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 March 1, 2026

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

Medicaid Policies:

MP-144-MD-PA Observation and Inpatient Admissions– New Policy

MP-096-MD-PA Scanning Computerized Ophthalmic Diagnostic Imaging - Added procedure code. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.

MP-110-MD-PA Speech Generating Devices - Coding Revision: Added diagnosis code, along with coding directions.

MP-075-MD-PA Myoelectric Upper Extremity Orthoses - Policy changed from 'experimental/investigational' stance to 'covered when medically necessary'. Added medical necessity coverage criteria. Added covered and noncovered HCPCS codes

MP-005-MD-PA Gene Expression Testing for Cancer Treatment (Breast, Colon, Prostate) - No changes to clinical criteria. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.

MP-061-MD-PA Molecular Tumor Markers for Non-Small Cell Lung Cancer (NSCLC) - No changes to clinical criteria. Updated ‘Summary of Literature’ and ‘Reference Sources’ sections.

MP-133-MD-PA Treatment of Varicose Veins/Venous Insufficiency - Policy Retired as InterQual® criteria exists for procedure codes listed in the ‘Coding Requirements’ section.

MP-085-MD-PA Artificial Pancreas - Policy Retired as InterQual® criteria currently exists for all procedure codes in ‘Coding Requirements’ section.

Medicare Policies:

MP-105-MC-PA Post-Acute Care – New Policy

MP-104-MC-PA and Inpatient Admissions – New Policy

MP-039-MC-PA Hyperbaric Oxygen Therapy (HBOT) (NCD 20.29) - Policy to be Retired. InterQual® criteria exists for all codes in ‘Coding Requirements’ section.

MP-103-MC-PA Treatment of Chronic Venous Insufficiency of the Lower Extremities (L34924) - Policy to be Retired. InterQual® criteria exists for all procedure codes listed in ‘Coding Requirements’ section.