Prior Authorization Required / Not Covered — summary and guidance

The code list below identifies CPT/HCPCS/other codes that either require prior authorization or are not covered for SelectHealth Small Employer and Individual commercial plans in Colorado. Coverage may vary by plan — always confirm member eligibility and benefits prior to scheduling or billing. These lists are updated quarterly and do not reflect immunizations, injectable drugs, or specialty medications; specialty medication coverage inquiries should be directed to the Pharmacy link on the SelectHealth website.

• Provider action: Prior authorization and noncoverage indicators are shown per-code (e.g., Preauthorization Required = X or Not Covered = X).
• Provider action: Preauthorization requirement summary — selected spine (fusion, arthroplasty), stereotactic radiosurgery, certain implantable device procedures, many molecular/genomic tests, and specific behavioral and home-visit services require prior authorization for Small Employer and Individual plans (see code excerpts below).
• Provider action: Coverage variability and Pharmacy redirect — coverage may differ by plan type; lists updated quarterly and exclude immunizations, injectable drugs, and specialty medications (direct such inquiries to Pharmacy).
• Providers must confirm member eligibility and obtain prior authorization where shown before providing services to avoid claim denials or member financial liability.

Preauthorization requirement summary (examples)

Examples of selected codes flagged as Preauthorization Required (not exhaustive). Obtain preauthorization for these services on Small Employer and Individual plans in Colorado prior to delivery or billing.

• Spine and related: 22515 (vertebral augmentation) — Preauthorization Required = X; 22533, 22551, 22552, 22554, 22558, 22600 — many lumbar/thoracic fusion procedures show Preauthorization Required = X.
• Disc / stabilization / arthroplasty: 22860 (total disc arthroplasty second interspace) — Preauthorization Required = X.
• Stereotactic radiosurgery / spine: 63620, 63621 (spinal SRS) — Preauthorization Required = X; 77371–77373 (stereotactic radiosurgery/radiation delivery) — Preauthorization Required = X.
• Neurodestruction / basivertebral nerve: 64628, 64629 — Preauthorization Required = X.
• Facet / paravertebral injections: 64490–64495 — Preauthorization Required = X.
• Molecular / genomic testing: examples include 81121, 81162–81166, 81233–81237, 81272–81279, 81400–81407, 81439–81442 — many are marked Preauthorization Required = X.
• Proton therapy and advanced radiation: 77520–77525 — Preauthorization Required = X.
• Adaptive behavior and ABA services: 97153–97155, 97158 — Preauthorization Required = X.
• Hearing services: selected evaluation, selection, fitting, and follow-up codes 92628–92641, 92634–92639 — several are Preauthorization Required = X.

Denial risk: Not Covered codes (selection)

Examples of selected codes explicitly marked Not Covered (denial risk). If a code is shown as Not Covered = X for Small Employer and Individual plans, claims submitted for those codes risk denial.

• Spine/implants/devices: 22526, 22527 (percutaneous intradiscal electrothermal annuloplasty) — Not Covered = X.
• Interlaminar/interspinous devices: 22867–22870 — Not Covered = X.
• Transplant and major procedures: 32850–32853 (donor pneumonectomy/lung transplant codes) — Not Covered = X.
• Gastric band procedures: 43770–43773 — Not Covered = X.
• Certain ophthalmic and implant procedures: 64405? and multiple 657xx, 67516 — numerous ophthalmic repair and implant codes marked Not Covered = X.
• MR safety assessment services: 76014–76019 — Not Covered = X (MR safety assessment and related codes are not covered).
• Bone marrow / stem cell transplant codes: 38230, 38232, 38240, 38241 — Not Covered = X.
• Laboratory / diagnostics: 77081, 77086 (peripheral DXA and fracture assessment) — Not Covered = X; many molecular/biomarker panels and cytogenetics entries are Not Covered = X where shown.
• Reproductive and assisted reproduction: numerous ART lab and procedure codes (e.g., 89250–89259, 89260–89356 series) — many are Not Covered = X (see reproductive section below).
• Behavioral and other services: 90865, 90885–90889 (certain behavioral/psych services) — Not Covered = X.
• Home and administrative services: multiple 99xxx series (e.g., 99339, 99358–99359, 99417, 99450–99456) — many marked Not Covered = X.

