Prior Authorization Updates Effective July 1, 2025
Date: 05/22/25
MHS Health Wisconsin requires prior authorization (PA) as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements, which is also applicable to all Medicare products offered by MHS Health.
MHS Health is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.
It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.
For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool.
The following are changes to prior authorization requirements, effective July 1, 2025.
Service Category | Prior Auth (PA) Rule | Services | Procedure Codes |
Durable Medical Equipment | PA Required | Wheelchairs | E1012 |
No PA Required | Beds | E0184 | |
Neurostimulators | E0720, E0730 | ||
Equipment & Accessories | E0953 | ||
Wheelchairs | E0954, E0956, E0973, E0990, E2359, E2361, E2363, E2365, E2607, E2624, K0019, K0043, K0733 | ||
Surgery Procedures | PA Required | Skin Grafts | Q4205 |
Codes that will require prior authorization to be submitted to MHS Health Wisconsin as of July 1, 2025:
| Code | Description |
|---|---|
| 64568 | Open implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator |
| 37229 | Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performedRevascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed |
| 37227 | Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed |
| 31276 | Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa |
| 31295 | Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia |
| 31298 | Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty) |
| 42145 | Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium |
| 31296 | Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500-99602 can be used) |
Codes that will not require prior authorization to be submitted to MHS Health Wisconsin as of July 1, 2025:
| Code | Description |
|---|---|
| 97605 | Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters |
| 97606 | Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters |
| 11055 | Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion |
| 11056 | Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 2 to 4 lesions |
| 11057 | Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); more than 4 lesions |
| 81257 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; common deletions or variant (eg, Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7, alpha4.2, alpha20.5, Constant Spring) |
| K0001 | Standard wheel chair |
Thank you for being a valued partner in caring for the health and well-being of our members. If you have any questions about the information above, please contact your Provider Relations 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.