Important Prior Authorization Updates Effective April 1, 2026
2026/2/27
•
Posted by Provider Relations
in
Provider News
As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, Fidelis Care wants to share some important updates to our PA requirements for Medicaid, Ambetter From Fidelis Care and Medicare lines of business. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care.
Code change details for each line of business 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.
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Medicaid
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Service Category
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PA Rule
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Services
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Procedure codes
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Breast Services
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No PA Required if billed with breast cancer diagnosis. PA Required if billed with any other diagnosis
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Breast Reconstruction
|
19350, 19364
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Surgery-Integumentary System
|
19303
|
|
DME Services
|
PA Required
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Neurostimulators
|
E0745
|
|
Orthotic & Prosthetic
|
L0460, L0462
|
|
Supplies and Devices
|
E1390
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|
Wheelchairs
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E1028, K0826, K0836, K0837, K0838, K0839, K0841, K0843, K0850, K0857, K0858, K0863, K0884
|
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No PA Required if member is under 21 years old at date of service. PA Required for all other members.
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Nutritional Services
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B4100
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|
No PA Required for PAR providers
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Neurostimulators
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E0730
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Orthotic & Prosthetic
|
L2330
|
|
Supplies and Devices
|
E0600
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|
Wheelchairs
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E0950, E0956
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Drug Codes
|
PA Required
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Injections
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J0485, J0878, J1437, J3240, Q0138, Q0139, Q4081, Q5105
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Medications
|
J0604
|
|
Genetic Analysis
|
PA Required
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Genetic Testing
|
81201, 81292, 81329, 88262, 88271, 88275
|
|
Other Medical Services
|
No PA Required for PAR providers
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Wound Care
|
97605, 97606, 97607, 97608
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|
Pain Management
|
PA Required
|
Surgery-Nervous System
|
62350, 62362
|
|
PA Required
|
Surgery-Nervous System
|
64445
|
|
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
|
|
Skin Grafts
|
15271, 15274, 15275, 15276
|
|
No PA Required for PAR providers
|
Skin Grafts
|
14060, 14061, 15100, 15101, 15120
|
|
PA Required after 12 visits per calendar year
|
Surgery-Integumentary System
|
11043
|
|
Surgery Procedures
|
PA Required
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Bariatric Surgery
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43644, 43645
|
|
Hysterectomies
|
58545
|
|
Joint Replacement Surgery
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25447, 27702
|
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Spinal Surgery
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22830, 63200
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|
Surgery-Heart
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92920
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Surgery-Musculoskeletal System
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28285, 28296
|
|
No PA Required for PAR providers
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Hysterectomies
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58260, 58262, 58550, 58552, 58553, 58554
|
|
Surgery-Male Genitalia
|
54520
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|
Ambetter From Fidelis Care
|
|
Service Category
|
PA Rule
|
Services
|
Procedure codes
|
|
Breast Services
|
No PA Required if billed with breast cancer diagnosis. PA Required if billed with any other diagnosis
|
Surgery-Integumentary System
|
19303
|
|
DME Services
|
No PA Required for PAR providers
|
Wheelchairs
|
K0004
|
|
Drug Codes
|
PA Required
|
Injections
|
J3240, Q0138, Q0139, Q5105
|
|
Genetic Analysis
|
PA Required
|
Genetic Testing
|
0037U
|
|
No PA Required for PAR providers
|
Genetic Testing
|
81252
|
|
Physical Medicine
|
No PA Required for PAR providers
|
Orthotic & Prosthetic
|
L5652
|
|
Skin Procedures
|
PA Required
|
Muscle Flap Procedures
|
15734, 15736, 15738
|
|
Surgery Procedures
|
PA Required
|
Surgery-Musculoskeletal System
|
25111, 29848
|
|
Medicare
|
|
Service Category
|
PA Rule
|
Services
|
Procedure codes
|
|
DME Services
|
No PA Required for PAR providers
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Beds
|
E0185
|
|
Orthotic & Prosthetic
|
L1951
|
|
Supplies and Devices
|
E0486, K0738
|
|
Drug Codes
|
No PA Required for PAR providers
|
Medications
|
J1096
|
|
Genetic Analysis
|
No PA Required
for PAR providers
|
Genetic Testing
|
81240, 81256
|
|
Other Medical Services
|
No PA Required for PAR providers
|
Wound Care
|
E2402
|
|
Physical Medicine
|
No PA Required for PAR providers
|
Orthotic & Prosthetic
|
L5629, L5637
|
|
Physician Services
|
No PA Required for PAR providers
|
Other Services
|
99499, G3002
|
|
Skin Procedures
|
PA Required
|
Muscle Flap Procedures
|
15734, 15736, 15738
|
|
No PA Required for PAR providers
|
Surgery-Integumentary System
|
11721, 17000, 17250
|
|
Surgery Procedures
|
No PA Required for PAR providers
|
Surgery-Nervous System
|
64718, 64719
|
|
Vision Services
|
No PA Required for PAR providers
|
Vision Evaluation
|
92004, 92201, 92250
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