Section 405IAC5-3-13. Services requiring prior authorization

   (a) Medicaid reimbursement is available for the following services with prior authorization:

(1) Reduction mammoplasties.

(2) Rhinoplasty or bridge repair of the nose when related to a significant obstructive breathing problem.

(3) Intersex surgery.

(4) Blepharoplasties for a significant obstructive vision problem.

(5) Sliding mandibular osteotomies for prognathism or micrognathism.

(6) Reconstructive or plastic surgery.

(7) Bone marrow or stem cell transplants.

(8) All organ transplants covered by Medicaid.

(9) Home health services.

(10) Maxillofacial surgeries related to diseases and conditions of the jaws and contiguous structures.

(11) Temporomandibular joint surgery.

(12) Submucous resection of nasal septum and septoplasty when associated with significant obstruction.

(13) Weight reduction surgery, including gastroplasty and related gastrointestinal surgery.

(14) Any procedure ordinarily rendered on an outpatient basis, when rendered on an inpatient basis.

(15) All dental admissions.

(16) Brand medically necessary drugs.

(17) Psychiatric inpatient admissions, including admissions for substance abuse.

(18) Rehabilitation inpatient admissions.

(19) Orthodontic procedures for members under twenty-one (21) years of age for cases of craniofacial deformity or cleft palate.

(20) Genetic testing for detection of cancer of the breast or breasts or ovaries.

(21) Medicaid rehabilitation option services, except for crisis intervention.

(22) Partial hospitalization, as provided under 405 IAC 5-20-8.

(23) Neuropsychological and psychological testing.

(24) As otherwise specified in this article.

  (b) If any of the surgeries listed in this section are performed during a hospital stay for another condition, prior authorization is required for the surgical procedure.

  (c) Requests for prior authorization for the surgical procedures in this section will be reviewed to determine if said procedure is medically necessary on a case-by-case basis in accordance with this rule. (Office of the Secretary of Family and Social Services; 405 IAC 5-3-13; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3306; filed Sep 1, 2000, 2:16 p.m.: 24 IR 14; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Jan 7, 2002, 10:11 a.m.: 25 IR 1613; filed Feb 26, 2004, 3:45 p.m.: 27 IR 2244; filed Feb 14, 2005, 10:25 a.m.: 28 IR 2132; filed Feb 3, 2006, 2:00 p.m.: 29 IR 1903; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; filed Aug 18, 2009, 11:32 a.m.: 20090916-IR-405080192FRA; filed May 27, 2010, 9:15 a.m.: 20100623-IR-405100045FRA; filed Jul 19, 2010, 11:24 a.m.: 20100818-IR-405090087FRA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA; filed Aug 1, 2016, 3:44 p.m.: 20160831-IR-405150418FRA; errata filed Nov 1, 2016, 9:36 a.m.: 20161109-IR-405160493ACA)