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Medicare codes not covered or requiring preauthorization - Utah & Idaho
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Quarterly-updated list of Medicare procedure codes that SelectHealth identifies as either not covered or requiring preauthorization for members in Utah and Idaho; applies to plan administration and provider billing/authorization processes.
Policy Summary
PayerSelectHealth
PolicyMedicare codes not covered or requiring preauthorization - Utah & Idaho
Policy CodePolicy N/A
Change TypeNo material change
Effective DateDec 22, 2025
Next Review DateN/A
Key ActionObtain prior authorization for codes marked 'Preauthorization Required = X' before billing.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
multiplelisted as not covered (some)
multiplelisted with preauthorization requirement
quarterlyupdate frequency
UT, IDapplicable states
Not Covered / Preauthstatus types applied
Per-code Coverage Indicators & Flags
Per-code coverage indicators
Per-code coverage stance is presented in a tabular/list format within the document; each code entry includes a Description, Not Covered indicator, and Preauthorization Required indicator.
Each listed CPT/HCPCS code is presented with: a short description, a 'Not Covered' marker (X or -), and a 'Preauthorization Required' marker (X or -).
Preauthorization and noncoverage flags
The document flags individual CPT codes with coverage or preauthorization indicators. Many surgical and device-related CPT codes are designated as requiring preauthorization.
Example code-specific stances
Per-code coverage flags shown in this segment
Examples
- 33277 — marked Preauthorization Required = X (device removal/replacement).
- 36468 — marked Not Covered = X (injection(s), spider veins).
- 43257 — marked Not Covered = X (UGI endoscopy w/ delivery of thermal energy).
- 43284 — marked Not Covered = X (laparoscopic esophageal sphincter augmentation device placement).
- 43842 — marked Not Covered = X (gastroplasty for obesity).
- 43644 — marked Preauthorization Required = X (laparoscopic gastric bypass Roux-en-Y).
Per-code stances
Per-code coverage stance (examples drawn from document):
Line-item coverage flags (sample nodes)
Per-code coverage flags as listed in the table:
Coverage stance for listed CPT codes
Codes in this list are indicated as Not Covered and/or require Preauthorization for SelectHealth Medicare members in Utah and Idaho; check plan-specific rules.
Per-code coverage flags
Codes in this list are labeled per-code as either Not Covered or Preauthorization Required. Providers should follow the flag for each code.
ANY of the following
- 64567 — Percutaneous electrical nerve field stimulation, cranial nerves, without implantation; Not Covered = X.
- 64625 — Radiofrequency ablation of nerve; Not Covered = X.
- 64654 — Initial open implantation of baroreflex activation therapy (BAT) system; Not Covered = X.
- 64461 — Paravertebral block, thoracic; Preauthorization Required = X.
- 64490 — Injection(s), paravertebral facet (zygapophyseal) joint; Preauthorization Required = X.
Excerpted code-based coverage stances
Selected codes and their stated coverage stance as shown in this extract.
ANY of the following
- 74261 — listed as Preauthorization Required = X in the imaging/procedural sample extract (chunk 128).
- 76014 — MR safety implant/foreign body assessment; Not Covered = X (chunk 129).
- 78350 — Bone mineral single photon; Not Covered = X (chunk 139).
- 80050 — General health panel; Not Covered = X (chunk 139).
- 80320 (and many in 80320–80375) — Quantitative drug assays; many entries marked Not Covered = X in this extract (chunks 140, 144).
Per-code coverage indicators
Per-code coverage indicators shown inline with each code entry.
ANY of the following
- 80350–80376 — Drug/toxicology panels: many codes listed as Not Covered = X in this range.
- 81105–81112 — Platelet antigen gene analyses show Description = X and Preauthorization = - (coverage descriptors vary).
- 81120–81195 — Various genetic tests; mixed Not Covered and Preauthorization Required markers; see line items.
- 81200–81242 — Single-gene and pharmacogenomic tests; mixed coverage/PA flags depending on code.
Per-code coverage/authorization flags
Per-code coverage markings within the document specify whether a code is Not Covered or requires Preauthorization (X).
ANY of the following
- 81243 — FMR1 expanded allele testing; Not Covered = X (chunk 165).
