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Prior Authorization

MDwise Medicaid prior authorization decisions are based on medical necessity, medical appropriateness, and benefit limits. To determine if a prior authorization is needed, please refer to Prior Authorization | MDwise.

MDwise follows the hierarchy for determining authorization criteria as outlined in BT2025102.

Below is the list of services that require authorization, and the criteria utilized when rendering the decision. Please note: if you would like to view the medical necessity criteria from InterQual, please call 1-800-365-1204 and request the criteria to be sent for the specific service.

Behavioral Health Services

Behavioral Health services that require prior authorization, with codes, descriptions, criteria type, and where to find criteria.
Service or Code Service Description Type of Medical Necessity Criteria Used Link to Criteria
Behavioral Inpatient Stay IP Psych and IP SUD InterQual InterQual: Please call 1.800.365.1204 for Criteria
H0010 Substance Use Disorder Residential Treatment – High 3.5 InterQual InterQual: Please call 1.800.365.1204 for Criteria
H2034 Substance Use Disorder Residential Treatment – Low 3.1 InterQual InterQual: Please call 1.800.365.1204 for Criteria
H0035 Partial Hospitalization Program InterQual InterQual: Please call 1.800.365.1204 for Criteria
S9480 Intensive Outpatient Program InterQual InterQual: Please call 1.800.365.1204 for Criteria
H0015 Intensive Outpatient Program InterQual InterQual: Please call 1.800.365.1204 for Criteria
97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T ABA (Applied Behavioral Analysis) InterQual InterQual: Please call 1.800.365.1204 for Criteria
96130, 96131, 96136, 96137, 96138, 96139, 96146 Psychological Testing InterQual InterQual: Please call 1.800.365.1204 for Criteria
96116, 96121, 96132, 96133, 96136, 96137, 96138, 96139, 96146 Neuropsychological Testing InterQual InterQual: Please call 1.800.365.1204 for Criteria
96112, 96113 Developmental Testing InterQual InterQual: Please call 1.800.365.1204 for Criteria
90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90853 Psychosocial Rehabilitation InterQual InterQual: Please call 1.800.365.1204 for Criteria
90791 Psychiatric Diagnostic Evaluation InterQual InterQual: Please call 1.800.365.1204 for Criteria
90792 Psychiatric Diagnostic Evaluation with Medical Services InterQual InterQual: Please call 1.800.365.1204 for Criteria
90845 Psychoanalysis InterQual InterQual: Please call 1.800.365.1204 for Criteria
90867, 90868, 90869 TMS (Transcranial Magnetic Stimulation) IHCP Behavioral Health Services (pg. 31) IHCP Behavioral Health Services
99408, 99409 Alcohol and/or Substance Abuse Screening & Brief Intervention Services Outpatient Behavioral Health Services under Screening and Brief Intervention Services (pg. 37) IHCP Behavioral Health Services
97129, 97130 Cognitive Function Therapeutic Interventions IHCP Therapy Services Code Sets (pg. 20) IHCP Therapy Services Code Sets
G0480, G0481, G0659 Drug Testing (< 15 drug classes) IHCP Laboratory Testing Laboratory Services
G0482, G0483 Drug Testing (15+ drug classes) IHCP Laboratory Testing Laboratory Services
80305, 80306, 80307 Drug Testing IHCP Laboratory Testing Laboratory Services
90870, 00104 Electroconvulsive Therapy (ECT) InterQual InterQual: Please call 1.800.365.1204 for Criteria
H0038 Peer Recovery Services Outpatient Behavioral Health Services under Peer Recovery Services (pg. 33) IHCP Behavioral Health Services
Q3014 Telehealth IHCP Provider Reference Module – Telehealth and Virtual Services (pg. 11) IHCP Provider Reference Module – Telehealth and Virtual Services

Medical Services

Medical services that require prior authorization, with codes, descriptions, criteria type, and links.
Service or Code Service Description Type of Medical Necessity Criteria Used Link to Criteria
Acute Inpatient Hospital Elective/emergent/urgent medical and surgical inpatient admissions; skilled nursing facility services InterQual InterQual: Please call 1.800.365.1204 for Criteria
Acute Inpatient Rehabilitation (Rehab – AIR) Inpatient Rehabilitation IHCP Inpatient Hospital Services / InterQual Inpatient Hospital Services

