s PA department.
    3. Submission of the Prior Authorization request and subsequent organization determination
      1. Following receipt of the prior authorization request, the PA RN assigned to its review will determine if all necessary documents are present and will collaborate with the providers’ offices as needed.
      2. iCare has 14 calendar days from the receipt of the PA request to the date the request is determined. If information requisite to determine the request is not provided by day 14, iCare may, at its discretion, request a date extension of 14 calendar days to provide time to collect missing data
      3. If the member does not meet medical necessity criteria, iCare will issue a benefit denial, notifying the member, the ordering provider and the vendor and providing appeal rights.
      4. If the member meets medical necessity criteria, iCare will issue the provider authorization notification to the ordering provider and the vendor and issue an approval letter to the member.

    Authorization will be given for 6 months at a time. The care team will identify members that continue to need the service and will re initiate the process.

  • Subacute Facilities Prior Authorization

    All sub-acute facility (skilled nursing facility, inpatient rehab facility, long term acute care hospital) admissions require prior authorization. All prior authorization requests and clinical documentation to support medical necessity must be faxed to iCare, using the Subacute Facilities Subacute Facilities Prior Authorization Request form, and approved prior to the member's admission to the facility. Prior authorization must be submitted at least 24 hours prior to the date of admission. iCare completes concurrent reviews on all subacute facility prior authorization requests.

  • Outpatient PT, OT, ST, And Cardiac & Pulmonary Rehabilitation Prior Authorization

    Prior Authorization is required for all outpatient therapy services including PT, OT, and SLP.

    iCare authorizes outpatient therapy by number of visits; however, the CPT codes that the provider anticipates billing MUST be listed on the prior authorization request form in order tocomplete the clinical review and determine medical necessity.

    Comprehensive information about the member helps to establish the functional potential of the member and forms the basis for determining whether the member will benefit from the requested services. Please submit the Prior Authorization Request form along with the completed therapy evaluation, plan of care, and signed physicians prescription for review to determine if the service is medically necessary.

    Outpatient therapy will be authorized based on medical necessity. Services that are medically necessary are defined under Wis. Admin. Code § DHS 101.03(96m). The provider is responsible to assure that the services provided are covered under the Medicare or Medicaid benefit, whichever applies.

    An approved PA request will be backdated to the initial date of the evaluation if the PA request is received within 14 calendar days of the initial therapy evaluation. iCare will not retro authorize any authorization requests submitted beyond the 14 calendar days of the initial evaluation.

    Continuing therapy requests may be requested when the member's need for therapy services is expected to exceed the maximum allowable treatment days authorized.

    For continuing therapy requests, prior authorization must be obtained. PA requests for ongoing therapy will not be backdated. To request additional visits, please submit the completed Prior Authorization Request form, as well as clinical documentation to support medical necessity for ongoing therapy services.

    PA requests are approved for varying periods of time based on the clinical justification submitted. The provider receives a copy of a PA decision notice when a PA request for a service is approved. Providers may then begin providing the approved service on the start date given.

    An approved request mean that the requested service, not necessarily by code, was approved. Providers are encouraged to review approved PA requests to confirm the services authorized and confirm the assigned start and end dates.

    All claims for services are subject to the coverage and medical necessity guidelines provided by Medicare and Medicaid.

    Medicare Guidelines for Outpatient Physical and Occupational Therapy Services can be found here.

    Medical Guidelines can be found here.

  • Home Health & Hospice Prior Authorization
    30 May 2017

    New Services:
    Effective July 1st, 2017 iCare will no longer require that new requests for PCW services be submitted with a copy of the PCST completed by the requesting provider. The requesting provider must fill out a PA request form leaving the following fields blank: units (with the exception of travel time) and dates of service). The initial request must also include a copy of the signed physicians order, history and physical/clinic notes from a medical doctor and MapQuest, Google Maps, etc. if travel time is being requested. Once iCare receives the request, a 3rd party assessment will be completed. The assessment will then be reviewed by a prior authorization nurse and services will be approved based on the findings of the 3rd party assessment. iCare will fax a copy of the approved authorization as well as the PCST completed by the 3rd party assessor to the requesting provider. All new PCW services will be authorize for 60 days from the date of assessment. iCare will not authorize any services rendered prior to the date of the 3rd party assessment.

