Preauthorization & Not Covered indicators (examples)

Prior authorization is frequently required for many procedures and advanced diagnostics listed below. Codes may be marked either Not Covered or Preauthorization Required — verify plan-specific coverage before scheduling. These lists are updated quarterly and do not reflect immunizations, injectable drugs, or specialty pharmacy medications.

• Examples of provider actions: check both the Not Covered and Preauthorization flags on claims; obtain preauthorization where indicated; confirm plan variation or pharmacy exceptions for specialty medications.
• Plan variation: coverage and prior authorization requirements may differ by plan type (e.g., Small Employer and Individual).
• Use the payer website Pharmacy link for specialty medication authorization guidance.

Preauthorization and Not Covered code flags (excerpt)

The coding lists include explicit code-level flags indicating when preauthorization is required vs when a code is not covered. Always verify the specific flag for the member's plan prior to service.

• Example flags shown in the source: 'Not Covered = X' and 'Preauthorization Required = X'.
• Many surgical, transplant, bariatric, spinal, radiosurgery, and advanced molecular/genomic codes carry a preauthorization flag.

Surgery / Bariatric code flags (excerpt)

Selected surgery and bariatric procedure codes in the list are marked Not Covered or require preauthorization. Confirm prior authorization for bariatric and GI procedures before scheduling.

• Bariatric/laparoscopic codes: 43770-43775, 43800, 43842-43848, 43860, 43865 — variously flagged Not Covered or Preauthorization Required.
• Gastric restrictive/open procedures (e.g., 43886-43889) and endoscopic sleeve gastroplasty (43889) are listed with Not Covered = X or Preauthorization flags.

Preauthorization required examples

Preauthorization is required for many high-cost or high-risk procedures. Obtain authorization prior to elective surgery, complex interventional procedures, or implantable device placement.

• Transplant and donor procedures (e.g., intestinal, liver, kidney transplant-related codes 44135-44136, 47135-47147, 50323-50365) have preauthorization indicators.
• Hysterectomy and laparoscopy/hysteroscopy codes (e.g., 58150, 58152, 58180, 58200, 58544-58554) include explicit preauthorization requirements.
• Stereotactic radiosurgery and stereotactic body radiation therapy codes (61796-61800, 63620-63621, 77371-77373) require preauthorization.

GI / bariatric preauthorization examples

Gastrointestinal and bariatric surgeries often have mixed coverage statuses; check both Not Covered and Preauthorization flags.

• Examples: adjustable gastric band placement/revision/removal (43770-43774) flagged Not Covered = X for some entries and Preauthorization Required for others; sleeve gastrectomy (43775) may require preauthorization depending on plan.
• Gastric bypass/revision (43845-43848, 43860, 43865) have preauthorization indicators for certain codes.

Spinal procedures preauthorization / denial risk

Spinal procedures and interventional spine care frequently require prior authorization and may be at higher risk for denial if documentation or preauthorization is missing.

• Spine fusion and arthrodesis codes (22515, 22526-22527, 22533, 22551-22554, 22558, 22600, 22610) include preauthorization flags.
• Interspinous device insertion codes (22860, 22867-22870) and total disc arthroplasty (22860) carry preauthorization requirements.
• Percutaneous lysis of epidural adhesions (62263) and other interventional spine procedures may be Not Covered or require prior auth.

Spine / radiosurgery codes requiring prior authorization (examples)

Certain spine and radiosurgery codes explicitly require prior authorization — obtain authorization for stereotactic spinal or cranial radiosurgery and specified interbody procedures.

• Stereotactic cranial radiosurgery: 61796-61799, 61800 — Preauthorization Required = X.
• Spine radiosurgery: 63620-63621 — Preauthorization Required = X.
• Posterior interbody arthrodesis and decompression adjunct codes (63052, 63053) — Preauthorization Required = X.

Pain management and neurostimulator procedures

Pain management injections, neurodestruction, and neurostimulator procedures have mixed coverage and authorization indicators — confirm clinical documentation and prior authorization where shown.

• Facet joint injections and related codes (64490-64495) require preauthorization (X).
• Neurodestruction and nerve ablation codes (64629, 64633-64636) list Preauthorization Required = X.
• Neurostimulator and neuromodulation device codes (64582-64584, 64654-64659) are frequently Not Covered = X or require preauthorization depending on the specific code.

Multiple gene analysis codes requiring preauthorization

Prior authorization requirements also apply extensively to molecular pathology, genomic panels, and exome sequencing. Many multi-gene and panel tests require preauthorization.

• Single-gene and multi-gene analyses (e.g., 81167, 81173-81180, 81201-81301) show Preauthorization Required = X for many entries.
• Molecular pathology levels and genomic panels (81400-81408, 81410-81418, 81439-81442, 81456-81459) are frequently flagged for prior authorization.
• Exome sequencing codes (81415-81417) and large genomic panels require prior authorization (X).

Expanded preauthorization / code status

Expanded preauthorization and code-status indicators apply across diagnostic, therapeutic, and ancillary services — check the code list for specific coverage or preauth flags.

• Molecular pathology (81400-81408) and genomic sequencing panels (81439-81459) frequently require preauthorization.
• Some advanced diagnostics are marked Not Covered (e.g., select cancer tumor profiling codes) — review claims carefully.

Molecular pathology panels and exome codes

Molecular pathology panels, exome sequencing, and complex genomic tests have explicit preauthorization indicators; some tests are Not Covered. Obtain authorization and confirm clinical indications before ordering.

• Exome sequence analysis codes (81415-81417) — Preauthorization Required = X.
• Drug metabolism and pharmacogenomic panels (81418) may be Not Covered = X or require plan review.
• Oncology and tumor profiling panels (81456-81459, 81504, 81540-81542) have preauthorization required for many entries.

Coverage / preauth indicators for advanced diagnostics

Advanced diagnostic coverage and preauthorization indicators vary by test; confirm both coverage and any required preauthorization prior to specimen collection.

• Examples of coverage/preauth indicators include Not Covered = X (some assays) and Preauthorization Required = X (many panels).
• Clinical utility and indication documentation are commonly required for prior authorization decisions.

Prior authorization requirements (examples)

Additional examples of procedures and services that may require prior authorization are listed throughout the code file. When in doubt, submit a preauthorization request.

• Audiology and hearing device services (92631-92639) — Preauthorization Required = X for many hearing evaluation and fitting services.
• Home visit services (99500-99512) — several codes require preauthorization depending on the specific service (see list).
• Telehealth and audio-only visit codes (98002-98005, 98012-98015, 98016) are listed as Not Covered = X in many entries; confirm allowed modalities by plan.

Telehealth / audio visit codes - Not Covered

Several telehealth, audio-only, and digital communication codes are explicitly Not Covered in the commercial code list. Do not bill these codes for members of plans where they are marked Not Covered.

• Synchronous audio-video visit codes (98002-98005) — Not Covered = X for some plan types.
• Synchronous audio-only visit codes (98012-98015) — Not Covered = X.
• Brief communication and digital education codes (98016, 98970-98972) and online digital E/M services are listed as Not Covered = X in many entries.

Communication / education digital service codes - Not Covered

Education, training, and other digital communication CPTs are often flagged Not Covered. Confirm alternative billing or referral pathways.

• Digital patient education and training codes (98960-98962, 98970-98972) are listed as Not Covered = X in the code list.
• Brief communication technology-based service (98016) and virtual check-ins are listed as Not Covered = X in many entries.

Ancillary service codes - Not Covered

Multiple ancillary service and miscellaneous supply codes are marked Not Covered. Do not bill these when indicated as Not Covered for the member's plan.

• Specimen and device handling codes (99000-99002), special supplies (99070), patient education materials (99071), and related codes are listed as Not Covered = X.
• Some home health and ancillary codes are Not Covered or require preauthorization depending on the service (see home visit code entries).

Preauthorization requirements for selected home visit codes

Selected home visit codes require prior authorization for coverage — verify and obtain authorization for home-based clinical services.

• Home visit for prenatal assessment, postnatal assessment, newborn care, respiratory therapy, mechanical ventilation, stoma care, intramuscular injections, catheter care, and hemodialysis per diem (99500-99512) include mixed Preauthorization Required indicators — check the specific code and plan.
• Some home visit codes are Not Covered = X; others require Preauthorization = X per the list.

Plan variation and pharmacy exceptions

Plan-specific variations and pharmacy-exception pathways affect coverage and authorization for specialty medications and some procedures. Use plan enrollment details to determine the correct authorization path.

• Specialty medications: refer to the payer's Pharmacy link for prior authorization and exception processes.
• Coverage may differ by plan type (e.g., Small Employer and Individual) — verify member plan before pursuing authorization or scheduling services.

Prior authorization required entries (selected)

Selected high-cost or clinically complex services are highlighted as prior authorization required in the source. When applicable, include complete clinical documentation with the authorization request.

• Selected prior authorization-required entries (examples): spine fusion codes (22558, 22600, 22610), stereotactic radiosurgery (61796-61799, 63620-63621), molecular panels (81400-81408, 81415-81417), oncology genomic panels (81439-81459), transplant-related procedure codes (47135-47147, 50323-50365).
• Include relevant imaging, prior conservative care, specialty consult notes, and pathology/genetics indications when submitting authorization requests for these services.

Not covered entries (selected)

Selected codes in the source are expressly Not Covered for the indicated plan types. Do not bill these codes for members covered under the plans where Not Covered = X is indicated.

• Examples of Not Covered entries: select bariatric and GI procedure codes (43770-43773, 43842-43843, 43889), certain pain and neurostimulation procedures (64654 series, 64582-64584), many telehealth/audio codes (98002-98005, 98012-98015), communication/education codes (98960-98962, 98970-98972), MR safety and implant assessment codes (76014-76019), and various advanced diagnostic assays (specific 81xxx–81xxx and 81xxx–81xxx codes listed).
• When a code is Not Covered = X, consider alternative covered services or obtain clinical exception if available.