26-1201 Updates to Prior Authorization Requirements

Date: 10/27/26

Review changes, effective immediately through January 1, 2027

Prior authorization (PA) requirement changes apply to certain services, procedures, equipment and outpatient medications.

These updates reflect new CPT/HCPCS codes issued by the Centers for Medicare & Medicaid Services (CMS) and other changes implemented by Health Net* for select services and medications.

In the tables below, “X” indicates the applicable line(s) of business. “N/A” indicates “not applicable.”

What providers need to do

• Review the code lists below for changes affecting your practice.
• Submit PA requests for services requiring authorization starting on the effective date.
• Verify member eligibility and benefits before providing services. Changes to PA requirements do not constitute, imply or confirm benefit coverage, as authorization requirements are independent of coverage determinations.
• Use current PA requirements when submitting requests.

Key effective dates

• Changes, effective immediately.
• Additions, effective January 1, 2027.
• Removals, effective November 1, 2026, and January 1, 2027.

Avoid appeals and grievances cases related to prior authorization

Incomplete or incorrect prior authorization requests may result in member appeals or grievances.

To help avoid delays and follow-up requests:

• Submit complete and accurate prior authorization requests.
• Follow the correct requirements and response time frames for the applicable line of business.

For more information and resources on appeals and grievances and prior authorization:

1. Go to Provider Library and select the appropriate line of business.
2. Open the Provider Manual and navigate to the following sections:

-  Appeals, Grievances and Disputes

-  Prior Authorization Requirements

How to access PA requirements

Use one of these options:

• Visit Prior Authorizations and select one of the following:
  • Medi-Cal Fee-for-Service Health Net
  • Commercial – California
  • Medicare – California
• Visit Provider Library > select line of business > Prior Authorization Requirements.

Changes, effective immediately

Changes to the preferred or non-preferred status for the biosimilar medications listed below are effective immediately.

HMO/POS/PPO	Medi-Cal	Medicare	Category	Change
N/A	X	N/A	Denosumab (Prolia®, Xgeva® and biosimilars)	Non-preferred (bone metastasis): Aukelso™, Bomyntra®, Jubereq®, Osenvelt®, Oziltus®, Wyost®, Xbryk®, Xgeva Preferred (bone metastasis): Bilprevda®, Xtrenbo™ Non-preferred (osteoporosis): Boncresa™, Bonsaya™, Conexxence®, Jubbonti®, Ospomyv™, Osvyrti®, Ponlimsi™, Prolia, Stoboclo® Preferred (osteoporosis): Bildyos®, Enoby™
N/A	X	N/A	Ustekinumab agents	Non-preferred: Imuldossa®, Starjemza™, Stelara®, Unbranded Pyzchiva®, Wezlana™ Preferred: Brand Pyzchiva, Otulfi®, Selarsdi™, Steqeyma®, Yesintek™
X	N/A	N/A	Denosumab (Prolia®, Xgeva® and biosimilars)	Nonpreferred (bone metastasis): Aukelso, Bomyntra, Jubereq, Oziltus, Xgeva Preferred (bone metastasis): Bilprevda, Osenvelt, Wyost, Xtrenbo Nonpreferred (osteoporosis): Boncresa, Bonsaya, Conexxence, Jubbonti, Ospomyv, Osvyrti, Ponlimsi, Prolia Preferred (osteoporosis): Bildyos, Enoby, Stoboclo
X	N/A	N/A	Ustekinumab agents	Nonpreferred: Imuldosa, Otulfi, Selarsdi, Starjemza, Unbranded Pyzchiva, unbranded Stelara, Wezlana Preferred: Brand Pyzchiva, brand Stelara, Steqeyma, Yesintek

 

Additions, effective January 1, 2027

PA is required for the following, effective January 1, 2027.

HMO/POS/PPO	Medi-Cal	Medicare	Category	CPT/HCPCS code
N/A	N/A	X	Wound care	97605, 97606
X	X	N/A	Outpatient pharmaceuticals: Gene therapy − Kresladi™	N/A
X	X	N/A	Outpatient pharmaceuticals: Pegfilgrastim − Ennumo™	N/A
X	X	N/A	Outpatient pharmaceuticals: Yondelis®	J9352
X	X	N/A	Scalp cooling	97007, 97008, 97009

 

Removals, effective November 1, 2026

The following no longer require PA, effective November 1, 2026.

HMO/POS/PPO	Medi-Cal	Medicare	Category	CPT/HCPCS code
N/A	N/A	X	Orthopedic − endoscopy (wrist)	29848
N/A	N/A	X	Reconstructive and cosmetic − nasal	30520
N/A	N/A	X	Ear, nose and throat (ENT) − nasal/sinus endoscopy	31256, 31267
N/A	N/A	X	Genetic testing	88271, 88275, 88280
N/A	N/A	X	Capsule endoscopy	91110, 91111, 91112, 91113
N/A	N/A	X	Durable medical equipment (DME) and supplies − BiLevel positive airway pressure (BiPAP); continue to refer members to Apria Healthcare	E0470, E0471
N/A	N/A	X	DME and supplies − lymphedema pumps and supplies	E0656, E0657
N/A	N/A	X	DME and supplies	E0935
N/A	N/A	X	DME and supplies − wheelchair accessory	E1032, E1033, E1034, E1226, E2310, E2374, E2608, E2613, E2622, E2623, E2615
N/A	N/A	X	Orthotics	L0457, L0650, L1932, L1940, L1960, L2330, L3030
N/A	N/A	X	Gender reassignment services	14000, 14040, 14041, 15100
N/A	N/A	X	Neuropsychological testing	96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146
N/A	N/A	X	Neurostimulator	64566
N/A	N/A	X	Home health services − home health aide	99341, 99342, 99344, 99345, 99347, 99348, 99350
N/A	N/A	X	Home health services − home IV infusion	99601, 99602

 

Removals, effective January 1, 2027

The following no longer require PA, effective January 1, 2027. For more information about the Community Supports removals, please refer to provider update 26-989, Changes to Community Supports Services, Effective January 1, 2027.

HMO/POS/PPO	Medi-Cal	Medicare	Category	CPT code
X	N/A	N/A	Cleft lip or other craniofacial anomalies	21089, 40650, 40652, 40654
N/A	X	N/A	Community Supports Assisted Living Facility Transitions Personal Care and Homemaker Services Short-Term Post-Hospitalization Housing	N/A

 

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Need help? Contact us

If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center.

Provider Services

Line of business	Phone number	Email
Ambetter from Health Net IFP Ambetter PPO	844-463-8188	email
Ambetter HMO	888-926-2164	email
Health Net Employer Group HMO, POS, & PPO	800-641-7761	email
Medicare (Individual & Employer Group) (Wellcare By Health Net)	800-929-9224	email
Medicare Supplement	800-641-7761	email
Medi-Cal (including CS and ECM providers)	800-675-6110	N/A
Behavioral Health providers	844-966-0298	N/A

 

This information applies to Physicians and 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.