Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.28 - List of Medical Services and Equipment Requiring Prior Authorization, Preprocedure Review or Preadmission Review

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Services, procedures, and medications
				prescribed by a physician, physician assistant, or advanced registered nurse
				practitioner which are subject to prior authorization or preprocedure review
				are as follows or as specified in the preferred drug list published by the
				department pursuant to Iowa Code section
				249A.20A:
a. Drugs require prior authorization as
				specified in the preferred drug list published by the department pursuant to
				Iowa Code section
				249A.20A.
				For drugs requiring prior authorization, reimbursement will be made for a
				72-hour supply dispensed in an emergency when a prior authorization request
				cannot be submitted.
b. Automated
				medication dispenser. Payment shall be approved pursuant to the criteria at
				78.10(5) "J."
c. Enteral products
				and enteral delivery pumps and supplies. Payment shall be approved pursuant to
				the criteria at 78.10(5)"/. "
d.
				Rescinded IAB 5/11/05, effective 5/1/05.
e. Speech generating device. Payment shall be
				approved pursuant to the criteria at 78.10(5)
"f. "
f. Preprocedure review by the IME medical
				services unit will be required if payment under Medicaid is to be made for
				certain frequently performed surgical procedures which have a wide variation in
				the relative frequency the procedures are performed. Preprocedure surgical
				review applies to surgeries performed in hospitals (outpatient and inpatient)
				and ambulatory surgical centers. Approval by the IME medical services unit will
				be granted only if the procedures are determined to be medically necessary
				based on the condition of the patient and on the criteria established by the
				department and the IME medical services unit. If not so approved by the IME
				medical services unit, payment will not be made under the program to the
				physician or to the facility in which the surgery is performed. The criteria
				are available from the IME medical services unit.
g. Enclosed beds. Payment shall be approved
				pursuant to the criteria at 78.10(5)
"a."
h. Prior authorization is required for
				external insulin infusion pumps and is granted according to Medicare coverage
				criteria. (Cross reference 78.10(2)
"c"
)
i. Oral nutritional products. Payment shall
				be approved pursuant to the criteria at 78.10(5)
"m."
j. Vest airway clearance system. Payment
				shall be approved pursuant to the criteria at 78.10(5)
"c."
k. Diabetic equipment and
				supplies. Payment will be approved pursuant to the criteria at
				78.10(5)
"e."
I.
				Reimbursement over the established Medicaid fee schedule amount. Payment shall
				be approved pursuant to the criteria at 78.10(5)
"w."
m. Bathtub/shower chair, bench.
				Payment shall be approved pursuant to the criteria at
				78.10(5)
"g."
n.
				Patient lift, nonstandard. Payment shall be approved pursuant to the criteria
				at 78.10(5)
"h."
o.
				Power wheelchair attendant control. Payment shall be approved pursuant to the
				criteria at 78.10(5)"/."
p. Shower
				commode chair. Payment shall be approved pursuant to the criteria at
				78.10(5)
"j."
q.
				Ventilator, secondary. Payment shall be approved pursuant to the Medicare
				coverage criteria.
r. Customized
				wheelchairs, subject to the requirements of 78.10(2)
"d. "