Internal Coverage Criteria
iCare Health Solutions’ (iCare) utilization management (UM) program is fully accredited by the National Committee for Quality Assurance (NCQA). The purpose of the program is to ensure the services to be provided to members are medically necessary and cost effective, in accordance with evidence-based criteria or guidelines, and that determinations are made consistently, fairly, and timely.
The iCare UM program scope varies by health plan. Prior authorization lists by health plan are available to providers through iCare’s secure web portal, eHealthDeck.
All determinations are made within regulatory timeframes and notifications are sent using CMS and health plan-approved letters within the required timeframes. Denial determinations are only made by board-certified ophthalmologists who take into consideration the member’s specific medical information and personal circumstances in addition to the criteria and/or guidelines previously mentioned. Rendering providers are given an opportunity to have a true peer-to-peer discussion with a board-certified ophthalmologist prior to a final decision being made.
iCare UM reviewers use criteria from one or more of the following when determining the medical appropriateness of eye care services: Medicare national coverage determinations (NCD), Medicare local coverage articles (LCA) and/or Medicare local coverage determinations (LCD) when the NCD is not available or the NCD is lacking the detail necessary to make a determination of medical necessity, the most current version of the American Academy of Ophthalmology’s Preferred Practice Patterns, the American Optometric Association Practice Guidelines, health plan-specific criteria, and criteria developed by iCare in collaboration with board certified sub-specialists (iCare Criteria) in keeping with applicable state and/or federal regulations. iCare Criteria are available on eHealthDeck or by using the links below:
Botox iCare Criteria #646.00
Cataract iCare Criteria #669.00
Cataract iCare Criteria #669.10
Corneal Graft w/ Amniotic Membrane iCare Criteria #654.00
Eyelid Surgery iCare Criteria #679.00
Punctal Plug iCare Criteria #687.00
Special Anterior Segment Photography with Specular Endothelial Microscopy and Cell Count iCare Criteria #922.20
Strabismus iCare Criteria #673.00
VEP-ERG iCare Criteria #922.10
YAG Laser iCare Criteria #668.00
iCare UM Program Disclaimers:
- Review criteria are not medical advice and are not intended to influence or alter a physician’s independent professional judgement in the care of members.
- iCare cannot modify, revise, or update the NCDs, LCAs, LCDs, or health plan criteria.
- When required, failure to obtain prior authorization in advance of services being rendered may result in payment being denied. Providers may not retrospectively bill patients for services in these instances.
