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Commercial CPT/HCPCS codes not covered or requiring preauthorization (Nevada)

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A payer-maintained list of procedure and service codes that are either not covered or require preauthorization for SelectHealth commercial plans in Nevada; affects providers submitting claims and authorization staff.

Policy Summary

PayerSelectHealth

PolicyCommercial CPT/HCPCS codes not covered or requiring preauthorization (Nevada)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 25, 2025

Last ReviewSep 25, 2025

Next Review DateN/A

Key ActionObtain prior authorization when a code in the list is marked 'Preauthorization Required' or follow plan-specific visit/rental thresholds before submitting claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Nevadastate-specific list

quarterlyupdate frequency

Small Employer & Individualplan types

dozens+codes flagged

Coverage criteria and per-code stances (Nevada)

Coverage flags and disclaimers

General notes and disclaimers

Coverage may vary by plan type; coding lists are updated quarterly; immunizations, injectable drugs, and specialty medications are not reflected in these lists and should be directed to the Pharmacy resources.

An 'X' adjacent to a plan column indicates the code is flagged for that plan type (e.g., Not Covered or Preauthorization Required).

Operational: 'Preauthorization Required = X' denotes prior authorization is required for the listed plan types.

Some services require preauthorization after a plan-specific number of visits or after the 3rd rental month if criteria are not met; limits depend on plan/provider type.

Per-code stances (sample)

Per-code coverage or preauthorization flags as listed (examples below).

CPT 36400 — Drawing blood: marked Not Covered in the listing for Small Employer and Individual plans.

CPT 36405 — Drawing blood: marked Not Covered in the listing for Small Employer and Individual plans.

CPT 36473 — Endovenous ablation therapy (mechanochemical): marked Preauthorization Required = X for Small Employer and Individual plans.

CPT 37186 — (vascular code) marked Not Covered = X in the listing.

Per-code prior authorization/not-covered indicators (partial)

Coverage annotations per code and plan type (partial listing in these chunks).

CPT 38225 — CAR-T harvesting: shown with plan fields; entries include 'Preauthorization Required' markers in the table (Small Employer and Individual).

CPT 43770 — Laparoscopic gastric restrictive procedure; listed with Preauthorization Required field populated for Small Employer and Individual in the extract.

CPT 47147 — (listed procedure) shown with 'Preauthorization Required = X' for Small Employer and Individual in the table.

Per-code coverage/preauth stance (excerpt)

Per-code status entries for Small Employer and Individual plans (Nevada)

CPT 50327 — Backbench reconstruction (venous anastomosis): Preauthorization Required = X for Small Employer and Individual.

CPT 50328 — Backbench reconstruction (arterial anastomosis): Preauthorization Required = X for Small Employer and Individual.

CPT 50382 — Removal/replacement ureteral stent (percutaneous): marked Not Covered = X in the excerpt.

CPT 54410 — Removal and replacement of multi-component inflatable penile prosthesis, same session: marked Not Covered = X for Small Employer and Individual.

CPT 54415 — Removal of penile prosthesis without replacement: marked Not Covered = X for Small Employer and Individual.

CPT 55880 — Ablation of malignant prostate tissue with HIFU: marked Not Covered = X for Small Employer and Individual.

CPT 57465 — Computer-aided mapping of cervix during colposcopy: marked Not Covered = X for Small Employer and Individual.

CPT 58263 — Vaginal hysterectomy with removal of tube(s)/ovary(s): Preauthorization Required = X.

CPT 60660 — Radiofrequency ablation (selected sites): Preauthorization Required = X.

CPT 61630 / 61635 / 61640 / 61641 — Intracranial angioplasty/stent/vasospasm procedures: marked Not Covered = X in the listing.

Per-code stance examples

Per-code coverage flags (selected examples from this extract):

CPT 61630 — Balloon angioplasty, intracranial: Not Covered = X (Small Employer and Individual).

CPT 61635 — Intracranial stent placement: Not Covered = X (Small Employer and Individual).

CPT 61640 — Balloon dilatation of intracranial vasospasm (initial vessel): Not Covered = X.