    Ongoing Services:
    Ongoing services may continue to be requested in 60, 90 and 180 day increments. Ongoing services must be requested and will continue to require an updated signed physician’s order/plan of care. For ongoing services, all PA requests are required to be submitted within 7 days after the expiration date of the previous authorization. iCare will not retro authorize any services submitted after the 7th day.

    Increase in Services:
    If a provider believes a member qualifies for additional services they will still be able to make a request for an increase in services. All requests for increased services must include a signed physicians order and clinical documentation to support the increase. iCare will conduct 3rd party reassessments on a case by case basis. Short term increases will be authorized based on a member’s condition and for a maximum of 60 days.

    A blank/fillable copy of the PCST is available at www.icarehealthplan.org under the Prior Authorization section.

    • In order to ensure that iCare members are receiving the appropriate level of care, all personal care worker (PCW) prior authorization requests will not be determined until a new or updated independent assessment is completed.  iCare will not retro authorize any services rendered prior the date of the independent assessment.
    • All PA requests for home health and hospice services must include a signed physician order and plan of care as well as the initial in home evaluation for review.
    • All PA requests for home health and hospice services must be submitted to iCare within 14 calendar days from the start of care.  iCare will not retro authorize any services submitted after the 14th day.
    • For ongoing services, all PA requests are required to be submitted within 7 days after the expiration date of the previous authorization.  iCare will not retro authorize any services submitted after the 7th day.
    • All late PA requests for home health and hospice services will be reviewed for medical necessity starting from the date the request was received by iCare.
    • iCare prior authorizes home health and hospice services for the following timeframes:
      • Personal Care Worker-180 days or 26 weeks
      • Skilled Nursing-60 days or 9 weeks
      • PT/OT/SLP/MSW-60 days or 9 weeks
      • Hospice-60 days or 9 weeks
  • Solid Organ Transplant Criteria
    Independent Care Health Plan Solid Organ Transplant Criteria

    Prior authorization is granted for a period of six months. Prior to the six-month time frame of this authorization, if the member remains active on the transplant list and continues to meet UNOS criteria, please resubmit updated clinical information with new prior authorization request. If at any time during the six-month authorization time period either the member or the institution no longer meets UNOS/CMS criteria, this authorization will be denied effective on the day of loss of eligibility.

    1. Presence of advanced chronic organ disease and end-stage disease, specific to the requested organ transplant; e.g., for kidney transplant, end-stage disease typically refers to stage 4-5 CKD, although individual circumstances are considered; for liver transplants, end-stage disease is usually indicated by irreversible pathology including cirrhosis
    2. Medical indications of severity of illness, as applicable to the type of organ transplant; e.g., Glomerular filtration rate of less than 30 mL/minute for kidney transplants or serum ammonia levels for liver transplants
    3. Interest in transplant following appropriate informed consent about survival and quality of life with and without a transplant, including the responsibility of strict adherence to medication and treatment plans after transplant, as well as palliative care options
    4. Presence of comorbid conditions such as: malignancy (cancer), heart disease, peripheral vascular disease, chronic liver disease, chronic lung disease, obesity (determined by Body Mass Index), infections (chronic viral infections, bacterial colonization, etc.), and other similar chronic conditions that jeopardize the safety of patient before, during, and after transplant surgery
    5. Non-compliance with medications and treatment regimen that will directly impact the survival of the transplanted organ.
      *Patients who have clinical documentation suggesting non-compliance will require documentation from a psychology/psychiatry transplant team member that the patient is still eligible for transplant with discussion of any barriers to compliance and recommended resolutions, as applicable
    6. Active or recent history of addiction disease including, but not limited to, alcohol dependence, use of illegal drugs including heroin, cocaine, crack cocaine, Ecstasy, methamphetamine, bath salts, and amphetamines.
      *Patients presenting with active addiction disease or history of active use during the past 6 months require at least a 6-month clean period to include documentation of urine or blood drug testing results
    7. Cognitive impairment: patients who have a history of mental illness or who develop symptoms of new onset mental illness or neurologic injury will be evaluated for their ability to understand the risks involved in transplant, social supports needed to be successful after transplant, and if they have the ability to be adherent to treatment regimen given their social support system and capacity to understand their health care needs
  • Telehealth/Telemedicine Intake and Enrollment Workflow
    Telehealth/Telemedicine Intake and Enrollment Workflow