- 81247 — G6PD common variant analysis; Preauthorization Required = X (chunk 165).
- 81256 — HFE hemochromatosis common variants; Preauthorization Required = X (chunk 166).
- 81260 — IKBKAP familial dysautonomia common variants; Not Covered = X (chunk 166).
- 81291 — MTHFR common variants; Not Covered = X (chunk 172).
- 81302 — MECP2 full sequence analysis; Preauthorization Required = X (chunk 177).
Preauthorization required codes
For the codes listed in this segment:
The following genetic/molecular pathology CPT codes (examples include 81320–81354 series) are marked 'Preauthorization Required = X' in the document; providers must obtain prior authorization before billing these codes.
Not covered codes
Examples of not-covered entries:
81355 — VKORC1 common variant analysis; Not Covered = X (chunk 186). Providers should not bill expecting reimbursement under this list without alternate coverage determination.
Document disclaimers
Administrative notes
Coverage may vary by plan type; coding lists are updated quarterly; immunizations, injectable drugs, and specialty medications are excluded from these lists and should be directed to Pharmacy resources.
Preauthorization required codes
Codes in this document are assigned one of two primary stances: Preauthorization Required (X) or Not Covered (X).
Not covered codes
Some codes are explicitly not covered and should not be billed as covered services.
Per-code coverage rules (examples)
Per-code stance indicated in list (Not Covered = X or Preauthorization Required = X).
ANY of the following
- 90723 — DTaP‑HepB‑IPV vaccine; Not Covered = X (chunk 228).
- 90912 — Biofeedback training, perineal muscles; Preauthorization Required = X* (chunk 228).
- 92634 — Hearing aid fitting services, first 60 minutes; Not Covered = X (chunk 234).
- 84999 — Clinical chemistry test; Preauthorization Required = X (chunk 216/234).
Per-code coverage flags
Codes are individually flagged as Not Covered or Preauthorization Required; providers must follow the marking for each code and consult plan-specific rules.
Per-code markings: 'Not Covered = X' indicates the service is not covered under the listed Medicare coding guidance for Utah & Idaho; 'Preauthorization Required = X' indicates prior authorization is required before the service will be considered. Providers must check the code-specific flag before providing or billing the service.
Per-code coverage flags
Per-code coverage and preauthorization flags as listed below.
ANY of the following
- 98940–98943 — Chiropractic manipulation codes: mixed markings (some Not Covered or Preauthorization Required; see code lines).
- 99441–99443, 99417–99418, 99500–99507 — Telephone, prolonged, and home visit codes are listed as Not Covered = X in this extract.
CPT / HCPCS Code Lists
Prior Authorization, Billing & Provider Notices
Prior Authorization
Prior Authorization Required
Codes marked "Preauthorization Required = X" require prior authorization before SelectHealth Medicare members in Utah & Idaho receive the service. Providers must submit a prior authorization request per payer guidelines; failure to obtain prior authorization may result in claim denial or member financial liability.
- All codes in the coding lists flagged with Preauthorization Required = X require prior authorization.
- Preauthorization applies to the specific CPT/HCPCS codes shown in the lists; verify the code and status before scheduling.
- Specialty medications, immunizations, and injectable drugs are managed by Pharmacy and are not covered by these code lists — use the Pharmacy link for those items.
Denial Risk
Not Covered — Do Not Bill as Covered
Some codes in these lists are explicitly identified as not covered ("Not Covered = X"). Do not bill SelectHealth for services listed as Not Covered unless an explicit exception or prior authorization policy states otherwise.
- If a code is marked Not Covered = X, the service is considered a plan exclusion for the applicable SelectHealth Medicare products in UT & ID.
- When a code shows both Not Covered and Preauthorization flags in the source, follow the Not Covered status (do not expect coverage).
- Coverage may vary by plan type; always confirm member-specific benefits and obtain prior authorization when indicated.
Billing Rule
Not Covered vs Preauthorization — Check Per-Code
Many codes in the source lists show mixed indicators (either Not Covered = X or Preauthorization Required = X). Providers must check each code’s status before performing or billing the service and follow plan-specific rules.
