CurrentSelectHealthPolicy N/A

Commercial codes not covered or requiring prior authorization — Colorado

A quarterly-updated listing of CPT/HCPCS procedure codes that SelectHealth classifies as either not covered or requiring prior authorization for Small Employer and Individual commercial plans in Colorado; providers should verify plan-specific coverage and consult Pharmacy for immunizations/injectables/specialty medications.

Policy Summary

PayerSelectHealth

PolicyCommercial codes not covered or requiring prior authorization — Colorado

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 26, 2026

Next Review DateN/A

Key ActionCheck the code table and obtain prior authorization where the listing shows 'Preauthorization Required = X' before rendering services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

03/26/26as-of date shown

Coloradojurisdiction

quarterlyupdate frequency

Manycodes flagged preauth

Severalcodes flagged not covered

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Per-code Coverage Indicators

Per-code coverage nodes (partial)

Per-code coverage stance (examples from the partial list):

22526 — Percutaneous intradiscal electrothermal annuloplasty: Not Covered for Small Employer and Individual plans (Not Covered = X).

Source indicates 22526 marked Not Covered = X; preauthorization column is '-' in the listing.

22533 — Arthrodesis, lateral extracavitary technique (lumbar): Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

22558 — Lumbar spine fusion: Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

22836 — Anterior thoracic vertebral body tethering: Not Covered for Small Employer and Individual plans (Not Covered = X).

22856 — Total disc arthroplasty (anterior approach): Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

22867 — Insertion of interlaminar/interspinous stabilization device (with open decompression), lumbar: Not Covered for Small Employer and Individual plans (Not Covered = X).

27130 — Total hip replacement: Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

Per-code coverage stance (excerpt)

Per-code flags shown in this segment (examples):

22867 — Insertion of interlaminar/interspinous device (lumbar): Not Covered for Small Employer and Individual plans (Not Covered = X).

22860 — Total disc arthroplasty, second interspace, lumbar: Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

43770 — Laparoscopic adjustable gastric band placement: Not Covered for Small Employer and Individual plans (Not Covered = X).

43774 — Removal of adjustable gastric band and subcutaneous port component: Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

38225 — CAR-T harvesting (blood-derived T lymphocytes): Not Covered for Small Employer and Individual plans (Not Covered = X).

Per-code coverage/authorization indicators

Per-code coverage indicators in the list show either 'Not Covered' or 'Preauthorization Required' for Small Employer and Individual plans; some transplant and complex procedure codes are variably marked.

43770 — Coverage indicator: Not Covered for Small Employer and Individual plans.

43774 — Coverage indicator: Preauthorization Required for Small Employer and Individual plans.

43800 — Coverage indicator: Preauthorization Required for Small Employer and Individual plans.

44135 — Coverage indicator: Preauthorization Required for Small Employer and Individual plans (intestine transplant, cadaver).

47135 — Coverage indicator: listed as plan-dependent/variable for liver transplantation (entries show both Not Covered and Preauthorization fields depending on row).

Sample code stances from this document section

Per-code coverage and prior authorization flags for Small Employer and Individual plans in Colorado; examples below illustrate varieties of stances.

55870 — Electroejaculation: Not Covered for Small Employer and Individual plans (Not Covered = X).

58565 — Hysteroscopy with bilateral fallopian tube cannulation for permanent implants: Not Covered for Small Employer and Individual plans (Not Covered = X).

61796 — Stereotactic radiosurgery (simple cranial lesion): Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

63052 — Laminectomy during posterior interbody arthrodesis, lumbar (single segment): Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

Per-code stances (examples)

Per-code coverage/preauthorization flags (partial extract):

63052 — Small Employer and Individual: Not Covered = -; Preauthorization Required = X (prior auth required).

64505 — Small Employer and Individual: Not Covered = X (listed as Not Covered in the table).

64628 — Small Employer and Individual: Preauthorization Required = X (thermal destruction/ablative nerve procedures).

76014 — Small Employer and Individual: Not Covered = X (MR safety implant/foreign body assessment).

Per-code coverage statements (sample)

Per-code coverage stance entries (examples extracted from this portion):

77081 — DXA appendicular skeleton: Not Covered for Small Employer and Individual plans (Not Covered = X).

77371 — Radiation treatment delivery, stereotactic radiosurgery (SRS): Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

77437 — Surface radiation therapy delivery =150 kV, per fraction: Not Covered for Small Employer and Individual plans (Not Covered = X).

81162 — BRCA1/BRCA2 full sequence + duplication/deletion analysis: Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

80354 — Fentanyl testing (as example lab code): Not Covered for Small Employer and Individual plans (Not Covered = X).

Code-level coverage stance (examples)

Per the listed entries, each code row indicates whether the code is Not Covered ('-') or requires Preauthorization ('X') for Small Employer and Individual plans in Colorado.

81167 — BRCA2 full duplication/deletion analysis: Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

81174 — AR gene analysis (known familial variant): Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

81216 — BRCA2 full sequence analysis: Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

81228 — Cytogenomic microarray analysis (genome-wide): Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

81261 — IGH gene rearrangement analysis: Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

Per-code stances (selected examples)

Per-code coverage status for Small Employer and Individual plans (Colorado):

81272 — KIT targeted sequencing: Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

81291 — MTHFR common variant analysis: Not Covered for Small Employer and Individual plans (Not Covered = X).

81327 — (example gene-specific code) listed as Not Covered = X in the excerpt.

81418 — Pharmacogenomics / drug metabolism panel (must include at least 6 genes including CYP2C19, CYP2D6 and CYP2D6 duplication/deletion analysis): Not Covered for Small Employer and Individual plans (Not Covered = X).

81403 — Molecular pathology procedure, level 4: Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

Per-code coverage/preauthorization examples

Per-code coverage/preauthorization indications (Small Employer and Individual plans):

81418 — Pharmacogenomics panel (must include testing of at least 6 genes, including CYP2C19, CYP2D6 and CYP2D6 duplication/deletion): Not Covered for Small Employer and Individual plans (Not Covered = X).

81422 — Cell-free fetal DNA for fetal microdeletion(s): Not Covered for Small Employer and Individual plans (Not Covered = X).

81449 — Targeted genomic sequencing panel (solid organ neoplasm, 5-50 genes): Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

81529 — Oncology (cutaneous melanoma) 31-gene mRNA profiling: Not Covered for Small Employer and Individual plans (Not Covered = X).

81479 — Unlisted molecular pathology: Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

Per-code coverage indications (examples)

Codes in this listing are presented with per-code indicators for Small Employer and Individual plans showing either Not Covered (X) or Preauthorization Required (X) where applicable.

Not Covered examples: Multiple diagnostic, specialty, fertility and other procedure codes are marked Not Covered for Small Employer and Individual plans (document contains many such entries).

Preauthorization examples: Certain molecular/genomic, transplant, and specialized diagnostic codes are marked Preauthorization Required for Small Employer and Individual plans (document contains many such entries).

Per-code coverage/authorization rules (selected examples)

Per-code coverage designations for Small Employer and Individual plans in Colorado (values shown as 'Not Covered' or 'Preauthorization Required').

Not Covered vestibular/audiology: 92531, 92532, 92533, 92534 — Selected vestibular and hearing diagnostic tests: Not Covered for Small Employer and Individual plans (Not Covered = X).

Preauthorization hearing services: 92590–92595 series (selected): Preauthorization Required for hearing-aid evaluation and related procedures as listed (Preauthorization Required = X).

Hearing aid fitting: 92631, 92634, 92636 — Hearing aid selection, fitting and post-fitting services: Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

Examples of Not Covered codes

Code-level coverage indicators (examples from this section):

98002 — Synchronous audio-video new patient moderate MDM, 45 minutes: Not Covered for Small Employer and Individual plans (Not Covered = X).

98971 — Online digital E/M for established patient 11–20 minutes: Not Covered for Small Employer and Individual plans (Not Covered = X).

99000 — Specimen handling and similar ancillary codes: Not Covered for Small Employer and Individual plans (Not Covered = X).

Per-code coverage/authorization summary

Per-code coverage indicators (Small Employer and Individual):

99367 — Medical team conference (patient/family not present): Not Covered for Small Employer and Individual plans (Not Covered = X).

99417 — Prolonged office/outpatient E/M service (add-on): Not Covered for Small Employer and Individual plans (Not Covered = X).

99500 — Home visit for prenatal assessment: Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

99605 — Medication therapy management service(s) by pharmacist: Not Covered for Small Employer and Individual plans (Not Covered = X).