CPT 61736 — Laser interstitial thermal therapy (LITT): listed in the extract with Not Covered / Preauthorization fields (example context).

ONE of

CPT 62263 — Percutaneous lysis of epidural adhesions: Not Covered = X.
CPT 62264 — Percutaneous lysis with catheter: Not Covered = X.
CPT 62287 — Percutaneous decompression of nucleus pulposus: Not Covered = X.

Per-code coverage indicators

Per-code coverage indicators shown inline (Not Covered = X; Preauthorization Required = X).

Markers in the table use 'Not Covered = X' and 'Preauthorization Required = X' to indicate status per plan column; examples include imaging and implant codes shown with those markers.

Per-code preauthorization stance (examples)

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

CPT 81162 / 81163 / 81164 — BRCA1/BRCA2 full analysis codes: Preauthorization Required = X in the listing.

CPT 81223 — CFTR gene analysis: Preauthorization Required = X as shown in the table.

CPT 81225 / 81226 / 81228 — CYP2C19, CYP2D6 and cytogenomic microarray codes: Preauthorization Required = X indicated for Small Employer and Individual.

Example per-code stance (partial)

Per-code coverage/preauthorization indicators (partial)

CPT 81262 / 81263 / 81264 / 81272 / 81273 — Selected gene/molecular codes: table entries show 'Preauthorization Required = X' for multiple codes in this group.

CPT 81301 — Microsatellite instability analysis: Preauthorization Required = X in the listing.

CPT 81400 — Molecular pathology procedure (level 1): Preauthorization Required = X as shown.

Per-code coverage/preauth indicators

Per-code coverage indicators present in the table:

CPT 81422 — Circulating cell-free fetal DNA: marked Not Covered = X in the listing.

CPT 81517 — Liver disease biomarker panel: marked Not Covered = X.

CPT 81536 — Live tumor cell culture (oncology gynecologic): marked Not Covered = X.

CPT 81419 / 81450 / 81451 — Selected genomic panels: Preauthorization Required = X for these molecular/genomic codes.

Per-code stance examples

Per-code coverage markers shown in the list (examples below):

CPT 83701 — High-resolution lipoprotein fractionation: marked Not Covered = X.

CPT 83950 — Oncoprotein HER2/neu assay: marked Not Covered = X.

CPT 90901 / 90912 / 90913 — Biofeedback training codes: marked Not Covered = X in the extract.

Conditional preauthorization and exclusions

Services with conditional preauthorization:

CPT 92507 / 92508 — Speech/hearing therapy: Preauthorization Required indicated with a footnote '*'; note states preauthorization may be required after a plan-specific number of visits (limit depends on plan/provider type).

CPT 92596 — Ear protector evaluation: flagged with X in the Small Employer and Individual columns (preauth/flag present in extract).

Per-code coverage flags (partial list)

Per-code coverage/preauthorization designations (examples from this segment):

CPT 92596 — Ear protector evaluation: marked X for Small Employer and Individual (preauth/status indicated).

CPT 92607 / 92608 / 92609 — Evaluation and therapeutic services for AAC devices: Preauthorization Required = X* (footnoted as conditional).

CPT 94005 / 94011 / 94012 — Selected pulmonary function/home ventilator management codes: some are marked Not Covered = X in the listing.

CPT 96931 / 96933 — Reflectance confocal microscopy codes for skin imaging: marked Not Covered = X for first-lesion and interpretation codes in this extract.

CPT 97010 — Hot or cold packs therapy: marked Not Covered = X.

CPT 97037 — Low-level laser therapy (nonthermal/non-ablative): marked Not Covered = X.

Not covered — dermatology imaging codes

Selected codes explicitly marked Not Covered in this extract

CPT 96935 / 96936 — Reflectance confocal microscopy additional-lesion acquisition and interpretation: marked Not Covered = X in the listing.

Not covered — selected therapy/wound care/caregiver training codes

Therapy codes with explicit not covered flags in this extract

CPT 97037 — Low-level laser therapy for post-operative pain: Not Covered = X.

