Important Prior Authorization Updates
Date: 01/06/26
Important Prior Authorization Updates
(Effective Apr. 1, 2026)
As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, Managed Health Services (MHS) wants to share some important updates to our PA requirements. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care.
Code change details can be found below. These changes may include:
Removing PA requirements based on criticality of review and clinical need.
Creating a more uniform set of prior authorization requirements across our markets and lines of businesses, including adding and changing some PA requirements, to simplify processes, reduce confusion for providers, and support future efforts to expand real-time responses to requests.
If you have questions about specific prior authorization codes or how these changes affect your practice, please reach out to your local Provider Engagement representative.
Service Category
|
PA Rule
|
Services
|
Procedure codes
|
|---|---|---|---|
DME Services
|
PA Required
|
Beds
|
E0277
|
Diabetic Drugs And Supplies
|
E0784
| ||
Nutritional Services
|
B4105
| ||
Orthotic & Prosthetic
|
L0460, L0462, L0464, L0650, L1832
| ||
Supplies and Devices
|
E0445, E0781
| ||
Wheelchairs
|
E1028, E2620, E2621
| ||
PA Required beyond 186 units per calendar month or the benefit limitation—whichever is greater
|
Incontinence Supplies
|
T4525, T4526, T4527, T4528, T4529, T4530, T4533, T4543
| |
PA Required after plan benefit limitation
|
Nutritional Services
|
B9998
| |
No PA Required if member is under 21 years old at date of service. PA Required for all other members.
|
Nutritional Services
|
B4100
| |
Drug Codes
|
PA Required
|
Injections
|
J0878, J0888, Q5126, Q5129, Q5130
|
Genetic Analysis
|
PA Required
|
Genetic Testing
|
0345U, 88262, 88271, 88275
|
Other Medical Services
|
PA Required
|
Hyperbaric Oxygen Therapy |
99183
|
Wound Care
|
E2402
| ||
Physical Medicine
|
PA Required
|
Orthotic & Prosthetic
|
L5673
|
Physician Services
|
PA Required
|
Neurological Tests
|
95700, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95721, 95722, 95723, 95724, 95725, 95726
|
Skin Procedures
|
PA Required
|
Muscle Flap Procedures
|
15736, 15738
|
PA Required if billed with diagnosis of gender dysphoria. For all others, PA Required for Non-PAR Providers only
|
Skin Grafts
|
14060, 14061
| |
Surgery Procedures
|
PA Required
|
Hysterectomies |
58545
|
Joint Replacement Surgery |
25447
| ||
Rhinoplasties
|
30460, 30462, 30520
| ||
Surgery-Cardiovascular System |
37232, 37247
| ||
Surgery-Endocrine System
|
60240, 60252, 60500
| ||
Surgery-Heart
|
92920, 92921
| ||
Surgery-Musculoskeletal System
|
28285, 28296
| ||
Surgery-Nervous System
|
64582
| ||
Surgery-Respiratory System
|
30130, 30140, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276
|