0001F — Quality measure codes (example): Not Covered for Small Employer and Individual plans (Not Covered = X).

Not covered / preauthorization indicators

Per the list, many F-codes are designated as Not Covered for Small Employer and Individual plans; some entries include a Preauthorization Required field.

Multiple F-codes (examples: 1451F, 1460F, 1490F, 1500F, 2000F, etc.) — marked Not Covered = X for Small Employer and Individual plans in the listing.

Preauthorization field — present in table rows; many F-code rows show '-' for Preauthorization Required indicating no preauth in excerpt; providers should verify per plan.

Per-code coverage and authorization flags (summary)

Per-code coverage stance as presented in the table lines:

Selected F-codes (2026F, 2027F, 2028F, 2029F, 2030F, 2031F, etc.) — Not Covered for Small Employer and Individual plans (Not Covered = X as shown).

Selected F-codes (3075F, 3077F, 3078F, 3079F, 3080F, etc.) — Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X as shown).

Some entries show '-' or blank preauthorization field in the excerpt; the document's disclaimer advises providers to confirm plan-specific coverage and preauthorization requirements.

Procedure & Diagnostic Codes (Examples)

Examples of codes listed in documentCPTNot Covered

11952	Therapy for contour defects
15780-15793	Abrasion/chemical peel codes (face/nonfacial)
15820-15879	Revisions, excisions, suction assisted lipectomy and related plastic surgery codes
20930	Allograft, morselized, for spine surgery
22515-22633	Percutaneous vertebral augmentation and multiple spine fusion/arthrodesis codes
22836-22870	Vertebral body tethering, total disc arthroplasty, interspinous stabilization device insertion
27130, 27447, 28890	Total hip/knee replacement; high-energy extracorporeal shock wave

Vascular/Vein proceduresCPT

36475	Endovenous ablation therapy of incompetent vein, extremity, percutaneous, radiofrequency; first vein treated
36478	Endovenous ablation therapy of incompetent vein, extremity, percutaneous, laser; first vein treated
37722	Ligation, division, and stripping, long (greater) saphenous veins

Cell therapy / Transplant relatedCPTNot Covered

38225	CAR-T therapy; harvesting of blood-derived T lymphocytes
38226	CAR-T therapy; preparation of blood-derived T lymphocytes for transportation
38227	CAR-T therapy; receipt and preparation of CAR-T cells for administration

GI / Bariatric proceduresCPT

43290	Esophagogastroduodenoscopy with deployment of intragastric bariatric balloon
43644	Laparoscopic gastric bypass (Roux-en-Y, <=150 cm limb)

Bariatric band proceduresCPTNot Covered

43770	Placement of adjustable gastric band
43771	Revision of adjustable gastric band component only
43772	Removal of adjustable gastric band component only
43773	Removal and replacement of adjustable gastric band component only

Intestine transplant proceduresCPT

44135	Intestine transplant, cadaver
44136	Intestine transplant, live
44137	Removal of transplanted intestinal allograft, complete

Penile prosthesis proceduresCPTNot Covered

54406	Removal of all components of a multi-component, inflatable penile prosthesis without replacement
54408	Repair of component(s) of a multi-component, inflatable penile prosthesis
54410	Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis, same operative session

Prostate/andrology codesCPTNot Covered

55870	Electroejaculation
55877	Ablation, irreversible electroporation, prostate
55880	Ablation of malignant prostate tissue, transrectal, with HIFU

Gynecologic and reproductive procedure codesCPT

58152	Total hysterectomy (approach variant)
58260	Vaginal hysterectomy, uterus <=250 g
58541	Laparoscopy supracervical hysterectomy, uterus <=250 g
58565	Hysteroscopy with bilateral fallopian tube cannulation for permanent implants
58970	Retrieval of oocyte

Neurosurgical and intracranial procedure codesCPTNot Covered

61630	Balloon angioplasty, intracranial
61715	MRgFUS stereotactic ablation, intracranial
61736	Laser interstitial thermal therapy (LITT), intracranial
61737	LITT multiple trajectories

Spinal percutaneous/decompression codesCPTNot Covered

62263	Percutaneous lysis of epidural adhesions
62264	Percutaneous lysis of epidural adhesions (other)
62287	Percutaneous decompression of nucleus pulposus
62330	Percutaneous decompression with partial ligamentum flavum removal