- Use the per-code entries in the coding lists to determine whether a specific code is Not Covered or requires Preauthorization.
- When planning procedures (notably spine, neurosurgery, transplant, device implantation, advanced imaging, genetic/molecular testing, and many surgical/rehabilitation services), review the code-level flag.
- Lists are updated quarterly — verify the latest status at the time of service.
- If a code is marked Preauthorization Required = X, obtain prior authorization; if marked Not Covered = X, do not provide expecting coverage.
Note
Coverage Disclaimer & Pharmacy Exceptions
Disclaimer: coverage may vary by plan type and these lists do not include information on immunizations, injectables, or specialty medications — those items are managed through Pharmacy. The code lists are updated quarterly; always validate the current status and follow SelectHealth submission rules for prior authorization.
- Consult member benefits and plan documents for final coverage determinations.
- Direct questions about specialty medications, immunizations, and injectables to the SelectHealth Pharmacy resources.
- When in doubt about a code’s applicability or status, contact SelectHealth Provider Services or the prior authorization department.
Key Terms & Scope Notes
inv-111: Preauthorization Required — definition mapping (flag meaning)
DefinitionPreauthorization Required = X indicates SelectHealth requires prior authorization for the listed code.
EffectCodes marked with this flag require prior authorization before the service will be considered for coverage.
Provider actionObtain prior authorization where the code line shows Preauthorization Required = X to avoid claim denials.
inv-112: Not Covered — definition mapping (flag meaning)
DefinitionNot Covered = X indicates the listed code is considered not covered under the policy for applicable plans.
EffectCodes marked Not Covered = X should not be billed expecting coverage for listed Utah & Idaho Medicare plans.
Exception guidanceCheck plan-specific rules or alternative coverage sources if a code is marked Not Covered.
inv-113: Preauthorization Required — alternate reference to flag meaning
Alternate phrasingPreauthorization Required = X indicates the listed code requires prior authorization from the payer.
Operational noteFlag X signifies prior authorization must be obtained before rendering the service for it to be eligible for coverage.
SourceStated across multiple list headers and disclaimers in the document.
inv-114: Not Covered — alternate reference to flag meaning
Alternate phrasingNot Covered = - or X (context-dependent) indicates the code may not be covered; consult plan-specific information.
Operational cautionSome lines show '-' vs 'X'—providers must read the per-line entry to determine coverage status for each plan.
Where listedPresent repeatedly in document headers and section footers as the definition of Not Covered markers.
inv-115: Preauthorization Required operational note — codes marked X require prior authorization before services rendered
Operational ruleCodes marked with 'Preauthorization Required = X' require prior authorization from the payer before services are rendered to be eligible for coverage.
Provider implicationObtain PA prior to service to reduce risk of claim denial or nonpayment.
Document locationExplicitly noted in multiple per-code entries and summary statements across the list.
inv-116: Not Covered operational note — codes marked X identified as non-covered services under Medicare lists for UT & ID
Operational ruleCodes marked with 'Not Covered = X' are identified by the payer as non-covered services under the listed Medicare coding guidance for Utah and Idaho.
Billing implicationDo not expect reimbursement for codes flagged Not Covered unless alternate coverage guidance applies.
Provider actionConfirm plan-level exceptions or appeals processes if clinical necessity supports a service marked Not Covered.
inv-117: Disclaimer — coverage may vary by plan type; lists updated quarterly; immunizations/injectables/specialty meds not represented here
Scope disclaimerCoverage may vary by plan type; coding lists are updated quarterly; immunizations, injectable drugs, and specialty medications are not represented here and are managed via Pharmacy resources.
ActionUse the Pharmacy link for medication/immunization coverage questions and confirm plan-specific applicability for listed codes.
Update cadenceLists are refreshed quarterly—check the current quarter’s list before authorization or billing.
inv-118: Preauthorization Required = X (definition variant)
Flag meaningPreauthorization Required = X indicates the listed code requires prior authorization from SelectHealth for applicable Medicare plans in Utah & Idaho.
Effect on claimsClaims submitted without required prior authorization may be denied or adjudicated as non-covered.
