Preauthorization required — sample codes

SelectHealth marks the listed cosmetic/reconstructive/dermatologic CPT codes as requiring prior authorization before services will be considered for coverage.

• Examples include 01999, 11960, 11970, 11971, 15775–15783, 15788–15793, and related codes shown with Preauthorization Required = X in the table.

Preauthorization required / Not covered — additional sample codes

Some breast, skin, and injectable procedure codes in the list are either designated Not Covered or require preauthorization; providers must check each code's line entry.

• Examples include 19325, 19328, 19340 (Preauthorization Required = X) and some injectable entries marked Not Covered or with mixed flags (see code rows).

Spine procedure authorizations and exclusions

Multiple spine procedure CPT codes are listed as requiring preauthorization; a small subset (e.g., 22526, 22527) are explicitly marked Not Covered.

• Providers should obtain prior authorization for spine codes marked 'Preauthorization Required = X' and avoid billing codes marked 'Not Covered = X' for Colorado members.

Spine fusion/arthrodesis codes requiring preauthorization

Select spine fusion and arthrodesis CPT codes are shown with Preauthorization Required = X and require authorization prior to service.

• Examples: 22614, 22630, 22632, 22633, 22634 are marked Preauthorization Required = X in the table.

Additional spine and tethering codes requiring preauthorization

Additional spine stabilization and vertebral body tethering codes require prior authorization as indicated in the coding table.

• Examples include 22800, 22802, 22804, 22808, 22810, 22812, 22836, 22837 which are marked Preauthorization Required = X.

Example Not Covered code

Code 22862 is explicitly designated as Not Covered and may be denied if billed for Colorado members.

• 22862 — Revision including replacement of total disc arthroplasty (lumbar): Not Covered = X.

Preauthorization required — sample codes from cardiac/phrenic device and transcatheter procedures

Several cardiac, phrenic nerve stimulator, and transcatheter procedure codes are listed with Preauthorization Required = X; providers must secure authorization prior to performing these services.

• Examples include 33276, 33277, 33287, 33288, 33340 (all shown with Preauthorization Required = X).

Not covered vs preauthorization examples — vascular and vein procedures

Vascular and vein procedure codes in the list have mixed statuses; some codes are Not Covered while others require prior authorization — verify the code row before scheduling.

• Example: 36468 is Not Covered = X, while 36465/36466/36470 are marked Preauthorization Required = X; 37216 is Not Covered = X and 37215 requires preauthorization.

Not covered — hematopoietic progenitor cell preparation codes

Multiple hematopoietic progenitor cell and transplant preparation/cell-processing CPT codes are explicitly marked Not Covered; these services will not be reimbursed under the listing.

• Examples: 38207–38215 (cryopreservation, thawing, cell depletion) are shown as Not Covered = X in the table.

Preauthorization required codes (sample)

Multiple bariatric/laparoscopic gastric procedure CPT codes require prior authorization per the table; obtain authorization before proceeding.

• Examples: 43770–43774 and 43775 are marked Preauthorization Required = X.

Not covered and preauthorization examples

Some gastrointestinal and related procedure codes are explicitly Not Covered while others require preauthorization; confirm the code-specific designation prior to service.

• Examples: 43842 and 44705 are marked Not Covered = X; many sleeve gastrectomy and related codes (e.g., 43775) are marked Preauthorization Required = X.

Transplant-related codes

Transplantation and donor graft preparation codes are included with mixed flags; many transplant procedure codes require preauthorization and some are not covered.

• Examples: 47135 (transplantation of liver) and 50360 (transplantation of kidney) are shown with Preauthorization Required = X; 48160 (pancreas removal/transplant) is Not Covered = X.

Urology/device-related codes

Select urology and continence device CPT codes include entries explicitly Not Covered and others that require preauthorization; check each code row.

• Examples: 52443 and 53451–53454 are marked Not Covered = X; many prosthesis/device insertion or revision codes (e.g., 54410) are Preauthorization Required = X.

Preauthorization requirements for listed codes

The coding table indicates which listed codes require preauthorization (marked 'Preauthorization Required = X'); providers must obtain authorization for codes so marked before providing services.