Spine surgery / radiosurgeryCPT

63052	Laminectomy, facetectomy, or foraminotomy during posterior interbody arthrodesis, lumbar; single vertebral segment
63053	Each additional segment for the above
63620	Stereotactic radiosurgery; 1 spinal lesion
63621	Each additional spinal lesion

Spine pain interventions / ablative proceduresCPT

64490	Injection(s), paravertebral facet (zygapophyseal) joint
64491	Injection(s), paravertebral facet joint
64492	Injection(s), paravertebral facet joint
64628	Thermal destruction of intraosseous basivertebral nerve; first 2 vertebral bodies
64629	Each additional vertebral body

MR safety servicesCPTNot Covered

76014	MR safety implant/foreign body assessment, initial 15 minutes
76015	MR safety implant/foreign body assessment, each additional 30 minutes
76016	MR safety determination by physician

Selected codes marked Not CoveredmixedNot Covered

76977	Ultrasound bone density measure — listed as Not Covered for Small Employer and Individual
77078	Bone density study — listed as Not Covered for Small Employer and Individual
77081	DXA appendicular skeleton (peripheral) — listed as Not Covered for Small Employer and Individual
77086	Fracture assessment via DXA — listed as Not Covered for Small Employer and Individual
77437	Surface radiation therapy delivery =150 kV, per fraction — Not Covered
77439	Surface radiation therapy image guidance ultrasound (add-on) — Not Covered
78350	Bone mineral, single photon — Not Covered
80328	Anabolic steroids; 3 or more — Not Covered
80329	Analgesics, non-opioid; 1 or 2 — Not Covered
80330	Analgesics, non-opioid; 3-5 — Not Covered

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Genetic testing codes with preauth flagsCPT

81120

IDH1 testing — preauthorization = X (code entry shows Preauthorization Required = X)

Single-gene analysis codes (8117x series)CPT

81174	AR gene analysis; known familial variant
81175	ASXL1 full gene sequence
81176	ASXL1 targeted sequence analysis
81177	ATN1 expanded allele evaluation
81178	ATXN1 expanded allele evaluation

BRCA and hereditary breast/ovarian cancer codes (8121x series)CPT

81212	BRCA1/BRCA2 specific variant panel (selected variants)
81215	BRCA1 known familial variant
81216	BRCA2 full sequence analysis
81217	BRCA2 known familial variant

CMA and other gene testing codesCPT

81228	Cytogenomic microarray analysis (genome-wide)
81229	CMA with SNP variants
81233	BTK gene analysis common variants
81234	DMPK expanded allele evaluation

Gene-specific targeted analysesCPT

81272	KIT gene analysis, targeted sequencing
81273	KIT D816 variant analysis
81278	IGH@/BCL2 translocation analysis
81279	JAK2 targeted sequence analysis

Molecular pathology levels and panelsCPT

81400	Molecular pathology procedure, level 1
81403	Molecular pathology procedure, level 4
81408	Molecular pathology procedure, level 9 (full gene sequence >50 exons)
81415	Exome sequence analysis
81418	Drug metabolism (pharmacogenomics) genomic sequence analysis panel (must include at least 6 genes)

Selected molecular/genomic and advanced diagnostic codes from listCPT

81408	Molecular pathology / genomic sequencing code listed
81410	Genomic sequencing panel (examples: aortic dysfunction/dilation)
81418	Drug metabolism/pharmacogenomics panel; must include CYP2C19, CYP2D6, and CYP2D6 duplication/deletion analysis
81422	Fetal chromosomal microdeletion(s) cell-free fetal DNA
81432	Hereditary breast cancer-related disorders panel (must include sequencing of at least 14 genes)
81449	Targeted genomic sequence analysis panel, solid organ neoplasm, 5-50 genes
81456	Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, 51+ genes
81518	Oncology (breast) mRNA gene expression profiling, RT-PCR of 11 genes
81521	Oncology (breast) mRNA microarray gene expression profiling (70 content genes & 465 housekeeping genes)
81524	Oncology (CNS tumor) DNA methylation analysis of at least 10,000 sites

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Oncology/genomic assay codes (examples)CPT

