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 Aug. 1, 2026

As a reminder, we have updated or reviewed the following Medical Policies, with changes effective Aug. 1, 2026. These updates were 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.