26-877 Updates to Prior Authorization Requirements
Date: 07/28/26
Review code changes, effective July 1 – October 1, 2026
Prior authorization (PA) requirement changes apply to certain services, procedures, equipment and outpatient drugs.
These updates reflect new CPT/HCPCS codes issued by the Centers for Medicare & Medicaid Services (CMS) and support efforts to streamline the PA process and improve timely access to appropriate care.
What physicians and other 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
- New CPT and HCPCS issued by the Centers for Medicare & Medicaid Services (CMS) requiring authorization, effective July 1, 2026.
- Addition, effective July 28, 2026.
- Additions and removals, effective October 1, 2026.
How to access PA requirements
To access the LA-DHS PA requirements, go to Prior Authorizations and select Medi-Cal Los Angeles County Department of Human Services (LA-DHS) Participating Physician Groups.
Additions, effective July 1, 2026
The following new codes issued by CMS require PA, effective July 1, 2026.
Category | CPT/HCPCS code |
|---|---|
Genetic testing | 0631U, 0632U, 0634U, 0635U, 0640U, 0641U, 0642U, 0643U, 0644U, 0645U, 0646U, 0647U, 0648U, 0649U, 0650U, 0651U, 0652U, 0653U, 0654U, 0655U, 0656U, 0657U, 0658U, 0659U |
Outpatient pharmaceuticals | C9310, J1289, J1577, J2361, J3386, J3405, J9053, J9062, Q5164, Q5165, Q5166, Q5167, Q5168, Q5169, Q5170, Q5171 |
Proprietary laboratory analyses | 0636U, 0637U, 0638U, 0639U |
Addition, effective July 28, 2026
PA is required for the following code, effective July 28, 2026.
Category | CPT/HCPCS code |
|---|---|
Experimental/investigational services and new technologies | 0686T |
Additions, effective October 1, 2026
PA is required for the following codes, effective October 1, 2026.
Category | CPT/HCPCS code |
|---|---|
Dental anesthesia | G0330 |
Proprietary laboratory analyses | 0558U, 0559U, 0570U, 0572U, 0573U, 0574U, 0581U, 0584U, 0590U, 0593U, 0594U |
Respite services (Community Supports service) | S9125 |
Unlisted services and procedures | 91299 |
Removals, effective October 1, 2026
The following codes no longer require PA, effective October 1, 2026. Changes include reduced requirements for members under age 21.
Category | CPT/HCPCS code |
|---|---|
Behavioral health | 96121 |
Durable medical equipment
| A4651, A4657, A4660, A4663, A4670, A4673, A4927, A4930, A5051, A5054, A5055, A5056, A5061, A5062, A5063, A5071, A5073, A5081, A5082, A5102, A5112, A5114, A5120, A5121, A5122, A5126, A5131, A5200, A5500, A5503, A5504, A5507, A5512, A5513, A5514, A6011, A6021, A6022, A6154, A6196, A6198, A6199, A6203, A6204, A6205, A6206, A6207, A6209, A6211, A6212, A6213, A6214, A6215, A6216, A6217, A6218, A6219, A6220, A6222, A6224, A6229, A6231, A6232, A6234, A6235, A6236, A6237, A6240, A6242, A6246, A6248, A6250, A6251, A6252, A6253, A6254, A6255, A6256, A6257, A6258, A6259, A6260, A6261, A6262, A6266, A6402, A6403, A6404, A6407, A6412, A6441, A6442, A6443, A6444, A6445, A6446, A6447, A6448, A6449, A6450, A6451, A6452, A6453, A6454, A6455, A6456, A6457, A6504, A6507, A6509, A6510, A6530, A6531, A6532, A6533, A6534, A6535, A6536, A6539, A6545, A6549, A7004, A7006, A7014, A7020, A7025, A7504, A7505, A7507, A7521, A7523, A7525, A7527, E0100, E0105, E0110, E0111, E0114, E0116, E0117, E0118, E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0154, E0155, E0156, E0158, E0159, E0162, E0165, E0167, E0168, E0181, E0182, E0184, E0185, E0188, E0189, E0190, E0191, E0434, E0776, E0779, E0780, E0781, E0791, E0849, E0900, E0910, E0912, E0940, E0945, E0950, E0953, E0954, E1022, E1032, E1033, E1034 |
Enteral nutrition
| B4220, B4222, B4224, B9999, S9340 |
Genetic testing | 0449U, 0578U, 81200, 81241, 81242, 81250, 81251, 81255, 81256, 81304 |
Neuro stimulators
| B4035, B4088 |
Outpatient pharmaceuticals
| J2597 |
Proprietary laboratory analyses | 0552U, 0553U, 0554U, 0555U, 0566U, 0575U, 0576U, 0579U, 0591U, 0599U |
Prosthetics
| B9002, B9998, L5657 |
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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 |
|---|---|
Medi-Cal (including CS and ECM providers) | |
Behavioral Health providers |
This information applies to Physicians and Practitioners, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.
This information applies to Medi-Cal in Los Angeles.