Section 405 IAC 5-19-7 - Prior authorization criteriaAuthority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 7.
Prior authorization requests for DME shall be reviewed on a case-by-case basis by the office, using all of the following criteria:
(1) The item must be medically necessary for the treatment of an illness or injury or to improve the functioning of a body member.(2) The item must be adequate for the medical need; however, items with unnecessary convenience or luxury features will not be authorized.(3) The anticipated period of need, plus the cost of the item will be considered in determining whether the item shall be rented or purchased. This decision shall be made by the office based on the least expensive option available to meet the member's needs.(4) Documentation of a face-to-face encounter for home health services in accordance with 42 CFR 440.70(f) is required for specified items in accordance with section 2.5 of this rule.(5) Rehabilitation potential is not required for prior authorization requests for specialized wheelchairs if the member is a resident of a nursing facility designated by the office as a children's nursing facility as defined at 405 IAC 1-14.6-2(k).Office ofthe Secretary of Family and Social Services; 405 IAC 5-19-7; filed Jul 25, 1997, 4:00p.m.: 20 IR 3330; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Oct 3, 2001, 9:47 a.m.: 25 IR 379; readopted filed Sep 19, 2007, 12:16p.m.: 20071010- IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFAFiled 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRAErrata filed 11/1/2016, 9:36 a.m.: 20161109-IR-405160493ACAFiled Jul 23, 2018, 3:32 p.m.: 20180822-IR- 405180125FRAReadopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA