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Prior Authorization Documents

This is the place for providers to find Prior Authorization-related forms and other documents. You can also find them on the Provider Documents page.

To locate a Medicare Advantage coverage policy referenced in a letter you received, you can type the four-digit policy number (for example WI.PA-1223) in the Keywords search box below. iCare has also prepared some FAQs for Medicare Advantage coverage policies.

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Policies and Guidelines

WI.PA-1011 - Ambulatory Cardiac Monitoring Devices

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WI.PA-1020 - Bariatric Surgery

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WI.PA-1221 - Thyroid Surgeries (Thyroidectomy_Lobectomy)

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WI.PA-1267 - Tecelra (afamitresgene autoleucel)

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WI.PA-1182 - Peripheral Artery Revascularization of the Lower Extremities

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WI.PA-1151 - Liquid Biopsy

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WI.PA-1266 - Irreversible Electroporation

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WI.PA-1139 - Interspinous Process Decompression Spacers

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WI.PA-1097 - Genetic Testing

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WI.PA-1089 - Gastric Pacing - Gastric Electrical Stimulation

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WI.PA-1032 - Foot Surgical Procedures

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WI.PA-1076 - Electrical Stimulators - Diaphragmatic Phrenic Nerve Functional and Neuromuscular

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WI.PA-1250 - Cardiac Pacemakers

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WI.PA-1034 - Cardiac Catheterization

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WI.PA-9000-Psychiatric Inpatient Hospitalization

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WI.PA-1249-Hospital Services (Long Term Care Hospitals (LTCH), Observation)

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WI.PA-1241-Measurable (Minimal) Residual Disease Testing

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WI.PA-1235-Videofluoroscopy, Dynamic MRI for Musculoskeletal Indications

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WI.PA-1234-Ventricular Assist Device, Total Artificial Heart

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WI.PA-1229-Ultraviolet Light/Laser Therapy for Skin Conditions

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WI.PA-1225-Transcatheter Peripheral Vascular Stents-Chest, Abdomen and Pelvis

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WI.PA-1201-Rheumatoid Arthritis: Biologic Markers and Pharmacologic Assessment

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WI.PA-1186-Outpatient Rehabilitation (Physical Therapy, Occupational Therapy)

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WI.PA-1180-Percutaneous Vertebroplasty, Kyphoplasty (Balloon-Assisted Vertebroplasty), Sacroplasty

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WI.PA-1174-Ocular Surface Disease Diagnosis and Treatments

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WI.PA-1173-Obstructive Sleep Apnea and Other Sleep Related Breathing Disorders Surgical Treatments

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WI.PA-1158-Molecular Diagnostic Assays and Breath Testing for Transplant Rejection

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WI.PA-1154-Lymphedema - Diagnosis and Treatments

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WI.PA-1130-Hyperthermia for Treatment of Cancer

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WI.PA-1128-Hyperbaric Oxygen Therapy, Topical Oxygen Therapy

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WI.PA-1124-Hip, Knee and Shoulder Arthroscopic Surgeries

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WI.PA-1081-Erectile Dysfunction and Peyronie's Disease Treatments

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WI.PA-1066-Deep Brain Stimulation and Cortical Stimulation

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WI.PA-1053-Cold and Heat Therapy Devices

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WI.PA-1051-Code Compendium (Wound Care)

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WI.PA-1048-Code Compendium (Musculoskeletal and Neurologic)

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WI.PA-1019-Balloon Dilation (Eustachian Tube and Sinus), Functional Endoscopic Sinus Surgery and RhinAer

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WI.PA-1017-Autologous and Allogeneic Bone Marrow Transplants/Peripheral Stem Cell Transplants/Umbilical Cord Blood Transplants

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WI.PA-1016-Autism Spectrum Disorders Diagnosis and Treatment

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WI.PA-1010-Allograft Transplantation of the Knee

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WI.PA-1062-Coronary CT Angiography Fractional Flow Reserve with CT, Calcium Scoring