• Providers should consult the Preauthorization Required column in the table for each CPT code and secure authorization where X is indicated.

Neurosurgery/cranial codes — coverage and prior auth

Neurosurgery and cranial procedure codes have mixed coverage stances; some are Not Covered while others are marked Preauthorization Required = X—obtain authorizations where indicated.

• Examples: 61640–61642 are Not Covered = X; 61715 and many stereotactic radiosurgery-related codes are Preauthorization Required = X.

Spine/pain and related surgical codes — prior authorization and not-covered items

Spine, pain management, and related surgical codes show explicit Not Covered or Preauthorization Required flags; secure prior authorization for codes marked with X to avoid denials.

• Examples: 62287 is marked Not Covered; codes such as 62330, 62350, 62360, 62361, 62362, 62380, and 63015 are shown as Preauthorization Required = X.

Preauthorization requirement for listed Medicare procedure codes

Numerous Medicare procedure codes in the spinal and neurosurgical ranges are flagged as either Not Covered or Preauthorization Required; obtain authorization when 'Preauthorization Required = X' appears.

• Affected codes include 63078, 63085–63091, 63170–63308, 63600–63685, and multiple 644xx paravertebral/facet injection codes as listed.

Preauthorization Required — selected codes

SelectHealth marks a set of targeted CPT codes (64491–64629 and related) as requiring preauthorization for Colorado Medicare members; secure prior authorization for these codes.

• Examples include 64491–64495, 64505, 64553, 64555, 64561, 64566, 64568–64575, and 64624–64629 (Preauthorization Required = X).

Not Covered — specific code

Specific percutaneous electrical nerve stimulation code 64567 is listed as Not Covered and may be denied if submitted for Colorado members.

• 64567 — Percutaneous electrical nerve field stimulation, cranial nerves, without implantation: Not Covered = X.

Neuro/nerve and implant-related codes — authorization summary

Additional neuro/nerve and implant-related procedure codes are designated as Preauthorization Required or Not Covered; providers must verify each code row for the correct authorization requirement.

• Examples include 64628–64636 and other nerve ablation/implant procedure codes with mixed flags in the table.

Ophthalmology/ENT/imaging codes — authorization summary

Ophthalmology, ENT, implant, and imaging CPT codes in the list are marked either Not Covered or require preauthorization; consult the specific line item before ordering or scheduling.

• Examples include 66989, 66991, 69949, 69979, 74261–74262, 75577 and other imaging/implant codes noted with Preauthorization Required = X.

Preauthorization required (examples)

A subset of CPT codes in the excerpt are explicitly shown as requiring preauthorization (marked 'X'); providers must obtain authorization prior to service to avoid denials.

• Examples listed with Preauthorization Required = X in the excerpt include 69729, 69730, 69949, 69979, 74261, 74262, 75577, 75580.

Radiation/proton therapy preauth examples

Radiation therapy and proton therapy related CPT codes in the document are shown with Preauthorization Required = X; obtain preauthorization for these high-cost radiation services.

• Examples: 77371–77373, 77520, 77522 and other stereotactic/proton therapy delivery codes are marked Preauthorization Required = X.

MR safety not covered examples

MR safety and related MRI service codes are listed as Not Covered = X in the table; these entries present denial risk if billed under the Medicare listing for Colorado.

• Examples include 76014–76017 and 76019, 76140, 76390 which are shown as Not Covered = X for Colorado.

Prior authorization and exclusion flags (partial list)

The code tables use 'Not Covered = X' and 'Preauthorization Required = X' flags across many CPT lines; providers must consult the table and request prior authorization where X is indicated.

• This is a partial list; refer to the complete quarterly-updated code tables for the full set of flagged codes.

Genetic testing authorization indicators

Numerous genetic testing CPT codes (81178–81195, 81200–81242, and others) are marked either Preauthorization Required = X or Not Covered = X depending on the specific code.

• Providers ordering genetic tests must check each CPT line for the Preauthorization or Not Covered flag before ordering/testing.