Hysterectomy-related prior authorization notes

Hysterectomy and related gynecologic procedures: multiple hysterectomy CPTs and laparoscopic hysterectomy codes are designated as requiring preauthorization for Small Employer and Individual plans. Confirm preauthorization for total, partial, and laparoscopic hysterectomy codes listed.

• Preauthorization Required examples: 58152, 58180, 58200, 58262, 58263, 58544, 58550, 58552, 58553, 58554, 58570–58573 — Preauthorization Required = X where indicated.
• Not Covered examples: 57465 (computer-aided mapping of cervix during colposcopy), 58565 (bilateral fallopian tube cannulation for permanent implants) — Not Covered = X.

Reproductive procedures — authorization and coverage flags

Assisted reproductive services and related laboratory procedures have many codes marked Not Covered for Small Employer and Individual plans in Colorado. Providers should verify coverage before performing or billing these services.

• Not Covered examples include laboratory and ART procedure codes: 89250–89259 (fertilization, embryo handling), 89260–89291 (sperm/oocyte processing, ICSI, assisted fertilization), 89335, 89337 (cryopreservation), 89342–89346 (storage), 89352–89356 (thawing) — many entries show Not Covered = X.
• Some specific service codes within reproductive category may show Preauthorization Required = X where noted; check the code-level designation.
• Providers should obtain prior authorization when a code is shown as Preauthorization Required and avoid provisioning services shown Not Covered without confirmed alternative coverage.

Spine / Stereotactic radiosurgery — preauthorization required

Spine and stereotactic radiosurgery procedures often require prior authorization. Confirm preauthorization for these services to reduce denial risk.

• Spine fusion/arthrodesis: 22533, 22551, 22552, 22558, 22600, 22610 — several fusion codes marked Preauthorization Required = X.
• Laminectomy/add-on: 63052, 63053 — Preauthorization Required = X.
• Stereotactic radiosurgery: 63620, 63621 and stereotactic RT delivery codes 77371–77373 — Preauthorization Required = X.

Neurodestruction procedures requiring preauthorization

Neurodestruction procedures such as thermal basivertebral nerve ablation and neurolytic agent destruction of facet joint nerves are identified as requiring preauthorization for Small Employer and Individual plans.

• Thermal basivertebral nerve: 64628, 64629 — Preauthorization Required = X.
• Neurolytic agent destruction (paravertebral facet nerve): 64633–64636 — Preauthorization Required = X.

MR safety assessment codes — not covered

MR safety assessment services (implant/foreign body assessment, physician MR safety determination, and related medical physics services) are not covered for Small Employer and Individual plans in Colorado.

• Not Covered examples: 76014, 76015, 76016, 76017, 76018, 76019 — Not Covered = X.

Preauthorization required codes (excerpt)

Excerpted lists of codes with Preauthorization Required = X (additional codes appear throughout the full list). The examples below are representative — always check the full quarterly list for complete code-level status.

• Selected musculoskeletal / implant / spine: 22515, 22533, 22551, 22552, 22558, 22600, 22860, 22867–22870.
• Selected injections / neurostimulation: 64490–64495 (facet/paravertebral injections) — Preauthorization Required = X.
• Selected neurodestruction: 64628–64636 — Preauthorization Required = X.
• Selected device/implant procedures that require preauth: 69730, 69930 (cochlear/osseointegrated implants) — Preauthorization Required = X where indicated.

Preauthorization required codes (continued)

Additional excerpt continued — molecular, genomic, and specialty testing examples requiring preauthorization for Small Employer and Individual plans. Confirm prior authorization for high-cost or specialized testing.