    Telehealth is a benefit provided by iCare as a supplemental benefit for members enrolled in Medicare and for members in the Medicaid lines of business for behavioral health access, as needed. Telehealth may be used by members from home using the American Well application, or by using the American Well Kiosk located at iCare.

    To request prior authorization for Telehealth, please submit the Telehealth Notification Form

    Coverage and Limitations

    Medicare members are able to utilize telehealth for urgent care, nutrition, and behavioral health services.

    The Telehealth benefit is limited to 12 appointments per member per year, regardless of service type.

    1. If a member is interested in telehealth they may contact iCare’s Customer Service Representatives or their care coordinator.
      1. Either the care coordinator or Customer Service staff may directly assist the member interested in Telehealth, referencing iCare’s Telehealth Information Sheet.
      2. iCare staff assisting members interested in participating in Telehealth may fill out the Telehealth Notification Form over the phone, including identifying the member’s email address, then emailing the completed form to the PA Department at department-priorauthorization@icare-wi.org
      3. Members without an email address may have an email address created for them with their permission. The American Well Telehealth platform requires an email address; members without an email address may not be added to the Telehealth benefit.
        1. PCC and Customer Service staff must seek permission for iCare’s PA Department to create an email to use to access the telehealth benefit from the member, otherwise iCare will not enroll the member into this benefit.
        2. CC and Customer Service staff must indicate whether or not the member gives their approval for iCare to create an email address for them on the Telehealth Notification Form.
        3. The Prior Authorization Department will be responsible for creating an email for the member only if the member has given their permission and it has been noted as such on the Telehealth Notification Form.
    2. If members wish to enroll themselves in the Telehealth benefit via the American Well application, the Telehealth Notification Form must be completed first and entered into TruCare
      1. The member will receive two letters via mail with the directions to enroll directly and with the site key and coupon code (see below). Instructions will include American Well’s 800 number for customer assistance, in the event the member has difficulty enrolling online
      2. If the member is requesting to use iCare’s Kiosk, please refer to the Telehealth Kiosk Administration Workflow
      3. At any time, the member may ask for iCare to enroll the member in the American Well application. All such requests should be sent to iCare’s Prior Authorization Department
    3. The Prior Authorization Staff will verify the member’s eligibility to ensure coverage and track utilization management
    4. The PA Staff will create an authorization in TruCare that will be valid for 12 visits within the benefit year
    5. Unless the member requests otherwise, the PA Staff will access the American Well application and enter the member’s information to enroll them into the AmWell system, including creating an email address for the member, provided there is documentation that the member has granted iCare permission to do so
    6. Once information from the Telehealth Notification Form is entered into TruCare and the member has been enrolled in the benefit, the PA staff will generate two letters, one outlining instructions for using the application, providing member-centric details such as email address used, as well as providing the current site key, password, and coupon code, the latter three disclosed in a separate letter. Both letters will be mailed to the member and a copy placed in TruCare attached to the prior authorization
    7. Using data from the Telehealth Notification Form, a letter to the member’s PCP, if listed, will be generated to confirm they are the member’s PCP and inform them of iCare’s Telehealth benefit, of their patient’s participation, and that they will receive the clinical care note from each visit, including any rendered diagnoses and treatments
    8. If a member no longer qualifies for continued Telehealth services due to exhaustion of benefit or other factors, a denial letter will be written and mailed to the member
    9. Prior Authorization will identify all members enrolled in Telehealth quarterly, notifying FCP CCs of their members’ utilization, and identify members who require a new coupon code
    10. Prior Authorization will send letters to enrolled members with instructions for using the application and the updated coupon code, quarterly
  • Transcutaneous Electrical Nerve Stimulation (TENS) Prior Authorization
    Prior Authorization: Transcutaneous Electrical Nerve Stimulation (TENS)

