CurrentSelectHealthPolicy N/A

Commercial codes not covered or requiring prior authorization — Idaho (quarterly updated code lists)

Quarterly-updated code lists (CPT/HCPCS/U-codes/Q-codes) indicating per-plan (Small Employer Individual / Large Employer) Not Covered or Preauthorization Required status for SelectHealth commercial plans in Idaho; excludes immunizations, injectable drugs, and specialty medications managed via Pharmacy.

Policy Summary

PayerSelectHealth

PolicyCommercial codes not covered or requiring prior authorization — Idaho (quarterly updated code lists)

Policy CodePolicy N/A

Change TypeMaintenance / operational clarifications (no material clinical change)

Effective DateSep 25, 2025

Next Review DateMar 25, 2026

Key ActionVerify the member's specific SelectHealth plan (Small Employer Individual vs Large Employer) and obtain prior authorization for any codes flagged as 'Preauthorization Required' before providing or billing services; do not bill codes marked 'Not Covered' for that plan.

POLICY UPDATE CHANGES

No material clinical or coverage policy changes were identified; the excerpt is a maintenance code list with repeated disclaimers that coverage may vary by plan and codes are updated quarterly.

Operational change note: Preauthorization is required after the 3rd rental month when rental criteria are not met (appears repeatedly in the document).

Numerous CPT/HCPCS/U-codes in the list are marked 'Preauthorization Required' (X) for Small Employer Individual and/or Large Employer plans — providers must obtain prior authorization where indicated.

Numerous CPT/HCPCS/U-codes are marked 'Not Covered' (X) for Small Employer Individual and/or Large Employer plans — do not bill these codes for members under the affected plan type.

QuarterlyUpdate cadence

IdahoState scope

MultiplePreauth flags present

MultipleNot Covered flags present

09/25/25As-of date

Policy Overview

Coverage determinations & rules

Coverage / Prior Authorization assignment by plan type

Render rules: each listed code is either Not Covered for a given plan type (do not bill) or requires Preauthorization for that plan type (obtain prior auth before rendering), as indicated below.

Not Covered X: means the code is excluded for that plan type and claims will deny if billed without an approved exception/documentation.

Preauthorization Required X: means prior authorization must be obtained for that code under that plan type before services are rendered or billed.

Operational notes: Preauth needed after certain number of visits; limit depends on plan/provider type.

Policy Summary

PayerSelectHealth

PolicyCommercial codes not covered or requiring prior authorization — Idaho (quarterly updated code lists)

Policy CodePolicy N/A

Change TypeMaintenance / operational clarifications (no material clinical change)

Effective DateSep 25, 2025

Next Review DateMar 25, 2026

On This Page

Operational notes: Preauth after 3rd rental month when criteria not met (DME rental authorization rule).

Billing Rule

Plan variability & quarterly updates

Code lists are maintained and updated quarterly. Immunizations, injectable drugs, and specialty medications are not managed in these coding lists; those items are handled through Pharmacy. Coverage and preauthorization requirements vary by plan type and employer group — verify member benefits before billing.

Code lists updated quarterly — verify member plan benefits before billing
Lists exclude immunizations, injectable drugs, specialty meds — consult Pharmacy link
Coverage differs by plan type (Small Employer Individual vs Large Employer)

Prior Authorization

Preauthorization: provider actions

Providers must obtain prior authorization when a code is marked Preauthorization Required for the member’s specific plan. For rental DME items, operational policy requires preauthorization if criteria are not met after the third rental month.

Obtain prior authorization for codes marked Preauthorization Required = X for the member’s plan
'Preauth after 3rd rental month when criteria not met' — applies to DME rentals (operational rule)

Denial Risk

Not Covered = denial risk

Codes flagged Not Covered for a given plan type are a denial risk. Do not bill these codes as covered for affected plans; claims submitted for Not Covered codes will deny unless an approved exception exists.

Do not bill codes marked Not Covered (X) for the specified plan type; claims will deny
Examples: representative Not Covered codes from the policy (sample CPT/HCPCS): 11950, 11951, 11952, 11954, 15775, 15776, 15780, 15781, selected U/Q codes

Provider actions, documentation, and timing rules

Note

Code Lists by status and category (select groups)

Codes listed (CPT) with Not Covered or Preauthorization flags by plan typeCPT

11950	Therapy for contour defects
11951	Therapy for contour defects
11952	Therapy for contour defects
11954	Therapy for contour defects
15775	Hair transplant punch grafts
15776	Hair transplant punch grafts
15780	Abrasion treatment of skin
15781	Abrasion treatment of skin
15786	Abrasion, lesion single
15787	Abrasion lesion add-on

1–10 of 28

1/3

Codes listed with status per plan type (Small Employer Individual / Large Employer)CPT

17360	Destruction of cutaneous vascular proliferative lesion
19105	Excision, breast lesion
19355	Mastopexy, augmentation
20560	Injection, tendon sheath
20561	Injection, tendon sheath, each additional
20930	Allograft, bone—spine
20936	Autograft, bone—spine
20985	Computer-assisted surgical navigation, musculoskeletal
21010	Genioplasty
21050	Excision of lesion of mandible

1–10 of 28

1/3

Not Covered (selected codes flagged with X)CPTNot Covered

21206	Nasal/sinus reconstruction
21240	Reconstruction of mandible—allograft
21242	Reconstruction of mandible—autograft
21243	Reconstruction of mandible—complex
21280	Mandibular reconstruction with prosthesis
21282	Mandibular reconstruction with bone graft and prosthesis
21295	Reconstruction of facial bones—extensive
21296	Reconstruction of facial bones—complex
21485	Open treatment of mandibular nonunion
21490	Other repair of jaw

1–10 of 22

1/3

Preauthorization Required (selected codes flagged with X)CPTCovered

22600	Arthrodesis, posterior or lateral approach, lumbar
22610	Arthrodesis, lumbar with posterior interbody
22612	Arthrodesis, lumbar with posterior interbody—complex
22632	Lumbar fusion; each additional segment
22633	Lumbar fusion—complex
22800	Application of halo
22802	Application of halo—removal
22804	Other spinal procedures
22836	Lumbar fusion with posterior segmental instrumentation
22837	Lumbar fusion with interbody instrumentation

1–10 of 15

1/2

HCPCS / Q-codes / Skin substitutes (mixed) - Not Covered / PA / Neutral consolidatedmixed

Q4100	Cultured epidermal autograft
Q4101	Other skin substitute
A2001	Skin substitute material
A2002	Skin substitute material
C1734	Skin substitute, per square cm
C1735	Skin substitute, per square cm
J7325	Injectable skin product (example)

U-codes / HCPCS - outpatient facility or surgical supply itemsHCPCS

U0001	Example molecular test
U0002	Example molecular test 2

Dental CDT (selected) - Neutralmixed

D1110	Prophylaxis adult
D1351	Composite with caries—anterior
D2740	Crown porcelain/ceramic

L / C Prosthetic codes (HCPCS) - NeutralHCPCS

L3000	Prosthetic foot, below knee
L5000	Prosthetic knee component

Use the table filters to view codes by status (Not Covered / Preauthorization Required / Neutral) and by plan type. If a code appears with conflicting flags in the document, verify member's plan and contact SelectHealth.

Quick action checklist for billing & clinical operations

Note

OpenPayer

Commercial codes not covered or requiring prior authorization — Idaho (quarterly updated code lists)

Policy Overview

Coverage determinations & rules

Provider actions, documentation, and timing rules

Code Lists by status and category (select groups)

Key definitions

Quick action checklist for billing & clinical operations

FAQs for billing and clinical operations

Revision history & document changes