81536	Oncology (gynecologic), live tumor cell culture and chemotherapeutic response — example listed
81538	Oncology (lung), mass spectrometric 8-protein signature — example listed
81539	Oncology (high-grade prostate cancer), biochemical assay of four proteins — example listed

Fertility and reproductive technology codes (examples)CPTNot Covered

89250	Fertilization of oocyte
89258	Cryopreservation, embryo
89337	Cryopreservation, mature oocyte(s)

Immunization and vaccine-related codesCPTNot Covered

90482	Immunization counseling when immunization not administered same date
90581	Anthrax vaccine
90668	Influenza vaccine, pandemic formulation, split virus, for intramuscular use

Optical and vestibular/audiology procedures (selected)CPTNot Covered

92353	Special spectacles fitting
92354	Special spectacles fitting
92355	Special spectacles fitting
92358	Eye prosthesis service
92370	Repair & adjust spectacles
92531	Spontaneous nystagmus study
92532	Positional nystagmus study
92533	Caloric vestibular test
92534	Optokinetic nystagmus

Hearing aid evaluation/selection/fittingCPT

92628	Evaluation for hearing aid candidacy; first 30 minutes
92629	Evaluation for hearing aid candidacy; each additional 15 minutes
92631	Hearing aid selection services; first 30 minutes
92632	Hearing aid selection services; each additional 15 minutes
92634	Hearing aid fitting services; first 60 minutes

Cardiac procedure codesCPTNot Covered

92921	Prq cardiac angio addl art
92925	Prq card angio/athrect addl
92929	Prq card stent w/angio addl
92934	Prq card stent/ath/angio

Misc diagnostic and therapy codesCPTNot Covered

94452	High altitude simulation test (HAST), with physician interpretation and report
94453	High altitude simulation test (HAST) with supplemental oxygen titration
94660	Continuous positive airway pressure ventilation (CPAP), initiation and management
95957	EEG digital analysis
96000	Comprehensive computer-based motion analysis by video-taping and 3-D kinematics

Selected therapy and behavior codesCPTNot Covered

97026	Infrared therapy
97037	Low-level laser therapy
97153	Adaptive behavior treatment by protocol, technician

E/M and facility care codes (examples shown as Not Covered or Preauth required per line)CPT

99221-99233	Initial and subsequent hospital care
99241-99245	Office consultation series
99304-99310	Nursing facility care codes (initial and subsequent)

Ancillary/administrative codesCPTNot Covered

99000-99082

Ancillary/administrative codes (specimen handling, supplies, travel, reports)

Selected CPT codes marked not coveredCPTNot Covered

99367	Medical team conference with interdisciplinary team, patient/family not present
99368	Medical team conference with interdisciplinary team, patient/family not present
99374	Home health care supervision
99417	Prolonged office/outpatient E/M service (add-on)
99452	Interprofessional EHR/referral service(s), 30 m
99474	Self-measured blood pressure monitoring, reporting
99605	Medication therapy management service(s) by pharmacist
99606	Medication therapy management service(s) by pharmacist
99607	Medication therapy management service(s) by pharmacist

Selected HCPCS/quality measure codes marked not coveredHCPCSNot Covered

0001F	Heart failure assessed (quality measure)
0500F	Initial prenatal care visit (quality measure)
0520F	Normal tissue dose constraints established (radiation oncology measure)
0580F	Multidisciplinary care plan (quality measure)
1000F	Tobacco use, smoking, assessed (quality measure)

Example F-codes (partial list)HCPCSNot Covered

1050F	History obtained regarding new or changing moles (ml)
1052F	Type, anatomic location, and activity all assessed (ibd)
1060F	Documentation of permanent or persistent or paroxysmal atrial fibrillation (str)

Additional F-codes (partial list)HCPCSNot Covered

1490F	Dementia severity classified, mild (dem)
1500F	Symptom + sign symm polyneuro
2000F	Blood pressure measured (ckd)(dm)

Ophthalmology / general exam F-codesHCPCSNot Covered

2026F	Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and reviewed
2028F	Foot examination performed (includes visual inspection, sensory exam with monofilament, and pulse)
2029F	Complete physical skin exam performed (ml)