InterQual: Please call 1.800.365.1204 for Criteria
E0617 Automatic External Defibrillator (AED), stand-alone IHCP DME / InterQual IHCP Durable and Home Medical Equipment and Supplies

InterQual: Please call 1.800.365.1204 for Criteria
K0606 Wearable Cardioverter Defibrillator (WCD) IHCP DME / InterQual IHCP Durable and Home Medical Equipment and Supplies

InterQual: Please call 1.800.365.1204 for Criteria
A0430, A0431, A0435, A0436 Air Ambulance IHCP Transportation Services IHCP Transportation Services
Artificial Heart — IHCP Surgical Services IHCP Surgical Services
S2235 Auditory Brainstem Implant IHCP Surgical Services IHCP Surgical Services
Roux-en-Y- 43846, 43847 Gastroplasty - 43842, 43843 Gastric banding sleeve - 43770, 43771, 43772, 43773, 43774 Gastrectomy - 43644, 43847, 43848, 43886, 43888 Duodenal switch - 43845 43645, 43659, 43775, 43999 Bariatric Surgery and Revisions (Roux-en-Y, Gastroplasty, Gastric banding/sleeve, Gastrectomy, Duodenal switch) IHCP Surgical Services IHCP Surgical Services
15820, 15821, 15822, 15823 Blepharoplasty IHCP Surgical Services / InterQual (starting 8/1/25) IHCP Surgical Services

InterQual: Please call 1.800.365.1204 for Criteria
19316, 19318, 19325 Breast Reduction IHCP Surgical Services / InterQual (starting 8/1/25) IHCP Surgical Services

InterQual: Please call 1.800.365.1204 for Criteria
Children’s Hospitals Out of State — IHCP (defined list) IHCP Out of State Providers
Chiropractic services Any Chiropractic Services IHCP Chiropractic Services / InterQual IHCP Chiropractic Services InterQual: Please call 1.800.365.1204 for Criteria
40700, 40701, 40702, 40761, 42200, 42205, 42215, 42225 Cleft lip/palate repair (Pediatric/Adult) Pediatric: InterQual; Adult: Peer-reviewed literature/medical journals

InterQual: Please call 1.800.365.1204 for Criteria
40720 Cleft lip/nasal repair Peer-reviewed literature/medical journals Please call 1.800.365.1204 for Criteria
Clinical trials   IHCP Clinical Trials  IHCP Clinical Trials 
69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8690 Cochlear Implants IHCP Surgical Services IHCP Surgical Services
Cochlear Implant-replacement replacement  IHCP Hearing Services  IHCP Hearing Services
Cochlear Implant-maintenance and repair maintenance and repair  IHCP Hearing Services  IHCP Hearing Services 
Certified Community Behavioral Health Clinics BT2024210 BT2024210
E0471 is on PA list (BIPAP). If any other codes are greater than $500 rented monthly or purchased amount, will need medical necessity review CPAP, BiPAP & Humidifiers IHCP DME (CPAP) and (BiPAP) and (humidifiers) AND BT2023153 IHCP Durable and Home Medical Equipment and Supplies BT2023153
S1040 Cranial Remolding Orthosis IHCP DME IHCP Durable and Home Medical Equipment and Supplies
Rev codes 082x,083x, 084x-, 085x 90935, 90937, 90940, 90945, 90947, 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90989, 90993, 90997, 90999, 90967, 90968, 90969, 90970, 90989, 90993, 90997, 90999 Renal Dialysis Services IHCP Renal Dialysis Services IHCP Renal Dialysis Services
E0251, E0250, E0255, E0256, E0260, E0261, E0265, E0266, E0277, E0290, E0292, E0293, E0294, E0301, E0302, E0303, E0304, E0316, E0328, E0329, E0372, E0373, E0465, E0466, E0471, E0472, E0483, E0636, E0652, E0783, E0786, E1006, E1008, E1035, E2402, E2510, K0606, K0826, K0828, K0829, K0839, K0840, K0850, K0851, K0852, K0853, K0854, K0855, K0857, K0858, K0859, K0860, K0862, K0863, K0864, K0868, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, L5856, L5857, L5858, L5961, L5987, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7180, L7181, L7185, L7186, L7190, L7191, Q0480, Q0481, Q0483, Q0489 Durable Medical Equipment (General) See specific type of DME for criteria IHCP Durable and Home Medical Equipment and Supplies
DME Replacement (General)   IHCP DME: see specific type of DME for replacement criteria, if available. IHCP Durable and Home Medical Equipment and Supplies
B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4100, B4105, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B4164, B4168, B4172, B4176, B4178, B4180 B4185, B4187, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200, B9002, B9004, B9006, B9998 Enteral and Parenteral Nutrition and supplies (Does NOT Include Oral) IHCP DME / InterQual