    Date in service: 12/31/2015

    Date reviewed: 01/12/2018

    DOCUMENTATION REQUIREMENTS

    A transcutaneous electrical nerve stimulator (TENS device) requires the following documentation in order for Independent Care Health Plan (iCare) to evaluate medical necessity:

    1. A physician’s medical order for a TENS device
      1. The physician ordering the TENS device and related supplies must be the treating physician for the disease or condition justifying the need for the TENS device
      2. For coverage of a purchase, the physician must determine that the beneficiary is likely to derive significant therapeutic benefit from continuous use of the device over a long period of time. Supportive criteria for this must be included in provided documentation
    2. Medical records documenting a face-to-face visit with the physician ordering the TENS device that includes the medical, behavioral, and social interventions used in treating the member for their disease or condition
      1. Medication lists, support services recommended/in place, psychiatry notes documenting treatment plans, etc.
      2. The documented history and physical examination and assessment must support the diagnosis and the treatment plan.
      3. The documentation should also include the causes and clinical effects of pain including an assessment of the ability of the individual to perform activities of daily living.
      4. The impact of previously attempted interventions for chronic pain should be documented.
    3. Additional clinical documentation of multidisciplinary approaches used in treating the member for their disease or condition
      1. Occupational therapy, physical therapy, pain management procedures and/or pain contracts, complementary and alternative medicine modalities used/recommended, etc
      2. Psychosocial evaluation, including information about the presence of symptoms of depression, anxiety, or anger; psychiatric disorders, personality traits or states; and coping mechanisms
    MEDICAL NECESSITY REQUIREMENTS

    A TENS device it covered for the treatment of beneficiaries meeting the following requirements:

    1. Acute post-operative pain
      TENS is covered for acute post-operative pain. Coverage is limited to 30 days (one month rental) from the date of surgery
      Members not meeting ALL of the aforementioned criteria will be denied a TENS device based on lack of medical necessity
    2. Chronic pain (other than low back pain)
      TENS devices are covered for chronic, intractable pain other than chronic low back pain when ALL of the following criteria are met:
      1. The pain must be documented to have been present for at least 3 continuous months, AND
      2. The individual must be actively participating in multimodal treatments for chronic pain, including, but not limited to: physical therapy or occupational therapy; regularly scheduled physical activity (e.g., swimming, yoga); massage therapy; acupuncture or other CAM modalities; psychological, psychiatric, and/or pharmaceutical treatments for chronic pain, AND
      3. Other appropriate pain treatments must have been tried and failed, AND
      4. The chronic condition documented must be of a type that is documented in the peer-reviewed medical literature to respond to TENS therapy
    3. Chronic low back pain (CLBP)
      TENS therapy for CLBP is only covered when ALL of the following criteria are met:
      1. The beneficiary has one of the following diagnoses listed in the diagnosis section below, AND
      2. The beneficiary is enrolled in an approved clinical study that meets all of the requirements set out in NCD §160.27 (CMS Internet Only Manual 100-3, Chapter 1).2 Refer to the APPENDICES section for additional information about approved clinical studies, AND
      3. The beneficiary has one of the following diagnoses:
        1. LUMBOSACRAL ROOT LESIONS NOT OTHERWISE CLASSIFIED
        2. SACROILIITIS NOT OTHERWISE CLASSIFIED
        3. LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY
        4. SPONDYLOSIS WITH MYELOPATHY LUMBAR REGION
        5. DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY
        6. DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC
        7. INTERVERTEBRAL DISC DISORDER WITH MYELOPATHY LUMBAR REGION
        8. POSTLAMINECTOMY SYNDROME OF LUMBAR REGION
        9. OTHER AND UNSPECIFIED DISC DISORDER OF LUMBAR REGION
        10. SPINAL STENOSIS, LUMBAR REGION, WITHOUT NEUROGENIC CLAUDICATION
        11. SPINAL STENOSIS, LUMBAR REGION, WITH NEUROGENIC CLAUDICATION
        12. LUMBAGO
        13. SCIATICA
        14. THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED
        15. ACQUIRED SPONDYLOLISTHESIS
        16. NONALLOPATHIC LESIONS OF LUMBAR REGION NOT ELSEWHERE CLASSIFIED
        17. CONGENITAL SPONDYLOLYSIS LUMBOSACRAL REGION
        18. SPONDYLOLISTHESIS CONGENITAL
        19. CLOSED FRACTURE OF LUMBAR VERTEBRA WITHOUT SPINAL CORD INJURY
        20. CLOSED FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY
        21. LUMBOSACRAL (JOINT) (LIGAMENT) SPRAIN
        22. SACROILIAC (LIGAMENT) SPRAIN
        23. LUMBAR SPRAIN
        24. INJURY TO LUMBAR NERVE ROOT

