Important Prior Authorization Updates

Date: 01/27/26

(Effective April 1, 2026)

As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, Sunshine Health wants to share some important updates to our PA requirements. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care.

Code change details can be found below. These changes may include:

Removing PA requirements based on criticality of review and clinical need.
Creating a more uniform set of prior authorization requirements across our markets and lines of businesses, including adding and changing some PA requirements, to simplify processes, reduce confusion for providers, and support future efforts to expand real-time responses to requests.

If you have questions about specific prior authorization codes or how these changes affect your practice, please reach out to your Provider Engagement Account Manager (PEAM) or call Sunshine Health Provider Services at 1-844-477-8313 Monday through Friday from 8 a.m. to 8 p.m. Eastern.

Service Category	PA Rule	Services	Procedure codes
DME Services	PA Required	Beds	E0277
		Orthotic & Prosthetic	L0650, L1940, L1970, L2280
		Wheelchairs	E1028, E2620, E2621
	PA Required beyond 186 units per calendar month or the benefit limitation —whichever is greater	Incontinence Supplies	T4525, T4526, T4527, T4528, T4529, T4530, T4533, T4543
	PA Required after plan benefit limitation or is under 21 years of age	Nutritional Services	B9998
Drug Codes	PA Required	Injections	J0878
Genetic Analysis	PA Required	Genetic Testing	81455
Hearing Services	PA Required	Implants and Supplies	V5257, V5260
Hearing Services	No PA Required for PAR providers	Special Services	92604
Laboratory	No PA Required for PAR providers	Drug Tests	80362, 80367, 80370, 80372
Other Medical Services	PA Required	Hyperbaric Oxygen Therapy	99183
Physical Medicine	PA Required	Orthotic & Prosthetic	L5673
Physician Services	PA Required	Neurological Tests	95700, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95721, 95722, 95723, 95724, 95725, 95726
Physician Services	No PA Required for PAR providers	Neurological Tests	95705
Skin Procedures	PA Required	Muscle Flap Procedures	15736, 15738
Skin Procedures	PA Required if billed with diagnosis of gender dysphoria. For all others, PA Required for Non-PAR Providers only	Skin Grafts	14060, 14061
Surgery Procedures	PA Required	Hysterectomies	58545
		Spinal Surgery	63200
		Surgery-Musculoskeletal System	28285, 28296
		Surgery-Nervous System	64568

Questions?

Sunshine Health has a wealth of resources available to help answer your questions and address your concerns:

Provider Support: Finding the Right Contact
Provider Services: Call 1-844-477-8313
Secure Provider Portal: Visit the Secure Provider Portal to check member eligibility, submit claims and more.
Provider Engagement: Use the Find Your Account Manager tool to find the Provider Engagement Account Manager (PEAM) supporting your specialty and region.
Claim Concerns: Resolve outstanding claims using the Claim Concerns form.
Provider News: Bookmark Provider News to keep up with the latest updates.
Provider Newsflash: Subscribe to our e-newsletter to get regular updates.
Provider Resources: Visit Manuals, Forms and Resources to find provider manuals, important forms, scheduling standards and other resources.

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