MedicaidPrior AuthHigh impact
Prior Authorization No Longer Required for Certain Advanced Breast Imaging Procedure Codes
Wisconsin Medicaid (ForwardHealth)·WI · Radiology, Oncology, OB-GYN +2 more·Prior Authorization
Effective date
Jul 1, 2026
We identified it
Aug 26, 2026
Summary
Effective July 1, 2026, Wisconsin Medicaid no longer requires prior authorization for the first instance of advanced breast imaging procedures (MRI and digital tomosynthesis) within a 12-month period for members with increased breast cancer risk or dense breast tissue. Providers must append modifier UA to specific CPT codes and submit claims directly without PA requests for qualifying cases; PA is still required for any subsequent imaging within the same 12-month period.
Action Required
By July 1, 2026: Billing team must update claims submission processes to automatically append modifier UA to CPT codes 77046, 77047, 77048, 77049, 77061, and 77062 when submitted for Wisconsin Medicaid members who meet clinical criteria (increased breast cancer risk per NCCN guidelines or heterogeneous/extremely dense breast tissue per BI-RADS). Update billing software to remove PA requirement flags for these codes on first submission within 12-month period. Providers must continue to request PA for any subsequent advanced breast imaging beyond the first instance in 12 months. Front desk and provider staff must document member risk status and breast density findings in EMR to support claim submission. Ensure medical records are retained per Wis. Admin. Code § DHS 106.02(9) to support audits. Claims submitted without modifier UA or for non-qualifying members may be denied; claims lacking supporting documentation may result in recoupment and sanctions.