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: National coverage determinations (NCD), Local coverage articles (LCA) and/or 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:
iCare Criteria #668.00 - YAG Capsulotomy
iCare Criteria #922.20 - Special Anterior Segment Photography with Specular Endothelial Microscopy and Endothelial Cell Count
iCare Criteria #922.10 - VEP-ERG
iCare Criteria #687.00 - Punctal Plug
iCare Criteria #679.00 - Upper Eyelid and Brow Surgical Procedures: Blepharoplasty, Blepharoptosis, and Repair of Brow Ptosis
iCare Criteria 673.00 - Strabismus
iCare Criteria #669.20 - MIGS (Microinvasive Glaucoma Surgery)
iCare Criteria #669.10 - Cataract Extraction with IOL Implant and Endoscopic Cyclophotocoagulation
iCare Criteria #669.00 - Cataract Extraction
iCare Criteria #654.00 - Amniotic Membrane Placement
iCare Criteria #646.00 - Botulinum Toxins
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.
