Code list summary and disclaimer

Code list summary and disclaimer: These code lists identify Medicare procedure and laboratory codes that are either Not Covered or require Preauthorization for SelectHealth Utah & Idaho plans. Coverage may vary by plan and provider type; lists are updated quarterly. These lists do not reflect pharmacy, immunization, injectable drug, or specialty medication coverage — refer to the Pharmacy resources on the payer website for those services.

• Coverage flags used in lists: Not Covered = X; Preauthorization Required = X (or X* where noted).
• Lists are refreshed quarterly; always verify member-specific benefits and medical necessity prior to service.
• Pharmacy, immunizations, and specialty medication information is not included here — consult Pharmacy resources.

Preauthorization timing and limits

Preauthorization timing and limits: Certain services require preauthorization before the first service; others become subject to prior authorization based on usage or time. Typical operational triggers in these lists include:

• Preauth after a certain number of visits — visit limits depend on plan and provider type; obtain prior authorization when visit-based thresholds are exceeded.
• Preauth after the 3rd rental month — durable medical equipment (DME) rentals require authorization starting the 4th month when rental-criteria are not met.
• Quarterly updates to code lists can change timing or thresholds; confirm current rules at time of authorization request.

Preauthorization indicators for listed Medicare codes

Preauthorization indicators for listed Medicare codes: Some CPT/HCPCS codes in the list include an explicit Preauthorization Required marker (X). Examples in the surgical and device sections include certain spine, sacroiliac, and cardiac device procedures. When a code is marked Preauthorization Required, obtain prior authorization before scheduling the procedure to avoid claim denials.

• Example Medicare procedure codes flagged Preauthorization Required: 22854 (insertion of interbody biomechanical device) — Preauthorization Required = X.
• 22869 (insertion of interlaminar/interspinous stabilization device, single level) — Preauthorization Required = X.
• 27278 (arthrodesis, sacroiliac joint; percutaneous with image guidance) — Preauthorization Required = X.
• 33275 (transcatheter removal of permanent leadless pacemaker) — Preauthorization Required = X.
• Note: not all instances of these procedure families are identical across plans — confirm member plan applicability.

Preauthorization / Not Covered codes

Preauthorization / Not Covered codes (examples): The lists include many codes with either Not Covered or Preauthorization Required designations. Below are sample codes called out in the source lists as Not Covered or Not Covered = X and as requiring preauthorization.

• Sample Not Covered examples: 68841 (insertion of drug‑eluting punctal implant) — Not Covered = X; 0004A (SARS‑CoV‑2 vaccine administration code) — Not Covered = X; 98000 (synchronous audio‑video new patient E/M, 15 minutes) — Not Covered = X for certain plans.
• Sample Preauthorization Required examples: 22854 — Preauthorization Required = X; 22869 — Preauthorization Required = X; 27278 — Preauthorization Required = X; 33275 — Preauthorization Required = X; Selected molecular/genomic panels (see oncology/genomic section) marked X or X*.

Operational preauthorization notes

Operational preauthorization notes: Providers must check member-specific benefit design and follow the payer’s prior authorization submission process. Typical operational notes from the lists:

• Preauthorization requirements and thresholds may vary by plan and provider type — always verify eligibility and authorization requirements for the member.
• Coding lists are updated quarterly; decisions should be based on the most recent published lists and payer portal guidance.
• When a code is marked with an asterisk (X*), additional clinical documentation or prior-authorization criteria may apply; submit full supporting records.
• For DME rentals, authorization is often required starting month 4 if documentation does not meet ongoing rental criteria.

Sample codes requiring preauthorization

Sample codes requiring preauthorization (representative, consolidated): When flagged in the source lists these codes require prior authorization; this is a representative subset consolidated for provider action.

• Spine and implant devices: 22854 (interbody biomechanical device) — Preauthorization Required = X; 22869 (interlaminar/interspinous device) — Preauthorization Required = X.
• Sacroiliac: 27278 (arthrodesis, sacroiliac joint, percutaneous) — Preauthorization Required = X.
• Cardiac device: 33275 (transcatheter removal of permanent leadless pacemaker) — Preauthorization Required = X.
• Neurostimulation / implant: selected neurostimulator and lead implantation/revision codes show Preauthorization Required flags (examples in source lists).
• Molecular/genomic panels: selected codes (e.g., 81450 series entries and specific 00xxxU lab codes) are flagged for preauthorization; check individual code entries.

Sample codes not covered

Sample codes not covered (representative, consolidated): The lists include codes explicitly marked Not Covered; below are representative examples to watch for.

• Cosmetic / reconstructive exclusions and select device removals: multiple CPT codes for extensive cosmetic/excisional procedures are listed as Not Covered in the source content.
• Procedure and service examples marked Not Covered = X in source: 68841 (drug‑eluting punctal implant) — Not Covered = X; 98000 (synchronous audio‑video new patient E/M) — Not Covered = X for certain plans; vaccine administration code 0004A — Not Covered = X.
• Certain laboratory/diagnostic assays and nonstandard imaging procedures were listed as Not Covered in the laboratory sections (see specific code rows).