IHCP Durable and Home Medical Equipment and Supplies

InterQual: Please call 1.800.365.1204 for Criteria
Enteral Feeding Cartridge-Digestive Enzyme In-line cartride (Relizorb) Enteral Feeding Cartridge IHCP DME IHCP Durable and Home Medical Equipment and Supplies
30520 Facial Plastic & Reconstructive Surgery – Septoplasty IHCP Surgical Services / InterQual

IHCP Surgical Services

InterQual: Please call 1.800.365.1204 for Criteria
81161, 81200, 81201, 81202, 81203, 81206, 81207, 81208, , 81218, 81230, 81231, 81232, 81235, 81238, , 81243, 81244, 81251, 81252, 81253, 81254, 81257, 81258, 81259, , 81276, 81278, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81310, 81311, 81317, 81318, 81319, 81321, 81322, 81323, 81330, 81346, , 81364, 81403, 81404, 81405, 81407, , 81479, 83950, 83951, 84999, 86849, 88120, 88121, 88230, 88233, 88235, 88237, 88240, 88241, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88289, 88291, 88299, 88361, 88364, 88365, 88366, 88367, 88368, 88369, 88373, 88374, 88377, 88387, G0452, 0029U, 0034U, 0037U, 0040U, 0045U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0094U, 0101U, 0102U, 0103U, 0111U, 0129U, 0130U, 0131U, 0132U, 0134U, 0135U, 0136U, 0137U, 0138U, 0158U, 0169U, 0209U, 0212U, 0213U, 0214U, 0215U, 0216U, 0217U, 0218U, 0231U, 0233U, 0235U, 0236U, 0237U, 0238U, 0242U, 0265U, 0267U, 0327U, 0335U, 0336U, 81170, 81185, 81191, 81192, 81193, 81194, 81222, 81223, 81225, 81226, 81227, 81248, 81249, 81272, 81274, 81285, 81286, 81314, 81324, 81325, 81336, 81340, 81342, 81349, 81351, 81352, 81353, 81362, 81363, 81406, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81425, 81426, 81427, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81441, 81442, 81443, 81445, 81448, 81449, 81451, 81456, 81460, 81465, 81518, 81520, 81521, 81523, 81539, 81546, 81595 Genetic Testing – General IHCP Genetic Testing/ InterQual for specific test if test is not found in IHCP Genetic Testing

IHCP Genetic Testing

InterQual: Please call 1.800.365.1204 for Criteria

81422, 81450, 0340U, 0345U, 0411U Biomarkers (expanded coverage)

BT2024126, BT2024185, BT202578

InterQual

BT2024126 
BT2024185 BT202578

InterQual: Please call 1.800.365.1204 for Criteria
81162, 81163, 81164, 81165, 81166, , 81432, 81215,81212, 81215, 81216, 81217 BRCA 1 and 2 Testing IHCP Genetic Testing/InterQual starting 8/1/25

IHCP Genetic Testing

InterQual (starting 8/1/25): Please call 1.800.365.1204 for Criteria

81519, 81522 Oncotype DX Breast Recurrent Score and EndoPredict Breast Cancer Assay IHCP Genetic Testing/InterQual starting 8/1/25 IHCP Genetic Testing

