Authorizations

Prior Authorization Updates: Two Additions and 90+ Removals

Tue, May 19, 2026

For: Professional and Facility Providers

Effective on the dates outlined below, the medical drug and procedure code changes will be applicable to all lines of business:

Sept. 1, 2026 – Prior Authorization Additions

Modality	Code	Terminology
Other Specialty Drugs	J3245	injection, tildrakizumab, 1 mg (Ilumya)
Joint	J7330	autologous cultured chondrocytes, implant (MACI)

June 1, 2026 – Prior Authorization Removal

Modality	Code	Terminology
Other Specialty Drugs	J2469	injection, palonosetron HCl, 25 mcg (Aloxi)

June 1, 2026 – Prior Authorization Removal for Nuclear Medicine and Chiropractic Procedures

Modality	Code	Terminology
Nuclear Medicine	78496	cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique (list separately in addition to code for primary procedure)
Nuclear Medicine	78012	thyroid uptake, single or multiple quantitative measurement(s) (including stimulation, suppression, or discharge, when performed)
Nuclear Medicine	78013	thyroid imaging (including vascular flow, when performed)
Nuclear Medicine	78014	thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) quantitative measurement(s) (including stimulation, suppression, or discharge, when performed)
Nuclear Medicine	78015	thyroid met imaging
Nuclear Medicine	78016	thyroid met imaging with additional studies
Nuclear Medicine	78018	thyroid scan whole body
Nuclear Medicine	78020	thyroid carcinoma metastases uptake
Nuclear Medicine	78070	parathyroid planar imaging (including subtraction, when performed)
Nuclear Medicine	78071	parathyroid planar imaging (including subtraction, when performed); with tomographic (spect)
Nuclear Medicine	78072	parathyroid planar imaging (including subtraction, when performed); with tomographic (spect), and concurrently acquired computed tomography (CT) for anatomical localization
Nuclear Medicine	78075	adrenal nuclear imaging
Nuclear Medicine	78102	bone marrow imaging, limited
Nuclear Medicine	78103	bone marrow imaging, multiple
Nuclear Medicine	78104	bone marrow imaging, whole body
Nuclear Medicine	78140	labeled red cell sequestration
Nuclear Medicine	78185	spleen imaging with & without vascular flow
Nuclear Medicine	78195	lymph system imaging
Nuclear Medicine	78201	liver imaging
Nuclear Medicine	78202	liver imaging with flow
Nuclear Medicine	78215	liver & spleen imaging
Nuclear Medicine	78216	liver & spleen imaging with flow
Nuclear Medicine	78226	hepatobiliary system imaging, including gallbladder when present;
Nuclear Medicine	78227	hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when performed
Nuclear Medicine	78230	salivary gland imaging
Nuclear Medicine	78231	serial salivary gland
Nuclear Medicine	78232	salivary gland function exam
Nuclear Medicine	78258	esophagus motility study
Nuclear Medicine	78261	gastric mucosa imaging
Nuclear Medicine	78262	gastroesophageal reflux exam
Nuclear Medicine	78264	gastric emptying study
Nuclear Medicine	78265	gastric emptying imaging study (eg, solid, liquid, or both); with small bowel transit
Nuclear Medicine	78266	gastric emptying imaging study (e.g., solid, liquid, or both); with small bowel and colon transit, multiple days
Nuclear Medicine	78278	GI bleeder scan
Nuclear Medicine	78290	meckels diverticulum imaging
Nuclear Medicine	78291	leveen shunt patency exam
Nuclear Medicine	78300	bone or joint imaging limited
Nuclear Medicine	78305	bone or joint imaging multiple
Nuclear Medicine	78306	bone scan whole body
Nuclear Medicine	78315	bone scan 3 phase study
Nuclear Medicine	78445	radionuclide venogram non-cardiac
Nuclear Medicine	78456	acute venous thrombosis imaging
Nuclear Medicine	78457	venous thrombosis imaging unilateral
Nuclear Medicine	78458	venous thrombosis images, bilateral
Nuclear Medicine	78579	pulmonary ventilation imaging (e.g., aerosol or gas)
Nuclear Medicine	78580	pulmonary perfusion imaging (e.g., particulate)
Nuclear Medicine	78582	pulmonary ventilation (e.g., aerosol or gas) and perfusion imaging
Nuclear Medicine	78597	quantitative differential pulmonary perfusion, including imaging when performed
Nuclear Medicine	78598	quantitative differential pulmonary perfusion and ventilation (e.g., aerosol or gas), including imaging when performed
Nuclear Medicine	78600	brain imaging limited static
Nuclear Medicine	78601	brain limited imaging and flow
Nuclear Medicine	78605	brain imaging complete
Nuclear Medicine	78606	brain imaging complete with flow
Nuclear Medicine	78610	brain flow imaging only
Nuclear Medicine	78630	cisternogram (cerebrospinal fluid flow)
Nuclear Medicine	78635	cerebrospinal ventriculography
Nuclear Medicine	78645	CSF shunt evaluation
Nuclear Medicine	78650	CSF leakage detection and localization
Nuclear Medicine	78660	radiopharmaceutical dacryocystography
Nuclear Medicine	78699	unlisted nuclear medicine procedures on the nervous system
Nuclear Medicine	78700	kidney imaging morphology
