Prior Authorization Required

Prior authorization required: Many CPT procedure codes in this listing are marked as requiring prior authorization (Preauthorization Required = X). Providers must obtain prior authorization before delivering or billing for codes that show the Preauthorization Required flag.

• Applicable to multiple specialty areas (surgery, imaging, genetic/molecular testing, neuro/spine, ophthalmology, otic/auricular procedures, vascular procedures, transplant and others).
• Codes marked with an X under "Preauthorization Required" must not be assumed reimbursable without prior approval.

Plan-dependent Preauthorization Limits

Plan-dependent limits and visit-triggered preauthorization: Several codes include a plan-dependent asterisk or note indicating that preauthorization is required only after a specified number of visits or that limits depend on the member's plan and provider type.

• Examples: liposuction and some physical/occupational therapy and evaluation codes (e.g., 15878, 22552, 97124, 97161–97163, 97034–97039, 97110, 97112, 97113) may require preauth after a certain number of visits (*).
• Rental equipment and some durable medical equipment codes may have preauth after the 3rd rental month when criteria are not met (**).
• Providers should verify member-specific plan rules and visit thresholds prior to scheduling multiple sessions or extended rentals.

Preauthorization and Not‑Covered Flags (sample rows)

Preauthorization vs Not Covered — sample procedure rows: The table uses two separate flags: Not Covered (X) and Preauthorization Required (X). Codes flagged Not Covered should not be billed expecting coverage; codes flagged Preauthorization Required must have approval obtained.

• Sample: 22526 and 22527 are marked Not Covered; 22533, 22548, 22551, 22552 are marked Preauthorization Required.
• Sample: 22862 is explicitly Not Covered while nearby interbody device codes (22854–22861) require preauthorization.
• Sample: Some hearing, reproductive medicine, and immunology lab codes are explicitly Not Covered (e.g., 58300, 44705, 90281/90283, 84378).

Coverage Variability and Exclusions

Coverage variability, exclusions, and maintenance: Coverage may vary by plan type; the code lists are updated quarterly. These lists do not reflect immunizations, injectable drugs, or specialty medications — those are managed under Pharmacy.

• Always confirm coverage for the member's specific plan before performing services.
• Immunizations, injectable drugs, and specialty medication coding/coverage are handled through the Pharmacy resources — consult the Pharmacy link on SelectHealth's site.
• The code list is maintained quarterly; consult the latest list as of the current As of date before acting.

Provider Actions by Specialty (neuro/spine, imaging, genetics, labs, therapy)

Specialty- and procedure-specific calls to action: Many specialty areas have discrete preauthorization or not-covered flags — providers should verify per-code requirements and obtain prior authorization where indicated.

• Neuro/spine and pain management: many spine fusion, laminotomy, ablation, neurostimulation and related codes require preauthorization (e.g., 22533, 22548, 63020–63051 series, 64490–64495, 64553–64596, 64624–64640, 64628–64629). Some ablative procedures or specific codes (e.g., 64625, 81355) are Not Covered — check the per‑code flag.
• Ophthalmology/eyelid procedures: large set of ocular and eyelid procedure codes require preauthorization (e.g., 66989, 66991, 67027, 67900–67975, 68399).
• Otic/auricular and lacrimal procedures: mixed status — some codes Not Covered (e.g., 68841, 69090, 69710) while many others require preauthorization.
• Imaging and MR safety: certain advanced imaging (CT colonography, PET, specialized CT/MR services) and MR safety/consultation codes may be Not Covered or require preauthorization (e.g., 74261–74262, 75577, 75580, 76014–76019, 76390–76391, 76496–76499).
• Genetic/molecular testing: many genetics and molecular pathology CPT codes require preauthorization (examples include BRCA and many 8xxxx/81xxx–81xxx ranges such as 81164–81167, 81201–81205, 81229–81237, 81302–81311, 81348–81355, 81457–81464, 81458–81463, 81493, 81500–81510, 81523–81536). Some genetic test codes are explicitly Not Covered — verify per code.
• Laboratory, immunology and pathology: a number of lab and cytogenetics codes require preauthorization while others are Not Covered (examples: 84378, 84431, 86152–86153, 86305, 86318, 86677, 86829–86831, 88273–88275, 88280–88299, 88399, 88749).
• Therapy, vision, audiology and hearing services: many therapy and evaluation CPTs are marked Preauthorization Required or Not Covered; several hearing aid/device fittings and verification codes are Not Covered (e.g., 92551–92595 series) or have mixed flags (e.g., 92628, 92639–92642).

Preauthorization Requirement Overview

Operational reminder — verification and authorization workflow: Before scheduling or performing services listed with either Not Covered or Preauthorization Required flags, verify member eligibility and plan‑specific rules and obtain authorization when required.

• Use the current quarterly code list and the member’s plan details to determine whether preauthorization or denial risk applies.
• If a code is Not Covered (X) do not schedule expecting coverage unless an exception is obtained in writing.
• For codes with plan‑dependent visit triggers or asterisk notes, track visit counts and secure preauthorization at the required threshold.