InterQual (starting 8/1/25): Please call 1.800.365.1204 for Criteria
81228, 81229 Chromosomal Microarray Analysis Genetic Testing IHCP Genetic Testing/InterQual starting 8/1/25 IHCP Genetic Testing

InterQual (starting 8/1/25): Please call 1.800.365.1204 for Criteria
81270, 81219 JAK2/CLAR Genetic Testing InterQual InterQual: Please call 1.800.365.1204 for Criteria
81420, 81507, 81220, 81329, 81361 Prenatal Genetic Testing IIHCP Genetic Testing/ If not pregnant, use InterQual by code IHCP Genetic Testing

InterQual (starting 8/1/25): Please call 1.800.365.1204 for Criteria
Left and Right ear- V5030, V5040, V5050, V5060, V5080, V5095, V5100, V5120, V5130, V5140, V5246, V5247, V5252, V5253, V5256, V5257, V5260, V5261, V5267, Bilateral- V5100, V5120, V5130, V5140, V5252, V5253, V5260, V5261, V5299 Hearing Aids (General); purchase IHCP Hearing Services/InterQual IHCP Hearing Services
Hearing Aids; Replacement/Maintenance/Repair   IHCP Hearing Services IHCP Hearing Services
Hearing Tests   405 IAC 5-22-7 Audiology services IAC Medicaid Services
G0151, G0152, G0153, 99600, 99600 TE, 99600 TD, 99601, 99602, 92610 Home health services: PT/OT/ST/SN/HHA IHCP Home Health Services and BT202525 and BT202545 InterQual IHCP Home Health Services
BT202525
BT202545
All POS 34, For POS 12, 651, 652, 655 and 656 Hospice (inpatient and outpatient) IHCP Hospice Services IHCP Hospice Services
E0250, E0255, E0256, E0260, E0261, E0265, E0266, E0277, E0290, E0292, E0293, E0294, E0301, E0302, E0303, E0304, E0316, E0328, E0329 Hospital and Specialty Beds  IHCP DME IHCP Durable and Home Medical Equipment and Supplies
REV 413, 99183 Hyperbaric oxygen 405 IAC 5-28-11 Hyperbaric oxygen therapy/InterQual

IAC Medicaid Services

IHCP Therapy Services

InterQual: Please call 1.800.365.1204 for Criteria

51925, 58150, 58152, 58180, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58951, 58952, 58953, 58954, 58956 Hysterectomy IHCP Obstetrical and Gynecological Services/InterQual 

IHCP Obstetrical and Gynecological Services

InterQual: Please call 1.800.365.1204 for Criteria

33270, 33271 Implantable cardio-defibrillator IHCP Surgical Services IHCP Surgical Services
64490, 64491, 64492, 64493, 64494, 64495, 62320, 62321, 62322, 62323, 64454, 64455, 64479, 64480, 64483, 64484 Injections (pain management) - including ESI, facet joint & MBB InterQual InterQual: Please call 1.800.365.1204 for Criteria
Mastectomy InterQual InterQual: Please call 1.800.365.1204 for Criteria
21010, 21025, 21026, 21050, 21060, 21070, 21073, 21110, 21116, 21137, 21138, 21139, 21172, 21175, 21179, 21180, 21181, 21182, 21183, 21184, 21193, 21194, 21195, 21196, 21198, 21199, 21208, 21209, 21230, 21235, 21240, 21242, 21243, 21244, 21245, 21246, 21247, 21248, 21249, 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21270, 21275, 21295, 21296, 21299, 21480, 21485, 21490, 21685, 29800, 29804 Maxillofacial Surgery (Orthognathic and TMJ Syndrome) IHCP Surgical Services/InterQual

IHCP Surgical Services

InterQual: Please call 1.800.365.1204 for Criteria

Myoelectric Upper-Limb Prosthetic IHCP DME IHCP Durable and Home Medical Equipment and Supplies
Negative Pressure Wound Therapy IHCP DME IHCP Durable and Home Medical Equipment and Supplies
Newborn Intensive Care Unit NICU InterQual InterQual: Please call 1.800.365.1204 for Criteria
E0744, E0745, E0747, E0748, E0749 Noninvasive Osteogenic Bone-Growth Stimulator IHCP DME IHCP Durable and Home Medical Equipment and Supplies
Oral Nutrition, including supplements, food thickeners and formula   IHCP DME and MM 061 Nutrition Supplementation