Provider recommendationInitiate preauthorization workflows when the code line shows X for Preauthorization Required.
inv-119: Not Covered = X (definition variant)
Flag meaningNot Covered = X indicates SelectHealth identifies the listed code as not covered under the applicable Medicare plans.
Billing implicationDo not bill expecting coverage for codes marked Not Covered = X unless an exception is documented.
Next stepsIf clinical necessity exists, consult plan exceptions or appeals process; contact provider services for guidance.
inv-120: Preauthorization Required (repeated note)
Repeated notePreauthorization Required = X indicates the code requires prior authorization before coverage.
Where appliedThis definition appears throughout the document headers and code line annotations.
Provider actionConfirm PA requirements on a per-code basis prior to service delivery.
inv-121: Not Covered (repeated note)
Repeated noteNot Covered = X indicates the code is not covered.
Provider implicationServices with this marking are excluded from coverage for the listed plans in Utah & Idaho.
DocumentationRefer to the per-line entry and disclaimer for plan-specific interpretation.
inv-122: Disclaimer / update frequency — lists updated quarterly and do not include immunizations/injectables/specialty meds
Update frequency & exclusionsLists are updated quarterly and do not include immunizations, injectable drugs, or specialty medications (refer to Pharmacy).
Plan variationCoverage may vary by plan type—verify applicability for the member’s specific plan.
Document locationThis disclaimer is shown in multiple section headers and code list footers.
inv-123: Not Covered / Preauthorization Required — many listed Medicare CPT codes designated Not Covered and requiring prior authorization
Combined flagsMany listed Medicare CPT/PLA codes are designated Not Covered and/or Preauthorization Required; providers should follow the flag shown for each code.
ExamplesLarge sets of molecular pathology and genetic codes (e.g., 81320–81355) are marked Preauthorization Required = X.
Provider actionObtain preauthorization for codes marked X and do not bill for codes marked Not Covered without exception.
inv-124: Not Covered — procedure codes marked Not Covered are excluded from coverage for UT & ID
Not Covered interpretationProcedure codes marked 'Not Covered' are indicated as excluded from coverage for the specified plans in Utah & Idaho.
ActionDo not expect reimbursement for services listed as Not Covered; pursue alternate coverage pathways if clinically justified.
ReferencePer-code entries and section headers specify these markings.
inv-125: Preauthorization Required — procedure codes marked Preauthorization Required require prior auth before service
Preauthorization interpretationProcedure codes marked 'Preauthorization Required' require prior authorization from SelectHealth before the service is provided.
Operational impactServices performed without required prior authorization may be denied or paid as non-covered.
Provider recommendationInitiate PA requests per payer instructions when a code line shows Preauthorization Required = X.
inv-126: Scope exclusions — coding lists do not reflect immunizations/injectables/specialty meds; managed through Pharmacy
Scope exclusionCoding lists do not reflect immunizations, injectable drugs, or specialty medications; such items are managed through the Pharmacy link on the website.
ActionDirect pharmacy-related coverage questions to Pharmacy resources rather than these coding lists.
NoteThis exclusion is stated in the document header and repeated in section footers.
inv-127: Not Covered — code indicated as Not Covered = X in the list
Not Covered markerThe code is indicated with 'Not Covered = X' in the list, meaning SelectHealth does not cover this service for the specified plans in this geographic list unless other guidance applies.
Provider implicationConfirm plan-specific exceptions before providing services marked Not Covered.
inv-128: Preauthorization Required — code indicated as Preauthorization Required = X in the list
Preauthorization markerThe code is indicated with 'Preauthorization Required = X' in the list, meaning prior authorization is required before the service will be considered for coverage.
Provider actionObtain required prior authorization before scheduling the service when X is shown.
inv-129: Not Covered / Preauthorization Required — annotation explanation: codes annotated X or - per entry; coverage may vary
Annotation practiceCodes are annotated as 'Not Covered' (X) or 'Preauthorization Required' (- or X) per code entry; coverage may vary by plan and lists are updated quarterly.
ImplicationProviders must consult each code line and the current quarterly list for the accurate flag before billing.
inv-130: Disclaimer / scope — coverage variability and quarterly updates; pharmacy items excluded
Disclaimer summaryCoverage may vary by plan type and lists are updated quarterly; pharmacy-related items are not included in these lists.