• Molecular/genomic: 81121, 81162–81166, 81174–81183, 81233–81237, 81272–81279, 81400–81408, 81439–81442, 81518–81525, 81529, 81535, 81542, 81546, 81551–81554, 81558.
• Radiation/advanced therapy: 77371–77373, 77520–77525 — Preauthorization Required = X.

Preauthorization required codes (additional)

Additional examples of codes marked Preauthorization Required = X or Not Covered = X across categories — use the full code list when validating coverage and preauthorization requirements.

• Hearing services and audiology: many 92xxx series entries show mixed status; selected evaluation and fitting services (92628–92641, 92634–92639) often require preauthorization.
• Behavioral/adaptive services: 97153–97155, 97158 — Preauthorization Required = X.
• Home and nursing facility care: 99307–99310, 99318, 99450–99456 — several entries require preauthorization or are Not Covered depending on the specific code.

Preauthorization and Not Covered codes — actionable guidance

Some codes are explicitly either Not Covered or show Preauthorization Required; providers should use the code-level flags to guide pre-service review and authorization workflows.

• If a code shows Not Covered = X, do not expect coverage under Small Employer and Individual plans — obtain alternative authorization or advise the member of potential financial liability.
• If a code shows Preauthorization Required = X, secure prior authorization prior to service delivery to reduce denial risk.

Prior authorization requirements for listed CPT molecular/genomic codes

Many molecular pathology and genomic CPT codes are marked Preauthorization Required = X. Due to complexity and cost, these tests commonly require preauthorization and clinical documentation supporting medical necessity.

• Examples: 81400–81408, 81439–81442, 81162–81166, 81233–81237, 81272–81279, 81360, 81490, 81518–81525, 81529–81535, 81542, 81546, and multiple others in the 81xxx–81xxx and 81xxx–82xxx series.
• Operational note: submit clinical indication, prior testing, and supporting documentation with preauthorization requests for molecular/genomic testing.

Denial risk (Not Covered) entries — laboratory/diagnostic examples

Denial risk entries (Not Covered = X) include a broad set of diagnostic, imaging, laboratory, toxicology, and reproductive codes. Review the list and verify coverage before ordering.

• Laboratory and diagnostic Not Covered examples: 77081, 77086 (peripheral DXA), 78350 (bone mineral single photon), 80320–80341 (various drug/alcohol biomarker panels) — Not Covered = X.
• Cellular and specialized lab tests: 86152–86153, 86343, 86352, 87183 (antimicrobial resistance genes) — mixed status; some are Not Covered = X while others require preauth.
• Assays and specialty diagnostics: 88738–88741 (transcutaneous hemoglobin) and multiple specialized cytogenetic/molecular tests show Not Covered = X where indicated.

Preauthorization required — selected hearing services

Selected hearing services and hearing device-related codes show preauthorization required or not covered statuses. Confirm preauthorization for candidacy evaluation, selection, fitting, and follow-up services where flagged.

• Examples: 92590–92596 (hearing aid exams/checks) — mixed status; 92591–92595 and 92628–92641 show several Preauthorization Required = X entries.
• Hearing assistive device fitting services: 92642 — Not Covered = X in some entries; verify code-level status before billing.

Not covered — selected devices/procedures

Selected devices and procedures are explicitly Not Covered for Small Employer and Individual plans; verify alternatives or discuss member financial responsibility prior to proceeding.

• Not Covered device examples: Baroreflex activation therapy (BAT) system implantation/revision/removal codes 64654–64659 — Not Covered = X.
• Certain corneal and ocular implant/revision codes (65760–65771, 66762) — Not Covered = X.
• Osseointegrated cranial implants and cochlear device implantation codes (69730, 69930) — Preauthorization Required = X for some cochlear implant procedure codes; verify individual code flags.

Not covered codes — examples

Examples of codes marked Not Covered (selection) are provided as a sample of the many entries in the full list. This is not exhaustive — consult the full quarterly list for complete determinations.