IHCP Durable and Home Medical Equipment and Supplies

MDwise MM 061 Nutrition Supplementation Policy
E0424, E0439, E0441, E0442, E0443, E0444, E0455, E1352, E1353, E1355, E1356, E1357, E1358, E1390, E1391, E1392, E1405, E1406, K0738 Home Oxygen IHCP DME

IHCP Durable and Home Medical Equipment and Supplies
15830 Panniculectomy IHCP Surgical Services

IHCP Surgical Services

Phrenic Nerve Stimulator IHCP Surgical Services

IHCP Surgical Services

30120 40500 40510, 40520 40527, 40530 40650, 40652, 40654 41512 41599 42210, 42220, 42227, 42235, 42280, 42281 42260 42299 Maxillofacial surgeries: Revision of Nose Partial excision of lip Lip reconstruction Partial Removal of lip Lip Repairs Tongue Suspension Tongue/mouth surgery Cleft Palate Reconstruction/Palate lengthening/repairs/prosthesis/Nose to Lip Fistula Repair Palate/uvula surgery Peer-reviewed literature/medical journals Peer-reviewed literature/medical journals: Please call 1.800.365.1204 for Criteria
42145 Maxillofacial surgeries: Repair of palate pharynx/uvula InterQual Peer-reviewed literature/medical journals

Peer-reviewed literature/ medical journals/ InterQual:

Please call 1.800.365.1204 for Criteria

L5987 Shank Foot System (prosthetic) InterQual InterQual: Please call 1.800.365.1204 for Criteria
Skilled Nursing Facility SNF IHCP Long-Term Care/InterQual

IHCP Long Term Care

InterQual: Please call 1.800.365.1204 for Criteria

Specialized Car Seats and Car Beds (includes replacements)
IHCP Durable and Home Medical Equipment and Supplies IHCP Durable and Home Medical Equipment and Supplies
Speech Generating Device (augmentative & alternative communication devices)   IHCP DME IHCP Durable and Home Medical Equipment and Supplies
L8680, L8687, L8688 Spinal Cord stimulator (Trial and permanent) BR202236 BR202236
Spinal Stenosis   IHCP Surgical Services

IHCP Surgical Services

E0638 Standers (Prone, Vertical, Supine) IHCP DME and InterQual

IHCP Durable and Home Medical Equipment and Supplies

InterQual: Please call 1.800.365.1204 for Criteria

E0641 Standers Multi-positional IHCP DME and InterQual

IHCP Durable and Home Medical Equipment and Supplies

InterQual: Please call 1.800.365.1204 for Criteria

E0637 Standers Sit-to-Stand IHCP DME and InterQual 

IHCP Durable and Home Medical Equipment and Supplies

InterQual: Please call 1.800.365.1204 for Criteria

A4556, A4557, A4558, A4595, A4630, E0720, E0730, E0731, A4290 TENS IHCP DME & InterQual

IHCP Durable and Home Medical Equipment and Supplies

InterQual: Please call 1.800.365.1204 for Criteria

PT - Revenue codes - 420, 421, 422, 423, 429, and 97018, 97022, 97024, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97164, 97168, 97530, 97533, 97535, 97537, 97542, 97750, 97760, 97761 OT - Revenue codes 430, 431, 432, 433, 439 ST - Revenue codes 440, 441, 442, 443, 444, 449, 92507, 92508, 92520, 92526 Therapy Services – Outpatient ST/OT/PT 405 IAC 5-22-6 and InterQual

IAC Medicaid Services

InterQual: Please call 1.800.365.1204 for Criteria

Transplants (General)   See specific transplant. IHCP Surgical Services/ BT BT2023130

IHCP Surgical Services

BT2023130

Bone Marrow (38240, 38241, 38242)/Stem Cell Transplant (38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38221, 38230, 38232) Bone Marrow/Stem Cell Transplant IHCP Surgical Services/BT BT2023130