Selected F-code descriptions from documentmixedNot Covered

2026F	Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and reviewed.
2027F	Optic nerve head evaluation performed.
2028F	Foot examination performed (visual inspection, sensory exam with monofilament, and pulse).
3011F	Lipid panel results documented and reviewed (must include total cholesterol, HDL-C, triglycerides and calculated LDL-C).
3014F	Screening mammography results documented and reviewed.
3020F	Left ventricular function assessment documented in the medical record.
3074F	Most recent systolic blood pressure less than 130 mm Hg.
3095F	Central dual-energy X-ray absorptiometry (DXA) results documented.
3111F	CT or MRI of the brain performed within 24 hours of arrival to confirm initial diagnosis of stroke, TIA or intracranial event.
3140F	Upper GI endoscopy report indicates suspicion of Barrett's esophagus.

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Prior Authorization & Billing Actions

Prior Authorization

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.

Prior Authorization

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.

Scope, Flags & Disclaimers

Per-code indicator usage summary

Per-code indicators usedEach code row shows either 'Not Covered' or 'Preauthorization Required' for Small Employer and Individual plans.

Example: genetic test preauth81167 (BRCA2 duplication/deletion analysis) is listed with Preauthorization Required = X.

Example: pharmacogenomics not covered81418 (drug metabolism/pharmacogenomics panel) is listed Not Covered = X in the table.

Pharmacy exclusions note

Pharmacy exclusionsImmunizations, injectable drugs, and specialty medications are not represented on this coding list and should be referenced via the Pharmacy link.

Where notedDisclaimer directs providers to the Pharmacy link for vaccine and specialty drug coverage details.

Policy Summary

PayerSelectHealth

PolicyCommercial codes not covered or requiring prior authorization — Colorado

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 26, 2026

Next Review DateN/A

Key ActionCheck the code table and obtain prior authorization where the listing shows 'Preauthorization Required = X' before rendering services.

SourceLink

On This Page

36475 — Endovenous ablation therapy (first vein treated): Not Covered = '-' in one listing and shows plan-specific flag; listed in the document as present in the table (see chunk).

43290 — Deployment of intragastric bariatric balloon during EGD: Not Covered for Small Employer and Individual plans (Not Covered = X).

54406 — Coverage indicator: Not Covered for Small Employer and Individual plans (penile prosthesis removal of components).

55870 — Coverage indicator: Not Covered for Small Employer and Individual plans (electroejaculation).

55970 — Coverage indicator: Preauthorization Required for Small Employer and Individual plans (sex transformation procedures).

81415 — Exome sequence analysis: Preauthorization Required for Small Employer and Individual plans (Preauthorization Required = X).

Pharmacogenomics panel gene minimum

Pharmacogenomics panel gene minimumMust include testing of at least 6 genes, including CYP2C19, CYP2D6, and CYP2D6 duplication/deletion analysis.

Related codeCPT 81418 references this requirement in the coding list.

Plan scopeApplies to Small Employer and Individual commercial plans in Colorado as listed.

Panel gene count thresholds referenced

Panel size groupings referencedDocument references targeted genomic panels grouped by gene count (examples: 5–50 genes; 51+ genes).

Minimum-gene examplesSome hereditary/familial disorder panels specify minimum gene counts (eg, hereditary breast cancer panels require >=14 genes per 81432).

ApplicationGene-count distinctions used to assign Preauthorization Required or Not Covered statuses for specific CPT panel codes.

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.

Prior Authorization

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.

Prior Authorization

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.

Prior Authorization

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.

Denial Risk

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.

Prior Authorization

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.

Prior Authorization

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.

Prior Authorization

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).

Prior Authorization

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.

Prior Authorization

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.

Prior Authorization

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

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.

Billing Rule

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.

Billing Rule

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.

Billing Rule

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).

Prior Authorization

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.

Note

Preauthorization and coverage flags

The code file includes both preauthorization-required and not-covered flags across a wide range of services. Always reconcile the code-level flag with the member's plan, and seek prior authorization where indicated.

Provider action: review both Not Covered and Preauthorization flags before rendering services.
If a code is marked Not Covered = X for the member's plan, do not expect payment; obtain alternatives or medical necessity exceptions where available.
If a code is marked Preauthorization Required = X, obtain prior authorization to avoid claim denials.

Note

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

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.

Denial Risk

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.

ImpactPharmacy-managed items are excluded from the per-code Not Covered/Preauthorization table.