• Examples: 22526, 22527 (Percutaneous intradiscal electrothermal annuloplasty) — Not Covered = X.
• 43770–43773 (adjustable gastric band procedures) — Not Covered = X for many related codes.
• 89250–89259, 89260–89356 (assisted reproduction and associated lab procedures) — many shown Not Covered = X.

Codes requiring prior authorization (selection)

Selected codes requiring prior authorization (representative selection). Use these examples to inform pre-service authorization workflows; review the full list for all codes.

• Orthopedic / spine / implant: 22515, 22533, 22551, 22552, 22558, 22600, 22860, 22867–22870.
• Radiation / proton / stereotactic: 77371–77373, 77520–77525, 77371–77373 — Preauthorization Required = X.
• Molecular/genomic: numerous 81xxx–81xxx codes (see molecular excerpt blocks) — Preauthorization Required = X.

Not covered codes (selection)

Selected Not Covered codes (selection) across categories — these examples illustrate breadth of services with Not Covered designations for Small Employer and Individual plans in Colorado.

• Diagnostic / imaging: 74263 (CT colonography) — Not Covered = X.
• MR safety and implant assessment: 76014–76019 — Not Covered = X.
• Laboratory / cytogenetics / specialized tests: 81291 (MTHFR common variants) — Not Covered = X; many reproductive lab codes Not Covered = X.

Not Covered / Preauthorization status (selected codes)

Selected F-code and quality-reporting related entries show Not Covered indicators; in many cases Preauthorization is not applicable (marked '-') where Not Covered applies.

• Examples of F-code / measure codes with Not Covered = X include 2040F, 2044F, 2050F, 3006F, 3011F, 3014F, 3015F, 3016F, 3017F, 3018F, 3019F, 3020F, 3021F, 3022F, 3023F, 3025F, 3040F, 3042F, 3044F, 3046F, 3048F, 3049F, 3050F, 3051F, 3052F, 3055F, 3215F.
• Operational note: where Preauthorization Required = '-' and Not Covered = X, do not seek preauthorization — the service is not covered for the plan type shown.

Not Covered / Preauthorization status (cardiac and respiratory codes)

Cardiac, respiratory, and other selected procedural F-code and CPT entries show Not Covered flags. Confirm member benefits when these codes are under consideration.

• Examples include select cardiology add-on/procedure codes (e.g., 92921, 92925) and multiple home-visit and transport care codes (99307–99310, 99318) which show mixed Not Covered or Preauthorization Required statuses as noted in the full list.
• When a code is Not Covered = X, do not expect reimbursement under Small Employer and Individual plans unless an exception is granted in writing.

Examples of codes marked not covered

Examples showing codes marked Not Covered — use these examples for quick reference but rely on the full quarterly list for final determination.

• Selected oncology and specialty test not covered examples: 81500, 81503, 81506, 81512, 81517, 81506 — many oncology/biomarker panels are listed as Not Covered = X.
• Selected toxicology and substance marker panels: 80320–80341 — Not Covered = X for multiple entries.

Additional not-covered codes

Additional not-covered codes and clarifying guidance — the full list contains many more entries; providers should consult the full quarterly code listing and contact SelectHealth for coverage clarifications or to request prior authorization where indicated.

• Not Covered examples across categories: 644? series, 65760–65771 (ophthalmic revisions/transplants), 67516 (suprachoroidal injection) — Not Covered = X where indicated.
• Operational suggestion: attach clinical rationale, prior imaging, chart notes, and relevant records when seeking prior authorization for any Preauthorization Required = X code.

Prostate / hepatitis / other Not Covered codes

Examples of prostate, hepatitis, and other measure/test related codes marked Not Covered — review and confirm if these services are clinically indicated and covered under the member's specific benefit plan.

• Prostate / staging / screening measure examples: 3268F, 3269F, 3270F — Not Covered = X for some prostate staging/screening measures as listed.
• Hepatitis and other public health measure codes may also be marked Not Covered or have plan-specific exclusions — verify prior to service.