IHCP Surgical Services

BT2023130

65710, 65730, 65750, 65755, 65756 Cornea Transplant IHCP Surgical Services and InterQual

IHCP Surgical Services

InterQual: Please call 1.800.365.1204 for Criteria

44705 Fecal Microbiota Transplant IHCP Surgical Services IHCP Surgical Services
33933, 33940, 33944, 33945 Heart Transplant IHCP Surgical Services, BT2023130 and InterQual

IHCP Surgical Services

BT2023130

InterQual: Please call 1.800.365.1204 for Criteria

32851, 32852, 32853, 32854, 32855, 32856 Lung Transplant IHCP Surgical Services and BT2023130

IHCP Surgical Services

BT2023130

33930, 33935 Heart/Lung Transplant IHCP Surgical Services and BT2023130

IHCP Surgical Services

BT2023130

50300, 50320, 50323, 50325, 50327, 50360, 50365 Kidney Transplant IHCP Surgical Services, BT2023130 and InterQual

IHCP Surgical Services

BT2023130

InterQual: Please call 1.800.365.1204 for Criteria

47133, 47135, 47143, 47144, 47145, 47146, 47147 Liver Transplant IHCP Surgical Services, BT2023130 and InterQual

IHCP Surgical Services

BT2023130

InterQual: Please call 1.800.365.1204 for Criteria

48554 Pancreatic Transplant IHCP Surgical Services, BT2023130 and InterQual

IHCP Surgical Services

BT2023130

InterQual: Please call 1.800.365.1204 for Criteria

44132, 44133, 44135, 44136 Intestinal (or small bowel) Transplant IHCP Surgical Services, BT2023130 and InterQual

IHCP Surgical Services

BT2023130

InterQual: Please call 1.800.365.1204 for Criteria

Multivisceral Transplant IHCP Surgical Services and BT2023130

IHCP Surgical Services

BT2023130

80305-80307, G0480-G0483 Urine Drug Testing IHCP Laboratory Testing IHCP Laboratory Services
Vagus Nerve Stimulator   IHCP Surgical Services IHCP Surgical Services
36479, 36478, 36476, 36475, 36474 Endovenous Ablation InterQual InterQual: Please call 1.800.365.1204 for Criteria
36482, 36483 Endovenous Ablation by Chemical Adhesive InterQual InterQual: Please call 1.800.365.1204 for Criteria
37760 Ligation InterQual InterQual: Please call 1.800.365.1204 for Criteria/td>
37700, 37718, 37722, 37780, 37785 Ligation/Excision (Stripping) InterQual InterQual: Please call 1.800.365.1204 for Criteria
37766, 37765 Phlebectomy InterQual InterQual: Please call 1.800.365.1204 for Criteria
36465, 36466 Sclerotherapy InterQual InterQual: Please call 1.800.365.1204 for Criteria
Ventricular Assist Devices (VAD)-includes LVADs, RVADs, and BiVADs IHCP Surgical Services IHCP Surgical Services
92065 Vision Training Therapy IHCP Vision Services/Physician Review IHCP Vision Services
E0955, E0956, E0957, E0983, E0984, E0986, E1002, E1003, E1004, E1005, E1007, E1010, E1012, E1028, E1399, E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2358, E2359, E2361, E2362, E2363, E2368, E2369, E2370, E2371, E2372, E2373, E2374, E2375, E2376, E2377, E2397, E2398, E2622, K0108, K0800, K0801, K0802, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0827, K0835, K0836, K0837, K0838, K0841, K0842, K0843, K0848, K0849, K0856, K0861, K0869, K0890, K0891, K0898 Wheelchairs and Accessories IHCP Durable Medical Equipment IHCP Durable and Home Medical Equipment and Supplies
58353, 58356 Gynecologic Procedures Peer-reviewed literature/medical journals Peer-reviewed literature/medical journals: Please call 1.800.365.1204 for Criteria
53445, 54406 Male Enhancement Procedures Peer-reviewed literature/medical journals Peer-reviewed literature/medical journals: Please call 1.800.365.1204 for criteria
11920, 11921, 11922 Correct Skin Color InterQual InterQual: Please call 1.800.365.1204 for Criteria
15730, 15731, 15733, 15734, 15736 Flaps/Grafts InterQual InterQual: Please call 1.800.365.1204 for Criteria
15780, 15781, 15782, 15783 Dermabrasion InterQual InterQual: Please call 1.800.365.1204 for Criteria
15832–15839, 15847 Excessive Skin/Subcutaneous Removal (excluding panniculectomy) InterQual InterQual: Please call 1.800.365.1204 for Criteria
17106, 17107, 17108 Destruction of Skin Lesions InterQual InterQual: Please call 1.800.365.1204 for Criteria
19300, 19328, 19340, 19350, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, S2066–S2068 Breast Reconstruction InterQual InterQual: Please call 1.800.365.1204 for Criteria
21740, 21742, 21743 Repair of Sternum