    Members not meeting ALL of the aforementioned criteria will be denied a TENS device based on lack of medical necessity.

    GENERAL REQUIREMENTS FOR CHRONIC PAIN AND CLBP

    A 4-lead TENS device may be used with either 2 leads or 4 leads, depending on the characteristics of the beneficiary's pain. If it is ordered for use with 4 leads, the medical record must document why 2 leads are insufficient to meet the beneficiary’s needs.

    SUPPLY COVERAGE REQUIREMENTS

    Separate allowance will be made for replacement supplies when they are reasonable and necessary and are used with a covered TENS. Usual maximum utilization is:

    • 2 TENS leads - a maximum of one unit of A4595 per month
    • 4 TENS leads - a maximum of two units of A4595 per month

    If the use of the TENS device is less than daily, the frequency of billing for the TENS supply code should be reduced proportionally.

    Replacement of lead wires (A4557) more often than every 12 months would rarely be reasonable and necessary.

    A conductive garment (E0731) used with a TENS device is rarely reasonable and necessary, but is covered only if ALL of the following conditions are met:

    1. a. It has been prescribed by the treating physician for use in delivering covered TENS treatment, AND
    2. a. ONE of the medical indications outlined below is met:
      The beneficiary cannot manage without the conductive garment because:
      1. There is such a large area or so many sites to be stimulated AND the stimulation would have to be delivered so frequently that it is not feasible to use conventional electrodes, adhesive tapes, and lead wires, OR
      2. The beneficiary cannot manage without the conductive garment for the treatment of chronic intractable pain because the areas or sites to be stimulated are inaccessible with the use of conventional electrodes, adhesive tapes, and lead wires, OR
      3. The beneficiary has a documented medical condition, such as skin problems, that preclude the application of conventional electrodes, adhesive tapes, and lead wires, OR
      4. The beneficiary requires electrical stimulation beneath a cast to treat chronic intractable pain.

    A conductive garment is not covered for use with a TENS device during the trial period unless:
    The beneficiary has a documented skin problem prior to the start of the trial period; AND the TENS is reasonable and necessary for the beneficiary.

    If the criteria above are not met for E0731, it will be denied as not reasonable and necessary.

    Reimbursement for supplies is contingent upon use with a covered TENS device. Claims for TENS supplies provided when there is no covered TENS device will be denied as not reasonable and necessary.

    REFILL REQUIREMENTS

    For Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. For DMEPOS products that are supplied as refills to the original order, suppliers must contact the beneficiary prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the beneficiary. This shall be done to ensure that the refilled item remains reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes or modifications to the order.

    For all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary.

    Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the ordering physicians that any changed or atypical utilization is warranted. Regardless of utilization, a supplier must not dispense more than a 3-month quantity at a time.