Nuclear Medicine	78701	kidney imaging with vascular flow
Nuclear Medicine	78707	kidney imaging with vascular flow & function single study without pharmacological intervention
Nuclear Medicine	78708	kidney imaging single study with pharmacological intervention
Nuclear Medicine	78709	kidney imaging - multiple studies without & with pharmacological intervention
Nuclear Medicine	78725	kidney function study - non-imaging radioisotopic
Nuclear Medicine	78730	urinary bladder residual study
Nuclear Medicine	78740	ureteral reflux study
Nuclear Medicine	78761	testicular imaging with vascular flow
Nuclear Medicine	78800	radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, single area (includes vascular flow and blood pool imaging, when performed); planar, single (includes vascular flow and blood pool imaging, when performed); planar, single
Nuclear Medicine	78801	radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, 2 or more areas (e.g., abdomen and pelvis, head and chest), 1 or more days imaging or single-area imaging over 2 or more days
Nuclear Medicine	78802	radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, whole body, single-day imaging
Nuclear Medicine	78803	radiopharm localization of tumor tomographic (spect)
Nuclear Medicine	78804	radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, whole body, requiring 2 or more days imaging
Nuclear Medicine	78830	radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (spect) with concurrently acquired computed tomography (CT) transmission scan for anatomical review, localization and determination/detection of pathology, single area (e.g., head, neck, chest, pelvis), single day imaging
Nuclear Medicine	78831	radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (spect), minimum 2 areas (e.g., pelvis and knees, chest and abdomen) or separate acquisitions (e.g., lung ventilation and perfusion), single day imaging, or single area or acquisition over 2 or more days
Nuclear Medicine	78832	radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (spect) with concurrently acquired computed tomography (CT) transmission scan for anatomical review, localization and determination/detection of pathology, minimum 2 areas (e.g., pelvis and knees, chest and abdomen) or separate acquisitions (e.g., lung ventilation and perfusion), single day imaging, or single area or acquisition over 2 or more days
Nuclear Medicine	78999	unlisted procedure, diagnostic nuclear medicine-radiation therapy treatment planning
Nuclear Medicine	93312	tee 2d;incl probe placement, imaging/interp/report
Nuclear Medicine	93313	echocardiography, transesophageal, real-time with image documentation (2d) (with or without m-mode recording); placement of transesophageal probe only
Nuclear Medicine	93314	echocardiography, transesophageal, real-time with image documentation (2d) (with or without m-mode recording); image acquisition, interpretation and report only
Nuclear Medicine	93315	transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report
Nuclear Medicine	93316	transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only
Nuclear Medicine	93317	transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only
Nuclear Medicine	0439T	myocardial contrast perfusion echocardiography, at rest or with stress, for assessment of myocardial ischemia or viability (list separately in addition to code for primary procedure)
Nuclear Medicine	C8926	transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report
Nuclear Medicine	C9762	cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with strain imaging
Nuclear Medicine	C9763	cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with stress imaging
Chiropractic	98940	chiropractic manipulative treatment (CMT); spinal, one (1) to two (2) regions
Chiropractic	98941	chiropractic manipulative treatment (CMT); spinal, 3 - 4 regions
Chiropractic	98942	chiropractic manipulative treatment (CMT); spinal, five (5) regions
Chiropractic	98943	chiropractic manipulative treatment (CMT); extraspinal, one (1) or more regions

Plan-preferred products and Site of Care considerations may apply in line with member benefits. Please confirm the most up-to-date coverage criteria outlined in Highmark’s applicable medical policies, which can be searched via the links available on the Medical Policies page of the Provider Resource Center (PRC).

Our List of Procedures and Durable Medical Equipment (DME) Requiring Authorization is subject to change. To view the current list for your region, go to the PRC’s Obtaining Authorizations page.

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Prior Authorization Updates: Two Additions and 90+ Removals

Sept. 1, 2026 – Prior Authorization Additions

June 1, 2026 – Prior Authorization Removal

June 1, 2026 – Prior Authorization Removal for Nuclear Medicine and Chiropractic Procedures

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