Disclaimer / Update frequency

Update frequencyCoding lists are updated quarterly.

Coverage may varyDisclaimer: coverage may vary by plan type and may not follow the listed services.

Pharmacy exception noteLists do not reflect immunizations, injectable drugs, or specialty medications (see Pharmacy link).

Disclaimer

General disclaimerCoverage may vary by plan type; providers should verify plan-specific coverage before rendering services.

Quarterly updatesDocument explicitly states coding lists are updated quarterly.

Pharmacy link instructionImmunizations and specialty medications should be directed to the Pharmacy section of the website.

Disclaimer / scope of coding lists

Scope limitationCoding lists do not include immunizations, injectable drugs, or specialty medications; those are handled via Pharmacy.

Update cadenceLists updated quarterly; effective/as-of dates are printed (example: As of 03/26/26).

Provider actionProviders should consult plan-specific resources for excluded items.

Not Covered / Preauthorization indicators

Not Covered indicator presentEntries display 'Not Covered = X' when a service is not covered for Small Employer and Individual plans.

Preauthorization indicator presentEntries display 'Preauthorization Required = X' when prior authorization is required for Small Employer and Individual plans.

F-code behaviorSome F-codes are marked Not Covered = X while others include a Preauthorization field (often set to '-'); verify per plan.

Preauthorization indicator meaning

Preauthorization Required meaning'Preauthorization Required = X' indicates SelectHealth requires prior authorization for that code under the Small Employer and Individual plans.

Action requiredObtain prior authorization before providing services billed under codes marked with 'X' in the Preauthorization column.

ExamplesMultiple genetic and molecular pathology codes (eg, 81167, many 81xxx codes) are shown with Preauthorization Required = X.

Not covered indicator meaning

Not Covered meaning'Not Covered = X' indicates the listed code is not covered for the referenced Small Employer and Individual plan.

Billing implicationServices billed for codes marked Not Covered = X are not payable under those plan types.

Examples81418 (pharmacogenomics panel) and multiple F-codes are listed as Not Covered = X in the document.

Disclaimer / scope of coding lists (repeat)

Scope reminderCoverage may vary by plan type; coding lists do not reflect immunizations/injectables/specialty meds and are updated quarterly.

Provider verificationProviders should confirm plan-specific coverage and prior authorization requirements via payer resources.

As-of date examplesDocument includes 'As of' dates (example shown: As of: 03/26/26) near code sections.

Preauthorization Required definition

Preauthorization Required — definitionA code flagged with 'X' in the Preauthorization Required column denotes that SelectHealth requires preauthorization for that service under the Small Employer and Individual plans in Colorado.

Where usedThis applies across multiple code groups including genetic, molecular pathology, and advanced diagnostics (many 81xxx and 81xxx/81xxx series codes).

Provider stepSubmit prior authorization requests per SelectHealth procedures before scheduling or performing the service.

Not Covered definition

Not Covered — definitionA code flagged as 'Not Covered = X' indicates the service is not covered for the specified Small Employer and Individual plan in this listing.

ExamplesSelected diagnostic, therapy, and F-code entries are explicitly marked Not Covered = X (eg, 81418, various F-codes, selected CPT codes).

ConsequenceBilling for these services to the payer for affected plan types is likely to be denied; confirm alternatives or plan exceptions separately.

Preauthorization Required (repeat)

Preauthorization Required (repeated)Codes marked with 'Preauthorization Required = X' must have prior authorization for Small Employer and Individual plans.

Common code groupsFrequent in genetic, molecular pathology, oncology panel and advanced diagnostics code ranges.

ActionFollow payer preauthorization process to avoid claim denials.

Not Covered (repeat)

Not Covered (repeat)Codes shown as 'Not Covered = X' are not covered for the Small Employer and Individual plans where indicated.

Examples in listPharmacogenomics panel 81418 and several F-codes are shown as Not Covered = X in the document.

Verify per planProviders should verify member-specific plan terms because coverage may vary by plan type.

Disclaimer

Standard disclaimer textPlease note that coverage may vary by plan type and may not follow the listed services; codes are updated quarterly.

ExclusionsLists do not reflect immunizations, injectable drugs, or specialty medications (see Pharmacy link).

Provider instructionCheck plan-specific resources and the Pharmacy section for excluded items.

