Prior Authorization and Medical Policy Updates 

Please be sure to regularly check our Highmark Wholecare Provider Resource Center (PRC) for a list of procedure codes added to the Highmark Wholecare Medicaid and Medicare Prior Authorization List (PAL) that require prior authorization. The changes effective April 1, 2026 were also sent via fax on January 22, 2026.  

To find these codes, visit the PRC and click on the “Resource Centers” tab. Then, under “Medicaid Resources” scroll down to Provider Updates. 

You may also search CPT codes in the Main Search Bar at the top of any page on the PRC to check prior authorization requirements. 

Additionally, Highmark Wholecare regularly reviews and updates our policies and procedures. To help you know when policies have been amended, an advanced notification will be provided via our newsletter or fax and posted on our website 60 days prior to the effective date. You can find the medical policy updates at the following links: 

Medicaid Provider Updates 

Medicare Provider Updates

Policy Updates Effective April 1, 2026

As a reminder, we have updated or reviewed the following Medical Policies, with changes effective April 1st. These updates were posted on the Highmark Wholecare provider website on February 1, 2026.

Medicaid Policies:

• MP-006-MD-PA Genetic Testing for Cystic Fibrosis - Reformatted ‘Procedures’ section with no changes to clinical criteria/coverage. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.

• MP-010-MD-PA Testing for Genetic Disease - No changes to clinical criteria. Updated ‘Summary of Literature’ section.

Medicare Policies:

• MP-094-MC-PA Acupuncture for Chronic Low Back Pain (NCD 30.3.3) - Policy is Retired. InterQual® criteria exists for all procedure codes listed in the ‘Coding Requirements’ section.

• MP-096-MC-PA Implantable Continuous Glucose Monitors (I-CGM) (L38617) - Policy Retired. InterQual® criteria exists for all procedure codes listed in ‘Coding Requirements’ section.

• MP-097-MC-PA Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor (L38495) - Policy to be Retired. InterQual® criteria exists for procedure code listed in ‘Coding Requirements’ section.

Policy Updates Effective May 1, 2026

As a reminder, we have updated or reviewed the following Medical Policies, with changes effective May 1st. These updates will be posted on the Highmark Wholecare provider website March 1, 2026.

Medicaid Policies:

• MP-112-MD-PA Prescription Digital Therapeutics - Added medical necessity guidelines for Prescription digital therapeutics (PDTs). Added Program Exception guidance for Somryst® PDT. Added list of PDT products that are considered unproven and experimental/investigational. Added ICD-10 diagnosis codes for Somryst®. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.

• MP-029-MD-PA Passive Oscillatory Devices in the Outpatient Setting - No changes to clinical criteria. Added and removed ICD-10-CM codes per CMS guidance. Updated ‘Reference Sources’ section.

Medicare Policies:

• MP-065-MC-PA Assessing Patient’s Suitability for Electrical Nerve Stimulation Therapy (160.7.1 & 160.7) - No changes to clinical criteria. Updated ‘Reference Sources’ section.

• MP-062-MC-PA Fecal Microbiota Transplant - No changes to clinical criteria. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.

• MP-082-MC-PA Speech-Generating Devices (L33739) - No changes to clinical criteria. Updated ‘Coding Requirements’ section.

• MP-072-MC-PA Ambulatory Blood Pressure Monitor (NCD 20.19) - Policy to be Retired. InterQual criteria exists for listed procedure code.