Pediatric: InterQual

Adult: Peer-reviewed literature/medical journals

InterQual/ Peer-reviewed literature/medical journals: Please call 1.800.365.1204 for Criteria
30620 Intranasal Reconstruction Peer-reviewed literature/medical journals Please call 1.800.365.1204 for Criteria
54660 Testis Revision Peer-reviewed literature/medical journals Please call 1.800.365.1204 for Criteria
67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909 Ptosis/Blepharoptosis Repair/Reduction IHCP Surgical Services/InterQual starting 8/1/25

IHCP Surgical Services

InterQual (starting 8/1/25):

Please call 1.800.365.1204 for Criteria

67911 Lid Retraction Correction IHCP Surgical Services/ Peer-reviewed literature/medical journals IHCP Surgical Services

Peer-reviewed literature/medical journals: Please call 1.800.365.1204 for Criteria

67912 Correction Eyelid with Implant IHCP Surgical Services/ Peer-reviewed literature/medical journals IHCP Surgical Services

Peer-reviewed literature/medical journals: Please call 1.800.365.1204 for Criteria
67914, 67915, 67916, 67917 Ectropion Repairs IHCP Surgical Services/ InterQual starting 8/1/25 IHCP Surgical Services

InterQual (starting 8/1/25): Please call 1.800.365.1204 for Criteria
67921, 67922, 67923, 67924 Entropion Repairs IHCP Surgical Services/ InterQual criteria starting 8/1/25 IHCP Surgical Services

InterQual (starting 8/1/25): Please call 1.800.365.1204 for Criteria
67930, 67935, 67938 Eyelid Wound Repair / FB Removal IHCP Surgical Services/Peer-reviewed literature/medical journals IHCP Surgical Services

Peer-reviewed literature/medical journals: Please call 1.800.365.1204 for Criteria
67961, 67971, 67975 Eyelid Excision/Repair/Reconstruction IHCP Surgical Services/ InterQual criteria only starting 8/1/25 IHCP Surgical Services

InterQual (starting 8/1/25): Please call 1.800.365.1204 for Criteria
69300 Otoplasty Peer-reviewed literature/medical journals Peer-reviewed literature/medical journals: Please call 1.800.365.1204 for Criteria
19301, 19302 Mastectomy InterQual InterQual: Please call 1.800.365.1204 for Criteria
33272, 93260, 93261, 93644 Subcutaneous Defibrillator Removal / Evaluations Peer-reviewed literature/medical journals Peer-reviewed literature/medical journals: Please call 1.800.365.1204 for Criteria
Gender Affirming Care (various codes may align with this policy) MDwise MM 056 Gender Affirming Care MDwise MM 056 Gender Affirming Care

To access the prior authorization (PA) criteria for medications covered under the medical benefit, also known as “Buy and Bill” medications, please refer to the “Coverage Status / Prior Authorization (PA)” column in the current MDwise Hoosier Healthwise and Healthy Indiana Plan Medication (HCPCS Codes) Prior Authorization and Exclusion List. Based on the details in that column, you can view the PA criteria by following the links provided below:

DR-08-2025-18051/HHW-HIPP1018 (8/25)