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WI.PA-1001-Ablation Techniques and Extracorporeal Shock Wave Therapy for Musculoskeletal Indications and Soft Tissue Wounds

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WI.PA-1045-Implantable Cardiac Devices for Hemodynamic Management

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WI.PA-1150-Left Atrial Appendage Closure and Cardiac Structural Defect Closure for Stroke Prevention

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WI.PA-1133-Implantable Infusion Pumps for Pain or Spasticity

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WI.PA-1064-Cosmetic and Reconstructive Surgery

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WI.PA-1039-Cardioverter Defibrillators/Cardiac Resynchronization Therapy

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WI.PA-1135-Infertility Evaluation and Treatment

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WI.PA-0574-Molecular Testing for HLA- B*27 for Ankylosing Spondylitis

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WI.PA-1175-Omisirge (omidubicel-onlv)

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iCare Coverage Criteria FAQ Document

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WI.PA-1000-Inpatient Hospital Services

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WI.PA-1002-Achalasia And Gastroesophageal Reflux Disease Treatments

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WI.PA-1007-Airway Clearance Devices

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WI.PA-1013-Artificial Intervertebral Disc Replacement

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WI.PA-1014-Athletic Pubalgia Surgery

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WI.PA-1021-Benign Prostatic Hyperplasia Treatments

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WI.PA-1024-Blepharoplasty Blepharoptosis Repair and Brow Lift

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WI.PA-1026-Bone Graft Substitutes

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WI.PA-1028-Brachytherapy

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WI.PA-1029-Breast Imaging

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WI.PA-1030-Breast Reconstruction

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WI.PA-1031-Bronchial Thermoplasty

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WI.PA-1033-Capsule Endoscopy

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WI.PA-1035-Cardiac Electrophysiological Studies and Cardiac Catheter Ablation

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WI.PA-1037-Cardiac Single- Photon Emission Computed Tomography

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WI.PA-1040-Carotid Revascularization

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WI.PA-1041-Carpal Tunnel Syndrome Surgical Treatments

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WI.PA-1054-Colorectal Cancer Screening and Surveillance

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WI.PA-1056-Complementary and Alternative Medicine

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WI.PA-1057-Comprehensive Genomic Profiling and Genetic Testing for Solid Tumors

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WI.PA-1063-Percutaneous Coronary Intervention

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WI.PA-1065-Cryoablation

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WI.PA-1067-Diagnostic Esophagogastroduodenoscopy or Esophagoscopy

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WI.PA-1070-Drug Testing

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WI.PA-1072-Dynamic Spinal Stabilization Devices

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WI.PA-1073-Elective Aorta and Iliac Artery Aneurysm Repair

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WI.PA-1074-Electric Tumor Treatment Fields

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WI.PA-1078-Electrothermal Intradiscal Therapies

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WI.PA-1080-Endobronchial Valves for Emphysema

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WI.PA-1084-Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis

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WI.PA-1085-Fecal Incontinence Evaluation and Treatments

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WI.PA-1087-Fusion Imaging for Cancer Indications

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WI.PA-1088-Fusion Imaging for Noncancer Indications

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WI.PA-1091-Gender Affirmation Surgery

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WI.PA-1092-Gene Expression Profiling for Cancer Indications

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WI.PA-1095-Genetic and Biomarker Testing for Alzheimer Disease

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WI.PA-1096-Genetic and Coagulation Testing for Noncancer Blood Disorders

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WI.PA-1100-Genetic Testing for Hereditary Breast Ovarian Pancreatic and Prostate Cancer

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WI.PA-1101-Genetic Testing for Hereditary Cancer

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WI.PA-1102-Genetic Testing for Cardiac Conditions

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WI.PA-1106-Genetic Testing for Hereditary Colorectal and Uterine Cancer

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WI.PA-1109-Genetic Testing for Diagnosis of Inherited Conditions

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WI.PA-1112-Genetic Testing for Hereditary Ataxias

