Medicare Prior Authorization Updates - Effective April 1, 2026

Date: 01/12/26

As part of our ongoing work to improve the prior authorization (PA) process for both Medicare providers and members, Wellcare 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. They are effective April 1, 2026. 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.
  
  

Service Category	PA Rule	Services	Procedure codes
DME Services	No PA Required for PAR providers	Beds	E0185
		Orthotic & Prosthetic	L1951
		Supplies and Devices	E0486
Drug Codes	PA Required	Injections	J0129, J0178, J1602, J1745, J2350, J2777, J3380, Q5124, Q5128
	No PA Required for PAR providers	Medications	J1096
Genetic Analysis	PA Required	Genetic Testing	0242U
Hearing Services	PA Required	Implants and Supplies	69930
Imaging Services	No PA Required for PAR providers	Nuclear Medicine	77002
Skin Procedures	PA Required	Muscle Flap Procedures	15734, 15736, 15738
	PA Required after 12 visits per calendar year	Surgery-Integumentary System	11042
Surgery Procedures	PA Required	Rhinoplasties	30465
	No PA Required for PAR providers	Surgery-Nervous System	64718, 64719

Thank you for being a valued partner in caring for the health and well-being of our members. If you have any questions about specific prior authorization codes or how these changes affect your practice, please reach out to your local Provider Engagement representative or call the Provider Inquiry Line at 1-800-222-9831. If you are unsure who is your representative, please email us at WI_Provider_Relations@mhswi.com.