Updates to Prior Authorization Codes
Date: 03/31/25
Effective July 1, 2025, Iowa Total Care will apply changes to prior authorization requirements. These changes are applicable to Medicaid products.
Iowa Total Care is committed to optimizing member health statuses while delivering cost-effective, quality care to our members. Iowa Total Care decision-making is based on appropriateness of care, service and the existence of coverage. Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in-network utilization, where applicable.
It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. Non-par providers and facilities require authorization for all HMO services except where indicated.
For a complete CPT®/HCPCS code listing, please visit our Prior Authorization Check Tool.
For additional information regarding codes impacted by this change, please refer to the Prior Authorization Code List listed below.
Prior Authorization Code List
| Services | Procedure Code |
|---|---|
| Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed. | 31276 |
| Open implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator. | 64568 |
| Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); frontal and sphenoid sinus ostia. | 31298 |
| Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); maxillary sinus ostium, transnasal or via canine fossa. | 31295 |
| Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); frontal sinus ostium. | 31296 |
Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500-99602 can be used). | S9123 |
| Services | Procedure Code |
|---|---|
| Intravenous infusion, hydration; each additional hour (list separately in addition to code for primary procedure). | 96361 |
| Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. | 99243 |
| Set-up portable x-ray equipment. | Q0092 |
| Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic. | 96402 |
| Telephone evaluation and management (E/M) service by a physician or other qualified healthcare professional who may report E/M services provided to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment: 5-10 minutes of medical discussion. | 99441 |
| Telephone E/M service by a physician or other qualified healthcare professional who may report E/M services provided to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment: 11-20 minutes of medical discussion. | 99442 |
| Irrigation of implanted venous access device for drug delivery systems. | 96523 |
| Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (list separately in addition to code for primary procedure). | 20939 |
| Standard wheelchair. | K0001 |
For questions or concerns, contact your provider engagement account manager in your area or call Provider Services at 1-833-404-1061, Monday – Friday 7:30 a.m. to 6 p.m. CT.
Thank you for your partnership in serving Iowa Total Care members.