Prior authorization and not-covered flags for listed CPT codes

The genetic/molecular CPT code segment flags individual codes as either Not Covered or requiring Preauthorization; providers must review the specific table entry for each code to determine required actions.

• Examples: 81239, 81240, 81242, 81247 show mixed Not Covered and Preauthorization flags; check the row for the exact designation.

Preauthorization required for selected 813xx codes

Selected 813xx single-gene and variant testing CPT codes are shown as Preauthorization Required = X; obtain authorization before ordering these tests.

• Examples: 81302, 81305, 81321 and many other 813xx entries are flagged Preauthorization Required = X.

Preauthorization required for listed codes

A broad set of genetic and molecular pathology CPT codes (81331–81355 and others) are listed with Preauthorization Required = X; providers must obtain prior authorization for codes marked X before testing.

• Note that some codes (e.g., 81355) may show Not Covered in the table; verify each code row for the exact designation to avoid denials.

Not covered codes

Some individual molecular/genetic CPT codes are explicitly Not Covered; do not bill these codes expecting reimbursement under this Colorado listing.

• Example: 81355 is shown as Not Covered = X; 81493 is listed Not Covered = X in the genomic panel section.

Preauthorization required — selected genomic/molecular codes

Multiple genomic and molecular pathology CPT codes (e.g., 81439–81443 and related) are indicated as requiring preauthorization for Colorado Medicare plans; secure authorization prior to testing.

• Examples: 81439 and other listed genomic sequence analysis panels are marked with Preauthorization Required = X in the table.

Preauthorization required — additional molecular and genomic codes

Additional molecular and genomic pathology CPT codes (81463–81504 and others) are marked Preauthorization Required = X except where specifically noted as Not Covered.

• Examples: 81463–81465, 81470–81471, 81479, 81490, 81500–81504 are shown with Preauthorization Required = X.

Mixed preauthorization and not-covered lab/oncology codes

Selected transplant, oncology, and laboratory procedure codes show mixed statuses; many are marked Preauthorization Required = X while some are explicitly Not Covered.

• Examples: 81558 and 81595 are Preauthorization Required = X; 81560 and 83519 are shown Not Covered = X.

Preauthorization and not-covered flags

This Colorado Medicare listing flags specific codes as either requiring prior authorization or as Not Covered; providers must consult the per-code table and follow the indicated authorization steps.

• The table shows many reproductive medicine, laboratory, immunoglobulin/antitoxin, and cytogenetic codes with Preauthorization Required = X or Not Covered = X.

Examples of affected code groups

Selected reproductive medicine, laboratory, and immunoglobulin/antitoxin code groups are either Not Covered or require prior authorization; verify the code row before providing services.

• Examples: 89250–89281 reproductive medicine codes and 90281–90283 immunoglobulin codes are flagged in the listing.

Preauthorization requirements (excerpt)

An excerpt of codes in the list is marked as requiring preauthorization (X) while others are Not Covered (X); providers must obtain preauthorization where indicated to avoid claim denials.

• Examples in the excerpt include 95199 (Preauthorization Required = X) and 95131–95134 (Not Covered = X).

Therapy/behavioral/acupuncture preauthorization and coverage flags

Many therapy, rehabilitation, behavioral health, and acupuncture CPT codes are flagged either Not Covered or as requiring conditional preauthorization (X or X*); follow the table guidance and seek prior authorization when X or X* is shown.

• Examples: 97010/97012/97110 and evaluation codes 97161–97163 are shown with Preauthorization Required = X or X*; several codes such as 97014, 97026, 97033, 97037 are Not Covered = X.

Preauthorization and pharmacy referral guidance

Providers should refer to the Preauthorization Required column and the Pharmacy link for immunizations, injectable drugs, and specialty medications; many codes in the list require preauthorization or are Not Covered.

• The document notes that the lists are updated quarterly and that pharmacy-managed items are not represented in these tables.

Update cadence and plan-type variation

The code lists are updated quarterly and include an 'As of' date; coverage can vary by plan type — confirm the current 'As of' date and plan applicability when checking preauthorization or coverage requirements.

• Operational note: the document states codes are updated quarterly and coverage may vary by plan type (As of: 12/22/25 in this extract).