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 July 1, 2026

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

Medicaid Policies:

• MP-012-MD-PA Chromosomal Microarray Analysis (CMA): Comparative Genomic Hybridization (CGH) and Single Nucleotide Polymorphism (SNP) - Updated guidelines for chromosomal microarray testing for intrauterine fetal demise or stillbirth, under ‘Procedure’ section. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.
• MP-108-MD-PA Multimarker Serum Testing Related to Ovarian Cancer - No changes to clinical criteria. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.
• MP-113-MD-PA Gastrointestinal Pathogen Assays - No changes to clinical criteria. Removed deleted procedure code 0369U from policy. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.
• MP-073-MD-PA Ambulance Services – Air - No changes to coverage criteria. Updated ‘Reference Sources’ section.
• MP-071-MD-PA Non-Oncologic/Congenital Anomalies Genetic Testing Panels – Removed ‘Coding Requirements’ section.
• MP-054-MD-PA Enteral Feeding In-Line Cartridge - Policy will be Retired and merged with new medical policy MP-147-MD-PA ‘Enteral Nutrition’ medical policy.
• MP-058-MD-PA Pulmonary Rehabilitation (PR) - No changes to clinical criteria. Removed procedure and diagnosis codes. Added diagnosis codes. Updated ‘Summary of Literature’ section.
• MP-148-MD-PA Respiratory Infection Pathogen Panel (RIPP) Molecular Testing – New Policy.
• MP-149-MD-PA Thyroid Disorder Laboratory Testing – New Policy.
• MP-150-MD-PA Somatic Mutation Testing – New Policy.
• MP-151-MD-PA Pathology Testing with Mohs Micrographic Surgery – New Policy.
• MP-152-MD-PA Nail Disorder Infectious Disease Testing, Including Onychomycosis – New Policy.

Medicare Policies:

• MP-045-MC-PA Cardiac Rhythm Device Evaluation (L34833) - No change to clinical criteria. Updated ‘Reference Sources’ section.
• MP-001-MC-PA Cataract Extraction (including Complex Cataract Surgery) (L35091) - Policy to be Retired. InterQual® criteria exist for all procedure codes listed in the ‘Coding Requirements’ section.
• MP-053-MC-PA Electrocardiographic Services (NCD 20.15) - Policy to be Retired. InterQual® criteria exist for electrocardiographic services.
• MP-073-MC-PA Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) (L35350) - Policy to be Retired. InterQual® criteria exist for all procedure codes listed in the ‘Coding Requirements’ section.
• MP-078-MC-PA Scanning Computerized Ophthalmic Diagnostic Imaging (L35038) - Policy to be Retired. InterQual® criteria exist for highlighted procedure codes in the ‘Coding Requirements’ section.
• MP-089-MC-PA Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (L38385) - Policy to be Retired. InterQual® criteria exist for all procedure codes listed in the ‘Coding Requirements’ section.
• MP-092-MC-PA Peripheral Nerve Stimulation (L37360) - Policy to be Retired. CMS LCD “Peripheral Nerve Stimulation (L37360)” has been Retired.
• MP-093-MC-PA Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs) (L38229) - Removed deleted procedure code 0369U from ‘Coding Requirements’ section, per CMS guidance. Updated CMS hyperlink and ‘Reference Sources’ section.
• MP-101-MC-PA Ambulatory Electrocardiograph (AECG) Monitoring (L39490) - Policy to be Retired. InterQual® criteria exist for all codes listed in the ‘Coding Requirements’ section.
• MP-106-MC-PA Knee Pain Treatment with Genicular Procedures – New Policy.

Policy Updates Effective Aug. 1, 2026

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

Medicaid Policies:

• MP-094-MD-PA Magnetic Resonance-Guided Focused Ultrasound (MRgFUS) - No changes to Experimental/Investigational stance. Updated ‘Summary of Literature’ section.
•  MP-022-MD-PA Negative Pressure Wound Therapy in the Outpatient Setting - No changes to clinical criteria. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.

Medicare Policies:

• MP-063-MC-PA Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder (LCD 34998) - Policy to be Retired. InterQual® criteria exist for all procedure codes listed in the ‘Coding Requirements’ section.
•  MP-040-MC-PA Home Oxygen Therapy (L33797) - Policy to be Retired. InterQual® criteria exist for home oxygen therapy.
• MP-058-MC-PA Cochlear Implantation (NCD 50.3) - Policy to be Retired. InterQual® criteria exist for highlighted procedure codes in the ‘Coding Requirements’ section.