CPT 97602 / 97610 — Wound care / non-thermal ultrasound: shown with Not Covered markings in the excerpt.

CPT 97551 — Caregiver training in ADLs/IADLs: marked Not Covered in the extract.

Not covered — patient education / digital E/M

Education and digital E/M codes with not covered flags

CPT 98960 / 98961 — Education and training for patient self-management by qualified nonphysician: marked Not Covered = X in the listing.

CPT 98970 / 98971 — Qualified nonphysician online digital E/M services: marked Not Covered = X for select codes in the extract.

Per-code coverage flags

Codes in this segment are annotated per-code with Not Covered = X or preauthorization requirement where indicated.

CPT 98960 / 98961 / 98970 / 98971 — Marked Not Covered = X as shown in the Small Employer and Individual columns.

CPT 99366 / 99367 — Medical team conferences (with/without patient/family): listed as Not Covered = X in the excerpt.

CPT 99474 / 99485 — Self-measured BP monitoring and supervision of interfacility transport: examples of codes marked Not Covered = X in this segment.

CPT 99605 / 99606 — Medication therapy management by pharmacist: flagged Not Covered = X in the listing.

General coverage marking

General coverage notes and status markers appearing in the list.

Many F-format quality/measure codes appear in the extract with per-code Not Covered or Preauthorization fields; specific status per F-code is shown in the table (examples include multiple F-codes flagged Not Covered = X).

Explicit examples

Specific not-covered markers

F-code 1070F — Alarm symptoms for GERD assessed; marked Not Covered = X in this excerpt (Small Employer and Individual).

Not Covered indicators

Specific F-codes are marked as Not Covered (X) in the Small Employer and Individual columns where indicated.

Selected F-codes such as 2040F, 2044F, 2050F, 3017F, 3018F, 3019F, 3020F, 3021F, 3022F, 3023F are shown in the fragment with Not Covered = X for Small Employer and Individual where noted.

Examples of codes flagged Not Covered

Some codes are explicitly marked as Not Covered (X) in the fragment (examples include several F-codes listed).

Examples include: 2040F (initial low back pain exam), 2044F (mental health assessment prior to intervention), 2050F (wound characteristics documented), each marked Not Covered = X in this extract.

Code lists and coding detail

Dermatologic/skin procedural codesCPTNot Covered

11055	Trim skin lesion
11719	Trim nails
15788	Chemical peel, face, epidermal

Spine intervention codesCPT

22526	Percutaneous intradiscal electrothermal annuloplasty, single level
22527	Percutaneous intradiscal electrothermal annuloplasty, multiple levels
22837	Anterior thoracic vertebral body tethering

Orthopedic joint replacement / proceduresCPT

27130	Total hip replacement
27447	Total knee replacement
28890	Extracorporeal shock wave, high energy (physician performed) - marked Not Covered

Examples of facial/airway procedural codes listedCPTNot Covered

30400	Reconstruction of nose
30410	Reconstruction of nose
30430	Revision of nose
30468	Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s)
31643	Bronchoscopy with placement of catheter(s) for intracavitary radioelement application

Examples of venous procedure and blood draw codesCPT

36400	Drawing blood
36405	Drawing blood
36473	Endovenous ablation therapy of incompetent vein, mechanochemical; first vein treated
36475	Endovenous ablation therapy, percutaneous radiofrequency; first vein

Transplant-related codesCPTNot Covered

33945	Transplantation of heart
33944	Backbench standard preparation of cadaver donor heart allograft
32851	Lung transplant_single

Sample procedural codes from list (partial)CPTNot Covered

37765	Stab phlebectomy of varicose veins, one extremity; 10-20 stab incisions
37766	Stab phlebectomy of varicose veins, one extremity; more than 20 incisions
38225	CAR-T therapy; harvesting of blood-derived T lymphocytes per day
38226	CAR-T therapy; preparation of blood-derived T lymphocytes for transportation (eg, cryopreservation, storage)

Bariatric procedure codes (partial)CPT

43290	Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon
43770	Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band
43773	Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric band component only
43775	Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (sleeve gastrectomy)