Coverage flag meanings

Coverage flag meanings'Not Covered = X' denotes the code is not covered for the referenced plan; 'Preauthorization Required = X' denotes the code requires prior authorization for that plan.

Use caseThese flags are applied per code row for Small Employer and Individual commercial plans in Colorado.

Provider stepWhen Preauthorization Required = X, obtain prior auth before service; when Not Covered = X, do not bill expecting coverage.

Disclaimer / scope limitation

Scope limitation reminderCoverage may vary by plan type; coding lists are updated quarterly and exclude immunizations/injectables/specialty meds.

Where to find exclusionsExcluded items are managed through the Pharmacy link on the payer website.

Effective datesDocument sections include 'As of' dates illustrating last update (example: 03/26/26).

Coding lists update frequency / exclusions

Coding lists update frequencyLists are updated quarterly.

Pharmacy exclusions restatedImmunizations, injectable drugs, and specialty medications are excluded and handled via Pharmacy.

Provider checkProviders must verify member-specific plan coverage when relying on these lists.

Not Covered (X) definition

Not Covered (X) definitionCodes marked with 'X' under 'Not Covered' are designated as not covered for the referenced Small Employer and Individual plan.

Example codesMultiple optical, vestibular and other procedure codes are explicitly shown Not Covered = X in the list.

Billing consequenceClaims for these services are likely to be denied; confirm exceptions separately.

Preauthorization Required (X) definition

Preauthorization Required (X) definitionCodes with 'Preauthorization Required = X' must have prior authorization obtained before services are rendered for the referenced plan.

Example codesSelected audiology and hearing-aid related codes (eg, 92590–92595, 92628–92629) are shown requiring preauthorization.

Provider actionSubmit preauthorization requests per SelectHealth procedures to avoid denial.

Not Covered (repeat)

Not Covered (repeat)Reiterates that codes flagged Not Covered = X are not covered for the Small Employer and Individual plans where indicated.

Example: pharmacogenomics81418 is listed Not Covered = X in the molecular/genomic section.

Verify plan-specific coverageMembers may have different plan-level coverage; confirm prior to service.

Preauthorization Required (repeat)

Preauthorization Required (repeat)Codes marked Preauthorization Required = X require prior authorization for Small Employer and Individual plans.

Common areasFrequent among molecular/genetic, oncology, and advanced diagnostics code ranges.

Follow payer processUse SelectHealth preauthorization workflow to request authorization before service.

Disclaimer (repeat)

General disclaimer (repeat)Coverage may vary by plan type; coding lists updated quarterly; immunizations/injectables/specialty meds excluded (see Pharmacy).

Provider verificationProviders should consult plan-specific resources and the Pharmacy link for excluded items.

Document currencyAs-of dates appear in sections to show last update (e.g., 03/26/26).

Not Covered (X) explanation

Not Covered (X) explanationWhen a code row shows 'Not Covered = X' for Small Employer and Individual, the service is not covered under those plan types as listed.

Document examplesMultiple gene analysis and panel codes are marked Not Covered = X in the genetic/molecular sections.

Provider guidanceConfirm member-specific plan details as coverage can vary by plan type.

Preauthorization Required explanation

Preauthorization Required explanation'Preauthorization Required = X' indicates prior authorization must be obtained for services billed under that code for the Small Employer and Individual plans.

Where commonOften applied to genetic, molecular pathology, oncology panels and advanced diagnostic assays.

Provider stepSubmit clinical documentation with preauthorization request as required by SelectHealth.

Disclaimer about plan variation and pharmacy exclusions

Plan variation disclaimerCoverage may vary by plan type; providers must verify member-specific coverage and prior auth requirements.

Pharmacy exclusions repeatImmunizations, injectable drugs, and specialty medications are excluded from these coding lists and handled via Pharmacy resources.

Quarterly updatesCoding lists are updated quarterly; check for the latest version prior to providing services.

Coverage flags / disclaimers (end)

Coverage flags summary'Not Covered = X' or 'Preauthorization Small Employer and Individual = X' indicate the payer's stance for that plan type; the document is updated quarterly and excludes pharmacy items.

Provider actionVerify plan-specific coverage and obtain prior authorization when required to avoid denials.

Where to lookRefer to the coding table rows and the Pharmacy link for excluded medication services.