Prior Authorization Metrics

To comply with the CMS Interoperability and Prior Authorization final rule, Highmark is required to annually report aggregated prior authorization metrics on our website. Specifically, this includes a list of all medical items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services (e.g., approvals, denials, etc.) over the previous calendar year. 

Reporting Period: January 1, 2025 to December 31, 2025

• To view view detailed information on prior authorization requests, including turnaround times, click here.
• To view the list(s) of procedure codes requiring authorization, reference the lists below.

Prior Authorization Coding Lists

The procedure codes contained in the lists below usually require authorization (based on the member’s benefit plan/eligibility). Effective dates are subject to change. Highmark will provide written notice when codes are added to the list; deletions are announced via online publication.

• Note: If an elective surgery will require an Inpatient Level of Care, prior authorization is required even if the procedure code is not listed.

• View the Federal Employee Program (FEP) List of Procedures/DME Requiring Authorization
  • This list applies to FEP Standard Option, Basic Option, and Blue Focus.

For additional information about prior authorization and the authorization submission process, review the Obtaining Authorizations page.