Selected CPT/procedure codes referenced in excerptCPTNot Covered

47382	Ablation one or more liver tumor(s), percutaneous, radiofrequency
48550	Donor pancreatectomy
50327	Backbench reconstruction of donor renal allograft; venous anastomosis
50328	Backbench reconstruction of donor renal allograft; arterial anastomosis
50382	Removal and replacement of internally dwelling ureteral stent via percutaneous approach
54410	Removal and replacement of all components of a multi-component inflatable penile prosthesis, same operative session
54415	Removal of non-inflatable or inflatable (self-contained) penile prosthesis, without replacement
55880	Ablation of malignant prostate tissue with high intensity-focused ultrasound (HIFU)
57465	Computer-aided mapping of cervix uteri during colposcopy (dynamic spectral imaging)
58263	Vaginal hysterectomy for uterus 250 grams or less; with removal of tube(s) and/or ovary(s) with repair of enterocele

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Selected CPT codes in extractCPT

58674	Ablation of uterine fibroid(s), radiofrequency (intraoperative ultrasound guidance and monitoring)
58750	Repair oviduct
58770	Create new tubal opening
58970	Retrieval of oocyte
59070	Transabdominal amnioinfusion, including ultrasound guidance
59072	Fetal umbilical cord occlusion, including ultrasound guidance
60660	Ablation, radiofrequency (thyroid)
61630	Balloon angioplasty, intracranial
61635	Transcatheter placement of intravascular stent(s), intracranial
61640	Balloon dilatation of intracranial vasospasm; percutaneous; initial vessel

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Example listed codes and descriptionsmixedNot Covered

69710	Procedures related to hearing implant/replace hearing aid (listed with Not Covered / Preauthorization fields).
69727	Removal, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor (Preauthorization Required = X for 69727 shown in window).
69728	Implantation involving bony defect >=100 sq mm; Preauthorization Required = X.
69930	Implant cochlear device (listed).
70554	Functional MRI brain (70554) - Preauthorization Required = X.
75559	Cardiac MRI with stress - Preauthorization Required = X.
76014	MR safety implant/foreign body assessment (listed).
76977	Ultrasound bone density measure - Not Covered = X.
77078	CT bone mineral density - Not Covered = X.
77081	DXA bone density (appendicular) - Not Covered = X.

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Selected laboratory and genetic test codesCPT

80374	Stereoisomer analyte single drug class
80375	Drug(s) definitive, qualitative or quantitative nos 1-3
81162	BRCA1 BRCA2 full sequence analysis
81225	CYP2C19 gene analysis; common variants
81226	CYP2D6 gene analysis; common variants
81228	Cytogenomic constitutional microarray analysis

Selected gene/molecular codes (partial)CPT

81262	IG gene rearrangement analysis to detect abnormal clonal populations; direct probe methodology
81263	Igh@ variable region somatic mutation analysis
81264	Evaluation to detect abnormal clonal population(s)
81272	KIT (V-KIT) targeted sequence analysis
81273	KIT D816 variant analysis
81278	IGH@/BCL2 (t(14;18)) translocation analysis

Oncology-related molecular codes (partial)CPT

81301	Microsatellite instability analysis for mismatch repair deficiency
81311	NRAS gene analysis, exon 2 and 3 variants
81314	PDGFRA gene analysis (GIST)
81316	PML-RARA translocation (t(15;17)) analysis

Molecular pathology and panel/exome codes (partial)CPT

81400	Molecular pathology procedure, level 1
81401	Molecular pathology procedure, level 2
81402	Molecular pathology procedure, level 3
81403	Molecular pathology procedure, level 4
81404	Molecular pathology procedure, level 5
81405	Molecular pathology procedure, level 6
81406	Molecular pathology procedure, level 7
81408	Molecular pathology procedure, level 9 (>50 exons)
81412	Ashkenazi Jewish associated disorders panel
81413	Cardiac ion channelopathies genomic sequence panel

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Selected molecular/genomic and oncology assay codes referencedCPT

