Prior Authorization Changes (Effective Apr. 1, 2026)

Date: 01/22/26

As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, Meridian, Ambetter from Meridian, and Wellcare want 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 via out our Provider Relations Inquiry Form.

Meridian (Medicaid) Prior Authorization Updates

Service Category	PA Rule	Services	Procedure codes
Behavioral Health	PA Required	Treatment Services	H2012, S9480
Behavioral Health	No PA Required for all providers for the first 8 combined hours per member per calendar year for codes 96130, 96131, 96132, 96133, 96136 and 96137 billed with behavioral health diagnoses. For all other diagnosis types and, or requests beyond 8 hours, PA is Required.	Treatment Services	96130, 96131, 96132, 96133, 96136, 96137
Breast Services	No PA Required if billed with breast cancer diagnosis. PA Required if billed with any other diagnosis	Breast Reconstruction	19364
DME Services	PA Required	Beds	E0277
		Nutritional Services	B4102, B4104
		Orthotic & Prosthetic	L0460, L0462, L1832, L1940, L1970, L2280
		Supplies and Devices	E0781, E1390
		Wheelchairs	E1010, E1011, 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	B4149, B4150, B4152, B4153, B4154, B4155
Drug Codes	PA Required	Injections	J0517
Drug Codes	PA Required	Medications	J0604
Genetic Analysis	PA Required	Genetic Testing	0345U
Home Services	PA Required	Home Therapy	S5120, S5121
		Infusion Services	S9351
		Nursing Services	S9123
Pain Management	PA Required	Surgery-Nervous System	64640
Physician Services	PA Required	Neurological Tests	95700, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95721, 95722, 95723, 95724, 95725, 95726
Skin Procedures	PA Required	Skin Grafts	15271, 15274, 15275, 15276
	PA Required if billed with diagnosis of gender dysphoria. For all others, PA Required for Non-PAR Providers only	Skin Grafts	14060, 14061, 15100, 15101, 15120
	PA Required after 12 visits per calendar year	Surgery-Integumentary System	11043
Surgery Procedures	PA Required	Hysterectomies	58545
		Joint Replacement Surgery	25447
		Rhinoplasties	30465
		Spinal Surgery	63200
		Surgery-Endocrine System	60240, 60252, 60500
		Surgery-Musculoskeletal System	28285, 28296
		Surgery-Nervous System	64582
		Surgery-Respiratory System	30130, 30140, 31253, 31254, 31255, 31256, 31257, 31259, 31267
	PA Required if billed with diagnosis of gender dysphoria. For all others, PA Required for Non-PAR Providers only	Surgery-Male Genitalia	54520

Ambetter from Meridian (Marketplace) Prior Authorization Updates

Service Category	PA Rule	Services	Procedure codes
DME Services	PA Required	Diabetic Drugs And Supplies	A9276
	No PA Required for PAR providers	Diabetic Drugs And Supplies	A9279
	No PA Required for PAR providers	Wheelchairs	K0004
Drug Codes	PA Required	Injections	J0887
Genetic Analysis	No PA Required for PAR providers	Genetic Testing	81252
Pain Management	PA Required	Surgery-Nervous System	64495
Physical Medicine	No PA Required for PAR providers	Orthotic & Prosthetic	L5652
Surgery Procedures	PA Required	Surgery-Musculoskeletal System	25111

Wellcare (Medicare) Prior Authorization Updates

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	No PA Required for PAR providers	Medications	J1096
Genetic Analysis	No PA Required for PAR providers	Genetic Testing	81240, 81256
Imaging Services	No PA Required for PAR providers	Nuclear Medicine	77002
Physician Services	No PA Required for PAR providers	Other Services	G3002
Skin Procedures	PA Required	Muscle Flap Procedures	15734, 15736, 15738
Surgery Procedures	No PA Required for PAR providers	Surgery-Nervous System	64718, 64719

Last Updated: 01/22/2026