Behavioral health / drug class specimen codes (partial)

Behavioral health and drug‑class specimen codes (partial): The lists include grouped specimen/testing codes by drug class with coverage or preauthorization status. Providers billing drug‑testing panels should confirm plan rules and obtain authorization when required.

• Drug class examples from source: Analgesics (non‑opioid) panels (80329–80331), Antidepressants (80332–80338), Antipsychotics (80342–80344), Benzodiazepines (80346–80347), Stimulants and opioids (80361–80364 series).
• Some specimen/drug classes may have visit-based or frequency limits — exceeding those thresholds can trigger preauthorization.
• When ordering definitive or presumptive drug testing, verify whether the specific panel code is covered, requires preauthorization, or is not covered for the member.

Drug testing / opioid-related specimen codes (partial)

Drug testing / opioid‑related specimen codes (partial): The source lists multiple opioid and stimulant screening/definitive testing codes; many have plan‑specific flags.

• Opioid and opioid‑analog panels: 80362–80364 series (opioids and opiate analogs) appear in the lists — confirm coverage or prior authorization requirements per plan.
• Specific analyte codes (e.g., oxycodone, methadone, buprenorphine) are represented in the 8036x series; some may be subject to utilization management.
• Definitive multi‑analyte panels (80376–80377) and urinalysis codes (81099) are present in the laboratory sections — check for preauthorization or coverage exclusions for each member.

Urinalysis and genetic testing codes (partial)

Urinalysis and genetic testing codes (partial): The lists include urinalysis and a wide range of genetic/histocompatibility and targeted gene analysis codes; many genetic tests require prior authorization or have denial risk.

• Urinalysis example: 81099 appears in the lists — verify coverage and prior authorization rules.
• HLA and platelet antigen testing (81105–81112 and 81378–81383 ranges) are present; these may be subject to plan review.
• BRCA and hereditary cancer panels (81162–81163; 0120U–0129U and related U‑codes) and numerous single‑gene and panel genomic CPT/HCPCS entries (811xx, 814xx series) are listed — many require prior authorization and clinical documentation.
• For genetic testing, confirm medical necessity, family/personal history, and submit requisite documentation to avoid denial.

Oncology/genetic analysis codes (partial)

Oncology and genomic analysis codes (partial): The molecular pathology and genomic sequencing/profiling code ranges (81400–81479, 00xxxU–00xxx ranges) appear in the source lists and include both Preauthorization Required and Not Covered flags for specific entries.

• Representative genomic/molecular examples: 81400 (molecular pathology level 1) — Preauthorization Required = X in the list; 81450–81459 (targeted panels / GSPS entries) include several entries with prior authorization flags.
• Selected oncology U‑codes (00###U) for transcriptome, targeted sequencing, and risk scoring algorithms are present; some show Preauthorization Required markers (X) or are otherwise flagged.
• Panel tests with broad gene content (e.g., 81456 and large panels) are listed — review payer‑specific clinical coverage criteria and prior authorization requirements before ordering.

Preauthorization and denial risk for listed genetic codes

Preauthorization and denial risk for listed genetic codes: The source emphasizes preauthorization and potential denial for genetic and molecular testing when criteria are not met. Providers must submit detailed clinical justification.

• Many molecular and genomic codes are annotated with Preauthorization Required (X) — failure to obtain authorization may result in denial.
• Submit clinical indication, prior testing history, and documentation of how results will impact management when requesting authorization for genetic panels.
• Complex panels and novel U‑codes may have additional documentation requirements; consult payer guidance for required forms or supporting records.

Preauthorization requirements and notes

Preauthorization requirements and notes (operational): The lists contain inline operational notes about when prior authorization applies and how it may be triggered by usage or time. Key operational reminders for providers:

• Visit‑based preauthorization limits: some therapy, rehabilitation, and visit‑based services become subject to preauthorization after a specific number of visits — limits vary by plan and provider type.
• Rental equipment preauthorization trigger: DME rentals may require prior authorization after the 3rd rental month if documentation does not continue to meet ongoing rental criteria.
• Codes with an asterisk (X*) often indicate an enhanced review or special authorization pathway — include requested documentation at submission to expedite review.
• Always check the member’s plan, since a code flagged in the consolidated list may be covered for one plan but require prior authorization or be denied for another.

Operational authorization notes

Operational authorization notes and prior authorization process reminders: To reduce claim denials and administrative delays, follow these operational steps.

• Verify member eligibility and benefit design prior to rendering service.
• Use the payer prior authorization portal or required submission form; include all clinical notes, prior conservative care documentation, and relevant imaging/lab results.
• When authorization is required due to usage thresholds (visits or rental months), request retro‑authorizations only in accordance with payer policy — timely pre-service authorization is preferred.
• If a code is listed as Not Covered for the member’s plan, pursue alternative covered services or obtain an exception review only when permitted by plan rules.

Operational preauthorization triggers

Prior authorization triggers and examples (operational triggers consolidated): The source lists multiple operational triggers — consolidate these into actionable checks.