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WI.PA-1119-Glaucoma Surgical Treatments

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WI.PA-1122-Headache and Occipital Neuralgia Treatments

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WI.PA-1123-Hip Arthroplasty

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WI.PA-1132-Implantable and Non-Implantable Hearing Devices

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WI.PA-1137-Injections for Chronic Pain Conditions

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WI.PA-1138-Intensity Modulated Radiation Therapy

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WI.PA-1140-Peripheral Nerve Stimulators

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WI.PA-1141-Intraoperative Neurological Monitoring

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WI.PA-1145-Knee Arthroplasty

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WI.PA-1146-Molecular Biomarkers for Prostate Cancer Risk Stratification

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WI.PA-1147-Laparoscopic Hiatal Hernia Repair

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WI.PA-1152-Low Level Laser Therapy and High Power Laser Therapy

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WI.PA-1156-Microwave Thermotherapy

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WI.PA-1161-Molecular Markers in Fine Needle Aspirates of Thyroid Nodules

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WI.PA-1163-Multianalyte Assays with Algorithmic Analyses for Cancer Indications

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WI.PA-1165-Multiplex Pathogen Identification Panels for Infectious Disease

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WI.PA-1166-Negative Pressure Wound Therapy

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WI.PA-1168-Neuroablative Techniques for Chronic Pain

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WI.PA-1169-Noninvasive Home Ventilators

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WI.PA-1171-Noninvasive Tests for Hepatic Fibrosis

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WI.PA-1172-Obstructive Sleep Apnea and Other Related Sleep Disorders Nonsurgical Treatments

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WI.PA-1176-Orthognathic Surgery

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WI.PA-1177-Orthotics

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WI.PA-1178-Osteochondral and Subchondral Defects Surgery

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WI.PA-1185-Pharmacogenomics and Companion Diagnostics

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WI.PA-1188-Platelet Derived Growth Factors for Wound Healing

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WI.PA-1193-Prostatectomy

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WI.PA-1194-Prosthetics

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WI.PA-1195-Proton Beam Neutron Beam and Carbon Ion Radiation Therapy

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WI.PA-1198-Radiofrequency Tumor Ablation

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WI.PA-1200-Reduction Mammaplasty

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WI.PA-1204-Serological and Fecal Testing for Inflammatory Bowel Disease

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WI.PA-1207-Shoulder Arthroplasty

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WI.PA-1208-Skin and Tissue Substitutes

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WI.PA-1210-Skysona (elivaldogene autotemcel)

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WI.PA-1212-Solid Organ Transplants

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WI.PA-1215-Spinal Cord Stimulators

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WI.PA-1216-Spinal Decompression Surgery

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WI.PA-1217-Spinal Fusion Surgery

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WI.PA-1218-Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Audience Type
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WI.PA-1220-Temporomandibular Disorders

Audience Type
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WI.PA-1223-Tinnitus Treatments

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WI.PA-1226-Transcatheter Valve Procedures

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WI.PA-1227-Cranial Electrical Stimulation

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WI.PA-1230-Urinary Bladder Dysfunction

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WI.PA-1231-Uterine Fibroid Surgical Treatments

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WI.PA-1232-Vagus Nerve Stimulation

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WI.PA-1233-Varicose Vein Treatments

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WI.PA-1239-Zynteglo (betibeglogene autotemcel)

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WI.PA-1240-Genetic Testing for Hematologic Malignancies and Suspected Myeloid Disorders

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WI.PA-1248-Gene Expression Profiling for Idiopathic Pulmonary Fibrosis

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WI.PA-1248-Gene Expression Profiling for Noncancer Indications

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WI.PA-1251-Transesophageal and Transthoracic Echocardiogram

Audience Type
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WI.PA-1252-Diagnostic Imaging

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WI.PA-1254-Excision and Mastectomy for Breast Lesions

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WI.PA-1255-Facility Based Sleep Studies

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WI.PA-1256-Lung Biopsy and Resection

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WI.PA-1259-Early Prostate Cancer Detection

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WI.PA-1260-Special Stains

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WI.PA-9001-Psychiatric Partial Hospital Program Services

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WI.PA-9002-Substance Use Disorder Inpatient Services

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WI.PA-9003-Substance Use Disorder Partial Hospital Program Services

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WI.PA-CAR-T-Pharmacy Policy-Tecartusbrexucabtagene autoleucel-

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More Prior Authorization Documents

Part D Transition Process

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription.

