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. The changes effective May 1, 2026 date were also sent via fax on February 24, 2026. 

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 May 1, 2026

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

Medicaid Policies:

• MP-112-MD-PA Prescription Digital Therapeutics - Added medical necessity guidelines for Prescription digital therapeutics (PDTs). Added Program Exception guidance for Somryst® PDT. Added list of PDT products that are considered unproven and experimental/investigational. Added ICD-10 diagnosis codes for Somryst®. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.
• MP-029-MD-PA Passive Oscillatory Devices in the Outpatient Setting - No changes to clinical criteria. Added and removed ICD-10-CM codes per CMS guidance. Updated ‘Reference Sources’ section.

Medicare Policies:

• MP-065-MC-PA Assessing Patient’s Suitability for Electrical Nerve Stimulation Therapy (160.7.1 & 160.7) - No changes to clinical criteria. Updated ‘Reference Sources’ section.
• MP-062-MC-PA Fecal Microbiota Transplant - No changes to clinical criteria. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.
• MP-082-MC-PA Speech-Generating Devices (L33739) - No changes to clinical criteria. Updated ‘Coding Requirements’ section.
• MP-072-MC-PA Ambulatory Blood Pressure Monitor (NCD 20.19) - Policy to be Retired. InterQual criteria exists for listed procedure code.

Policy Updates Effective June 1, 2026

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

Medicaid Policies:

• MP-041-MD-PA Panniculectomy/Abdominoplasty/Lipectomy - Policy is Retired. InterQual criteria exist for the listed procedure.
• MP-017-MD-PA BCR-ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia - No changes to clinical criteria. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.
• MP-079-MD-PA Hypoglossal Nerve Stimulation Implantation in the Treatment of Obstructive Sleep Apnea - Policy to be Retired. InterQual criteria exists for codes listed in the ‘Coding Requirements’ section below.
• MP-082-MD-PA Cosmetic Procedures - No changes to clinical criteria. Added the following tattooing and subcutaneous injection cosmetic procedure codes.
• MP-013-MD-PA Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders - Added procedure code requiring a Program Exception. In the ‘Coding Requirements’ section. Updated ‘Governing Bodies Approval’ and ‘Reference Sources’ sections
• MP-038-MD-PA Wireless Capsule Endoscopy - Policy title changed from ‘Capsule Endoscopy’ to ‘Wireless Capsule Endoscopy’ Removed ‘Program Exception’ requirement for procedure code 91110, code has been added to the PA Fee Schedule. Updated ‘Governing Bodies’, Summary of Literature’ and ‘Reference Sources’ sections.
• MP-128-MD-PA Nerve Conduction Studies (NCS) and Electromyography (EMG) - Policy to be Retired. InterQual criteria exists for codes listed in ‘Coding Requirements’ section.
• MP-130-MD-PA Intraoperative Neurophysiologic Monitoring - No changes to clinical criteria. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.
• MP-077-MD-PA Supervised Exercise Therapy (SET) in the Management of Peripheral Artery Disease - No changes to clinical criteria. Updated ‘Reference Sources’ section.

Medicare Policies:

• MP-019-MC-PA Bronchial Thermoplasty - No changes to clinical criteria. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.
• MP-090-MC-PA 4Kscore Test Algorithm (L37792) - No changes to clinical criteria.
• MP-079-MC-PA Assays for Vitamins and Metabolic Function (L34914) - No changes to clinical criteria. Removed and added ICD codes. Updated CMS hyperlinks. Updated ‘Reference Sources’ section.
• MP-091-MC-PA Micro-Invasive Glaucoma Surgery (MIGS) (L38223) - Policy to be Retired. InterQual exists for procedure codes listed in the ‘Coding Requirements’ section.