26-075 Updates to the Prior Authorization Requirements
Date: 01/26/26
Changes to codes requiring prior authorization, effective April 1, 2026
As part of our ongoing work to improve the prior authorization (PA) process for physicians, practitioners, other providers and members, Health Net* is sharing some important updates to our Commercial (Individual and Family Plans (Ambetter HMO/PPO) and Employer Group HMO/POS and PPO), Medi-Cal and Medicare PA requirements. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care.
How to access prior authorization requirements
Access the PA requirements lists via either option below:
- Go to the Provider Library > select a line of business > Prior Authorization Requirements (on the left side).
- Go to Prior Authorizations and select Medi-Cal Fee-for-Service Health Net, Commercial – California, or Medicare – California.
Additions and removals, effective April 1, 2026
The tables below include services, procedures, equipment or outpatient pharmaceuticals that either require PA or no longer require PA beginning April 1, 2026.
Additions, effective April 1, 2026
The below services, procedures, equipment or outpatient pharmaceuticals require PA beginning April 1, 2026.
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Medicare | Commercial | Medi-Cal | Category | CPT/HCPCS code |
|---|---|---|---|---|
PA required | No change | No change | Reconstructive and cosmetic surgery, services and supplies: excision, excessive skin | 15734, 15736, 15738 |
No change | PA required | No change | Outpatient surgery: wrist | 25111, 29848 |
No change | PA required | No change | Reconstructive and cosmetic surgery, services and supplies: treatment of varicose veins | 36482 |
No change | PA required | No change | Unlisted services and procedures | 37799 |
No change | PA required | PA required | Outpatient pharmaceuticals: Nulojix® | J0485 |
No change | No change | PA required | Reconstructive and cosmetic surgery, services and supplies: eye or brow procedures | 14060 |
No change | No change | PA required | Reconstructive and cosmetic surgery, services and supplies | 21235, 31254, 31256, 31267 |
No change | No change | PA required | Outpatient surgery: wrist or thumb surgery | 25447 |
No change | No change | PA required | Cardiac procedures: transluminal angioplasty on an additional unilateral tibial or peroneal artery | 37232 |
No change | No change | PA required | Cardiac procedures: intravascular stent | 37236, 37237, 37238, 37239 |
No change | No change | PA required | Balloon angioplasty | 37246, 37247, 37248, 37249 |
No change | No change | PA required | Outpatient surgery: laparoscopic myomectomy | 58545 |
No change | No change | PA required | Outpatient surgery: thyroid | 60240, 60252, 60500 |
No change | No change | PA required | Neurostimulator | 64555, 64561, 64568 |
No change | No change | PA required | Cardiac procedures: percutaneous transluminal coronary angioplasty additional artery branch | 92921 |
No change | No change | PA required | Electroencephalogram
| 95700, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95721, 95722, 95723, 95724, 95725, 95726 |
No change | No change | PA required | Hyperbaric oxygen therapy | 99183, G0277 |
No change | No change | PA required | Unlisted services and procedures | 99199 |
No change | No change | PA required | Enteral nutrition products | B4104, B4105 |
No change | No change | PA required | Durable medical equipment (DME): incontinence supplies | T4525, T4526, T4527, T4528, T4529, T4530, T4533, T4543 |
Removals, effective April 1, 2026
The below services, procedures, equipment or outpatient pharmaceuticals no longer require PA beginning April 1, 2026.
Medicare | Commercial | Medi-Cal | Category | CPT/HCPCS code |
|---|---|---|---|---|
No change | No PA required | No change | Prosthetic | L5652 |
No change | No change | No PA required | Outpatient elective surgery: pediatric members ages 0-20 | 11105, 11106, 11107, 26055, 29848, 52000, 52005, 52204, 52351, 54161, 54640, 64718, 64719, 64721 |
No change | No change | No PA required | DME: adults − items with a total Medi-Cal purchase price greater than $1,500 | A4322, E0600 |
No change | No change | No PA required | Pediatrics: DME for pediatric members | E0730 |
No change | No change | No PA required | DME: wheelchair accessory | E0950, E0956 |
No change | No change | No PA required | Orthotic | L2330 |
No change | No change | No PA required | Prosthetic | L8420, L8440, L8470, L8480, L8485 |
No change | No PA required | No PA required | Wound care | 13131, 13132, 13133, 13153,13160, 97602, 97605, 97606, 97607, 97608, 97610 |
No change | No PA required | No PA required | Genetic counseling | S0265 |
No PA required | No change | No change | Neurology: neuroplasty procedures | 64718, 64719 |
No PA required | No change | No change | DME: hospital beds and mattresses | E0185 |
No PA required | No change | No change | DME: custom made items | E0486 |
No PA required | No change | No change | Orthotics | L1951 |
No PA required | No change | No change | DME: oxygen | K0738 |
No PA required | No change | No change | Part B medication − Dexamethasone | J1096 |
No PA required | No change | No change | Genetic testing | 81256 |
No PA required | No change | No change | Ophthalmology: cataract procedures | 66982, 66984 |
Need help? Contact us
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by phone or through the Health Net provider portal. Behavioral health providers can call 844-966-0298.
Provider Services
Line of business | Phone number | |
Ambetter from Health Net IFP Ambetter PPO | ||
Ambetter HMO | ||
Health Net Employer Group HMO, POS, & PPO | ||
Medicare (Individual & Employer Group) (Wellcare By Health Net) | ||
Medicare Supplement | ||
Medi-Cal (including CS and ECM providers) | N/A |
This information applies to Physicians, Practitioners, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, and Behavioral Health Providers.
For Medi-Cal, this information applies to Amador, Calaveras, Inyo, Los Angeles, Molina, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.