• Visit count thresholds: outpatient therapy and visit‑based services may require preauthorization after plan‑specific visit counts are exceeded.
• DME rental month threshold: preauthorization often begins after the 3rd rental month if ongoing rental criteria are not met.
• Procedure/device flags: selected device implantation/removal and advanced procedures are marked Preauthorization Required — do not schedule without authorization.
• Laboratory/genomic panels: many molecular/genomic U‑codes and 814xx series entries require preauthorization; supply clinical rationale with requests.

Telehealth E/M code 98000

Telehealth E/M code 98000 and telehealth audio/video codes: The source marks 98000 (synchronous audio‑video new patient E/M, 15 minutes) with Not Covered = X for certain plans and lists additional synchronous audio‑only and audio‑video new patient codes with varying flags. Verify plan telehealth coverage.

• 98000 (synchronous audio‑video new patient 15‑minute E/M) — listed as Not Covered = X for some plans; confirm member plan telehealth coverage before billing.
• 98009 and other synchronous audio‑only/new‑patient codes appear in the lists — coverage and prior authorization status vary by plan.
• When using total time for E/M code selection, ensure documented time meets the code’s required threshold (e.g., 15 minutes for 98000).

Telehealth audio-only/video codes

Telehealth audio‑only / video codes and telephone E/M services: The lists include telephone (99441–99443) and prolonged E/M (99417/99418) entries with Not Covered flags. Check plan rules for telephonic and prolonged service billing.

• Telephone E/M services 99441–99443 are listed as Not Covered = X in the source — confirm member plan allowances prior to billing.
• Prolonged services 99417 is marked Not Covered = X in the source lists; 99418 entries are present — verify plan-specific coverage or prior authorization requirements for prolonged E/M.
• Synchronous audio‑only visit codes (e.g., 98009) and other telehealth codes may be handled differently across plans; confirm whether prior authorization is required or the code is excluded.

Prolonged E/M services

Prolonged E/M services: 99417 and related prolonged service codes are present in the lists. The source flags 99417 as Not Covered = X; providers should review plan coverage before appending or billing prolonged E/M services.

• 99417 (prolonged office/outpatient E/M, each additional 15 minutes) — listed as Not Covered = X in source for some plans.
• When using prolonged codes with total time selection, ensure documentation clearly captures total time and justification.
• If prolonged services are clinically necessary, consider submitting a prior authorization or coverage exception request where payer policy permits.

Surgical navigation (0054T)

Surgical navigation and selected device codes: Certain technology and navigation codes may require preauthorization. Example from source: 0054T surgical navigation is flagged in the lists.

• Surgical navigation taxonomy: codes such as 0054T (surgical navigation) appear with Preauthorization Required markers — obtain authorization where indicated.
• Device implantation and complex interventional device procedures in the lists often carry prior authorization requirements; include device documentation, indication, and prior conservative management when requesting authorization.

SARS-CoV-2 vaccine administration codes

SARS‑CoV‑2 vaccine administration and related codes: Multiple SARS‑CoV‑2 vaccine administration codes (0004A, 0003A, 0052A, 0053A, etc.) are present in the source lists with mixed coverage flags. Some specific vaccine administration codes are marked Not Covered = X for certain plans.

• Administration codes such as 0004A appear in the lists and may be Not Covered = X depending on plan — verify member benefit for COVID‑19 vaccine administration prior to billing.
• Other SARS‑CoV‑2 administration codes (0002A, 0003A, 0052A, 0053A, 0091A, etc.) are included; coverage and preauthorization status vary by code and plan.
• Refer vaccine administration questions to the Pharmacy or Immunization resources on the payer website for the most current guidance.

Preauthorization and Not Covered flags

Preauthorization and Not Covered flags — consolidated provider action: Many codes across procedural, device, telehealth, laboratory, and molecular testing sections include explicit Not Covered or Preauthorization Required flags. Providers should take these consolidated actions to reduce denials:

• Always verify member benefits and whether a specific code is flagged Not Covered or Preauthorization Required for that member’s plan.
• Obtain prior authorization pre‑service when a code is listed with Preauthorization Required = X.
• When a code is listed Not Covered = X, do not provide the service expecting coverage; pursue alternative covered services or an exception review if allowed.
• For DME rentals and visit‑based services, monitor cumulative usage thresholds (e.g., 3 rental months, visit counts) that trigger prior authorization and request authorization ahead of the trigger when indicated.

General preauthorization notes

General preauthorization notes (summary): The source repeatedly emphasizes that preauthorization rules depend on plan and provider type, that certain services trigger review after usage thresholds, and that code lists are maintained quarterly. Key takeaways: confirm member plan details, follow the payer authorization process, and include full clinical documentation for genetic, device, and high‑cost services.

• Plan dependency: coverage and prior authorization requirements vary by SelectHealth plan and by provider type.
• Usage triggers: visit counts and the 3rd rental‑month rule are commonly used triggers for initiating prior authorization reviews.
• Documentation: genetic, molecular, device, and high‑cost procedures commonly require comprehensive documentation to support medical necessity.
• Updates: code lists are updated quarterly — reference the most recent list before ordering services.