Prior Authorization

Updates from iCare’s Prior Authorization Department

Please note: Starting 04/01/2024, the PA Department will no longer be reviewing Medicaid Authorization requests that are received more than 14 days after admission.  The PA Department will respond to the request with our Retro Authorization Administrative Denial.

 

Prior Authorization Forms

 

Outpatient PA Form   Inpatient PA Form   Subacute PA Form   Behavioral Health PA Form   

DHS Outpatient Mental Health Assessment & Treatment/Recovery Plan Form    

To review for medical necessity, please submit the following:

• Prior Authorization Request Form
• Current Clinical Notes
• Supporting Documentation
• Physician/Provider Order 

 

For further guidance, please visit the Authorization Requirements page.

These forms and other documents can be found on Prior Authorization Documents or Provider Documents.

Please reach out to the Prior Authorization Department with questions by calling 1-855-839-1032 or emailing paassistants@icarehealthplan.org.

 

Prior Authorization List (PAL)

Current PAL (pdf)     

The PDF can be searched using the F5 option.

To prevent disruption of care, iCare does not require prior authorization for basic Medicare benefits during the first 90 days of a new member's enrollment for active courses of treatment that started prior to the enrollment. iCare may review the services furnished during that active course of treatment against permissible coverage criteria when determining payment.

 

For dates of service on or after 01/01/2026, iCare will no longer require prior authorization for the following codes for Medicare or Medicaid:

 

Molecular diagnostic and genetic testing:

C9784

 

Various PAL Categories:

0275T, 0508U, 0509U, 0623T, 0624T, 0625T, 0626T, 37500.

 

For dates of service on or after 01/01/2026, iCare requires prior authorization for the following codes for Medicare:

 

Ablation/Bone, liver, kidney and prostate cancer:

52597

 

Cardiac devices/Implantable carotid sinus stimulator:

64654, 64655, 64656, 64657, 64658, 64659, 93145, 93146

 

Peripheral revascularization (atherectomy, angioplasty):

37254, 37256, 37258, 37260, 37263, 37265, 37267, 37269, 37271, 37273, 37275, 37277, 37280, 37282, 37284, 37286, 37288, 37290, 37292, 37294, 37296, 37298

 

Radiation therapy:

77436, 77437, 77438, 77439

 

For dates of service on or after 02/02/2026, iCare will no longer require prior authorization for the following codes for Medicare or Medicaid:

 

Epidural injections (Outpatient Only):

0777T

 

Injection Codes:

J1299, J1300, J1458

 

For dates of service on or after 02/02/2026, iCare requires prior authorization for the following codes for Medicare:

 

Ablation/Bone, liver, kidney and prostate cancer:

47384, 55877

 

Cardiac devices/Aorta repair:

0994T, 0995T, 33882

 

Cardiac procedures/surgeries/ Coronary angioplasty/stent:

92930, 92945, C7571

 

Decompression of peripheral nerve (i.e., carpal tunnel surgery):

64728

 

Neurostimulators:

0988T, 0989T, 1013T, 1014T, 1015T, 64567, C1607

 

Obesity surgeries:

43889

 

Prostate surgeries (prostatectomy):

55868, 55869

 

Skin and Tissue Subs:

Q4398, Q4399, Q4400, Q4401, Q4402, Q4403, Q4404, Q4405, Q4406, Q4407, Q4408, Q4409, Q4410, Q4411, Q4412, Q4413, Q4414, Q4415, Q4416, Q4417, Q4420, Q4431, Q4432, Q4433

 

Spinal fusion, decompression, kyphoplasty and vertebroplasty:

62330, 62331, 63032

For Medicaid only – iCare will no longer require prior authorization for the following codes:

DME:

K0739

Specialty Drugs:

J0725, J1299, J1300, J1458

Services and Procedures Requiring Prior Authorization/Utilization Management Review

Prior authorization is required for:

• Behavioral Health (BH)
  • BH Inpatient Hospitalization
  • Partial Hospitalization Program (PHP)
  • Intensive Outpatient Therapy (IOP)
• Admission to a subacute facility (Skilled Nursing Facility, Long Term Acute Care Hospital, Inpatient Rehabilitation Facility)
• Home health care services
• Personal Care Services
• Hospice
• Select durable medical equipment
• Select procedures
• Outpatient physical, occupational, and speech therapy & cardiac and pulmonary rehabilitation
• Transplants
• Referrals
  • For second (or addition) opinions
  • Referrals to non-participating providers outside of the member’s home state
• 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 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 submission of a prior authorization request.

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

For authorization requirements, visit the Authorization Requirements page. 

 

Should you need to file a formal complaint:    Submit a CMS complaint form online 

 

H2237_IC2203_M 
Last Updated 12/26/25