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.

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:  November 1, 2026

Medicaid

New

1.    MP-156-MD-PA Hospital Beds

2.    MP-157-MD-PA Blood Glucose Monitors with Voice Synthesizer and Integrated Lancing/Blood Sample

Annual Review

1.    MP-013-MD-PA Whole Exome Genome

2.    MP-033-MD-PA Gender Affirmation

3.    MP-118-MD-PA Experimental and Investigational

4.    MP-072-MD-PA Ground Ambulance

Retire

1.    MP-052-MD-PA Breast Reconstructive

2.    MP-107-MD-PA Prostatic Urolift

Medicare

New

1.    MP-107-MC-PA Respiratory Pathogen Panel Testing (L38916)

2.    MP-108-MC-PA Thyroid Disorder Laboratory Testing

3.    MP-109-MC-PA Somatic Mutation Testing

4.    MP-110-MC-PA Pathology Testing with Mohs Micrographic Surgery

5.    MP-111-MC-PA Nail Disorder Infectious Disease Testing, Including Onychomycosis