    CODING REQUIREMENTS
    • E0720 Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation
    • E0730 Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, multiple nerve stimulation
    • E0731 Form fitting conductive garment for the delivery of TENS (with conductive fibers separated from the patient’s skin by layers of fabric)
    AFFORDABLE CARE ACT (ACA) 6407 REQUIREMENTS

    ACA 6407 contains provisions that are applicable to certain specified items:

    • E0720 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED STIMULATION
    • E0730 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS, FOR MULTIPLE NERVE STIMULATION
    • E0731 FORM FITTING CONDUCTIVE GARMENT FOR DELIVERY OF TENS OR NMES (WITH CONDUCTIVE FIBERS SEPARATED FROM THE PATIENT'S SKIN BY LAYERS OF FABRIC)

    These items require an in-person or face-to-face interaction between the beneficiary and their treating physician prior to prescribing the item, specifically to document that the beneficiary was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered. A dispensing order is not sufficient to provide these items. A Written Order Prior to Delivery (WOPD) is required.

    REFERENCES:
    1. Practice guidelines for chronic pain management. An updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. 1997 Apr (revised 2010 Apr). NGC:007951 http://www.guideline.gov/content.aspx?id=23845&search=chronic+pain
    2. CMS National Coverage Determinations: (NCD): Transcutaneous Electrical Nerve Stimulation for Acute Post-Operative Pain, for Chronic Low Back Pain, and Transcutaneous Electrical Nerve Stimulators (10.2, 160.27, 280.13, respectively) (All Active policies).
  • Urine Drug Screen Prior Authorization
    Independent Care Health Plan Urine Drug Screen Prior Authorization Requirements

    Effective April 2016, iCare updated its prior authorization policy for Testing for Drugs of Abuse in order to be compliant with the State's Policy for covered and non-covered services, substance abuse/dependence and chronic opioid pain treatment. Medicare beneficiaries must follow Medicare coverage determination guidelines.

    All outpatient drugs of abuse testing, both presumptive and definitive, require a prior authorization request.

    The following supporting clinical documentation is required to make a determination:

    • Clinical documentation that fully supports the medical necessity for the service rendered. This documentation includes, but is not limited to relevant medical history, physical examination, risk assessment, and results of pertinent diagnostic procedures
    • A signed and dated member-specific order for each drug test. This order must provide sufficient information to substantiate each testing panel component performed. Standing orders, custom profiles, and orders to conduct additional testing as needed are insufficient and cannot be used to verify medical nece3ssity
    • Rationale for ordering a definitive drug test for each drug class tested
    • If a direct-to-definitive drug test is ordered, documentation supporting the inadequacy of presumptive drug testing

    Independent Care Health Plan will authorize testing for drugs of abuse within the following guidelines:

    Presumptive Drug Testing in Treatment for Substance Abuse or Dependence (Presumptive tests):

    • Members who have abstained for ≤ 90 consecutive days: up to 1 to 3 tests per week
    • Members who have abstained for ≥ 90 consecutive days: up to 1 to 3 tests per month

    Definitive Drug Testing in Treatment for Substance Abuse or Dependence:

    • Members who have abstained for ≤ 30 consecutive days: up to 1 test per week (determined by medical necessity and clinical practice guidelines)
    • Members who have abstained for between 30-90 consecutive days, inclusive: up to 1 to 3 tests per month (determined by medical necessity and clinical practice guidelines)
    • Members who have abstained for ≥ 91 consecutive days: up to 1 to 3 tests per 3 months (determined by medical necessity and clinical practice guidelines)

    Presumptive Drug Testing in Chronic Opioid Therapy(Providers are required to document the prescribing frequency and rationale for prescribing opioid therapy, as well as performing a standardized risk assessment. This data must be included in the prior authorization request for presumptive drug testing in chronic opioid therapy)iCare will only authorize one urine drug screen at a time when the indication is chronic opioid therapy. Prior authorization requests for multiple urine drug screens will not be accepted:

    • Members with low risk for abuse: up to 1 to 2 times per year (determined by medical necessity and clinical practice guidelines)
    • Members with moderate risk for abuse: up to 1 to 2 times per 6 months (determined by medical necessity and clinical practice guidelines)
    • Members with high risk for abuse: up to 1 to 3 times per 3 months (determined by medical necessity and clinical practice guidelines)
  • Referrals

    Referrals are required for out of area providers, and all second (or additional) opinions. To request prior authorization for a referral, please submit the Prior Authorization Request form as well as clinical documentation to support medical necessity for the requested referral.

Notification:
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Modified: 10/1/2018
 

 
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