Current iCare Prior Authorization List (PAL) - excel

Current iCare Prior Authorization List (PAL) - pdf

WI.PA.001-Outpatient Skilled Services, Home Health Services, Durable Medical Equipment, and Procedures PA Process

iCare Prior Auth Request Form

Providers use this updated form to request a prior authorization

Subacute PA Form 2024

Inpatient Notification Form

Independent Care Health Plan (iCare) must be notified of all inpatient stays within one (1) business day of the admission.

PA Request - Personal Care Worker (PCW) fillable form

Procedure Specific Listing Q1-2023.pdf

Procedure Specific Listing Q1-2023.xlsx

COVID 19 Claims & Coverage Guide

COVID 19 Webinar for Providers to understand iCare's Prior Authorization guidelines related to COVID claims

Part D Coverage Determination Request

iCare Urine Drug Screen Guidance for Providers

iCare Urine Drug Screen Provider Education. As a standard benefit, all iCare members will receive 6 urine drug screens per year. For additional information about prior authorization, read this information document.

iCare Urine Drug Screen Policy

iCare Urinary Drug Screen prior authorization policy provides an overview of the minimum requirements to complete a urine drug screen (UDS) prior authorization (PA) request for Medicare, Medicaid, and BadgerCare Plus members.

iCare Pulmonary Artery Monitoring-CardioMems Guidance for Providers

Evidence-based guidelines and industry best practices that iCare follows regarding CardioMems

F02717-EVV-Live-In Worker ID fillable form

DHS Form: F02717-Electronic Visit Verification-Live-In Worker ID form

PCW HHC Message to Providers

3/31/2020 Update from iCare Prior Authorization to Personal Care Workers and Home Health Care Providers.

General Subacute Communication to Providers

3/31/2020 Update from iCare Prior Authorization to providers including Subacute care, Long Term Acute Care (LTAC), Skilled Nursing Facilities (SNF) and Inpatient Rehabilitation facilities (IRF) providers.

Medication Request Form

This form is used by participating physicians and providers to obtain coverage for a non-formulary drug for which there is no suitable alternate available.

Behavioral Health and AODA FAQs

This document answers frequently asked questions by providers about Behavioral Health and AODA as related to claims and prior authorization for treatment programs received by iCare members.

Personal Care Screening Tool (Form)

The Personal Care Screening Tool was developed to assist providers in determining the number of units to request for PA (prior authorization) of medically necessary personal care services that are to be provided by a PCW (personal care worker). Here is the form in PDF format.

Personal Care Screening Tool - MS Word Format

ForwardHealth requires persons who are requesting authorization for personal care (PC) service to complete and submit the Personal Care Screening Tool. Here is the form in Microsoft Word format.

Personal Care Screening Tool - Instructions

ForwardHealth requires persons who are requesting authorization for personal care (PC) service to complete and submit the Personal Care Screening Tool. Here are instructions to do so.

Prior Authorization Requirements - In Home Meals

In-home meal service is provided by iCare as a supplemental Medicare benefit to members immediately following surgery or an inpatient hospital stay, for a temporary duration when ordered by a practitioner.

iCare Remit Reason Codes

Remittance Reason Codes provide additional explanation for a claim

Leaving iCareHealthPlan.org

By clicking this link, you may be leaving the iCareHealthPlan.org website. Independent Care Health Plan (iCare) only provides these links and pointers for your information and convenience. When you select a link to an outside website, you are leaving the www.iCareHealthPlan.org website.

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