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Wisconsin Medicaid (ForwardHealth)Medicaid · Prior Auth · Prior Authorization · WI · Radiology, Oncology, OB-GYN +2 moreHigh impact

Prior Authorization No Longer Required for Certain Advanced Breast Imaging Procedure Codes

Act
by Jul 1, 2026
Effective date
Jul 1, 2026
Identified
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.

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What to do

by Jul 1, 2026 · 8 steps
01Billing 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).
02Update billing software to remove PA requirement flags for these codes on first submission within 12-month period.
03Providers must continue to request PA for any subsequent advanced breast imaging beyond the first instance in 12 months.
04Front desk and provider staff must document member risk status and breast density findings in EMR to support claim submission.
05Ensure medical records are retained per Wis.
06Admin.
07Code § DHS 106.02(9) to support audits.
08Claims submitted without modifier UA or for non-qualifying members may be denied; claims lacking supporting documentation may result in recoupment and sanctions.

Codes mentioned

770467704777048770497706177062

Original notice

Prior Authorization No Longer Required for Certain Advanced Breast Imaging Procedure Codes
forwardhealth.wi.gov · Always check the source before changing claims.
View original ↗

Related changes

See all Wisconsin Medicaid (ForwardHealth) changes →
2019 CPT and HCPCS Procedure Code ChangesMediumEffective Jan 1, 2019 · CodingBrowse every Wisconsin Medicaid (ForwardHealth) change in the policy list

Related policy hubs

Wisconsin Medicaid (ForwardHealth) policiesWI policy changesRadiologyOncologyOB-GYNFamily MedicineInternal MedicineCode 77046Code 77047Code 77048Code 77049Code 77061Code 77062

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