Provider instructionVerify member plan details and consult Pharmacy for medications or injectables.
inv-131: Preauthorization Required — flag X indicates prior authorization required
Flag conventionFlag 'X' next to a code indicates that prior authorization is required before the service will be reimbursed.
Operational effectServices without required PA are at risk of denial; follow payer PA process for X-marked codes.
inv-132: Not Covered — flag X indicates service not covered under listed Medicare coding list
Flag conventionFlag 'X' next to a code indicates the service is not covered under the stated Medicare coding list for the relevant geography/plan.
Billing implicationDo not bill expecting coverage for codes marked Not Covered = X without documented exception.
inv-133: Disclaimer / scope of lists — lists updated quarterly and pharmacy items excluded
List maintenanceThe coding lists are updated quarterly and may vary by plan type; immunizations, injectable drugs, and specialty medications are excluded and referenced to Pharmacy.
Provider checkAlways confirm the current quarter’s list and member plan before authorizing or billing services.
inv-134: Disclaimer — coverage may vary by plan type; lists are updated quarterly and do not reflect certain pharmacy-managed items
Disclaimer restatedCoverage may vary by plan type; lists are updated quarterly and do not reflect immunizations, injectable drugs, or specialty medications (direct to Pharmacy).
ActionConsult Pharmacy resources for medication coverage and verify plan-specific differences.
inv-135: Not Covered — codes marked Not Covered = X for SelectHealth Medicare UT & ID
Not Covered marker meaningCodes marked 'Not Covered = X' are indicated by SelectHealth as not covered under the listed Medicare code list for Utah & Idaho.
Provider noteRefer to specific code lines and the plan’s coverage rules for potential exceptions.
inv-136: Preauthorization Required — codes marked Preauthorization Required = X require prior authorization
Preauthorization marker meaningCodes marked with 'Preauthorization Required = X' require prior authorization from SelectHealth before services are rendered/billed.
Provider actionInitiate PA according to payer instructions for any code showing X to reduce denial risk.
inv-137: Disclaimer / scope — coverage may vary by plan type; codes updated quarterly; pharmacy items excluded
Scope & updatesCoverage may vary by plan type; coding lists updated quarterly; immunizations/injectables/specialty medications are not reflected and are handled via Pharmacy resources.
Provider implicationUse Pharmacy for drug-related items and confirm quarterly updates for procedural code status.
inv-138: Not Covered = X — marking indicating non-coverage for specified codes
Not Covered = XMarking indicating SelectHealth does not cover the specified code under the referenced Medicare-related plans for Utah & Idaho.
Billing guidanceDo not bill as covered for codes marked Not Covered = X without documented alternate coverage.
inv-139: Preauthorization Required = X — marking indicating prior authorization required
Preauthorization Required = XMarking indicating prior authorization is required before services billed with the specified code will be considered.
Provider actionObtain authorization when X is shown to avoid claim denials.
inv-140: Disclaimer / scope note — coverage may vary by plan type; lists updated quarterly; pharmacy items excluded
Repeat disclaimerCoverage may vary by plan type; lists are updated quarterly; coding lists do not reflect immunizations, injectable drugs, or specialty medications which are managed through Pharmacy resources.
Practice tipAlways verify member plan and the current quarter’s list before performing or billing services.
inv-141: Time-based code selection — selection of synchronous visit codes depends on total time on date of encounter
Time-based selection ruleSelection of synchronous visit codes when using total time on the date of encounter requires that the code-specific minimum minutes be met or exceeded (per-code minute thresholds listed).
Example implicationIf total encounter time does not meet the minimum, a lower-level or different code must be selected per coding rules.
DocumentationDocument total time on date of encounter to support selection of the time-based telehealth E/M code.
Policy Summary
PayerSelectHealth
PolicyMedicare codes not covered or requiring preauthorization - Utah & Idaho
Policy CodePolicy N/A
Change TypeNo material change
Effective DateDec 22, 2025
Next Review DateN/A
Key ActionObtain prior authorization for codes marked 'Preauthorization Required = X' before billing.
SourceLink
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