81415	Exome / genomic sequencing (listed in document)
81416	Exome sequence analysis, add-on
81418	Drug metabolism (pharmacogenomics) panel
81422	Circulating cell-free fetal DNA
81479	Unlisted molecular pathology
81523	Oncology (breast) gene expression profiling (NGS)
81536	Live tumor cell culture chemotherapeutic response (oncology gynecologic)

Selected specialized laboratory assay codesCPT

82233	Beta-amyloid 1-40
82234	Beta-amyloid 1-42
83701	High resolution lipoprotein fractionation
83950	Oncoprotein; HER2/neu

Laboratory / Biomarker codesCPTNot Covered

81596	Six biochemical assays for chronic hepatitis C virus (HCV) infection (ALT, a2-macroglobulin, apolipoprotein A-1, total bilirubin_GGT, and haptoglobin) - listed
82233	Beta-amyloid; 1-40 (Abeta 40)
82234	Beta-amyloid; 1-42 (Abeta 42)
82777	Assay of galectin-3
83006	Assay growth hormone (st2)
83701	Lipoprotein, blood; high resolution fractionation and quantitation
83704	Lipoprotein measurement (other)
83950	Oncoprotein; HER-2/neu

Reproductive/ART services and storageCPTNot Covered

89250	Fertilization of oocyte
89251	Culture oocyte with embryos
89272	Extended culture of oocyte(s)/embryo(s) 4-7 days
89342	Storage (per year); embryo(s)
89346	Storage (per year); oocyte

VaccinesCPT

90581	Anthrax vaccine
90587	Dengue vaccine, quadrivalent, live (3-dose)
90625	Cholera vaccine, oral
90717	Yellow fever vaccine, SC

Biofeedback servicesCPTNot Covered

90901	Biofeedback training
90912	Biofeedback training, perineal muscles; initial 15 minutes
90913	Biofeedback training, perineal muscles; each additional 15 minutes

Vision and speech/hearing servicesCPT

92311	Contact lens fitting
92341	Fitting of spectacles
92507	Speech/hearing therapy
92508	Speech/hearing therapy

Audiology and vestibular testingCPT

92531	Spontaneous nystagmus study
92533	Caloric vestibular test
92570	Acoustic immittance testing
92587	Distortion product evoked otoacoustic emissions
92596	Ear protector evaluation

Audiology and related codesCPT

92570	Acoustic immittance testing; includes tympanometry, acoustic reflex threshold testing
92571	Filtered speech hearing test
92572	Staggered spondaic word test
92575	Sensorineural acuity test
92579	Visual audiometry (VRA)
92583	Select picture audiometry
92584	Electrocochleography
92587	Distortion product evoked otoacoustic emissions; limited evaluation
92596	Ear protector evaluation

Auditory/communication evaluationsCPT

92607	Evaluation for prescription for speech-generating AAC device, face-to-face
92608	Evaluation for prescription for speech-generating AAC device, face-to-face (variant)
92609	Therapeutic services for use of speech-generating device, including programming and modification
92620	Evaluation of central auditory function, with report; initial 60 minutes
92621	Evaluation of central auditory function; each additional 15 minutes

Cardio/pulmonary tests and servicesCPT

93701	Bioimpedance-derived physiologic cardiovascular analysis
94005	Home ventilator management care plan oversight (patient not present)
94011	Measurement of spirometric forced expiratory flows in infant/child through 2 years
94012	Measurement of spirometric forced expiratory flows, before and after bronchodilator, in infant/child through 2 years

Miscellaneous therapy, dermatology, motion analysisCPTNot Covered

96000	Comprehensive computer-based motion analysis by video-taping and 3-D kinematics
96105	Assessment of aphasia
96904	Whole body integumentary photography
96931	Reflectance confocal microscopy (RCM) first lesion (acquisition & interpretation)
96932	RCM image acquisition only, first lesion
96933	RCM interpretation & report only, first lesion
97010	Hot or cold packs therapy
97037	Low-level laser therapy (nonthermal/non-ablative)

Selection of therapy and dermatology imaging codesCPT

96935	Reflectance confocal microscopy (image acquisition only), each additional lesion
96936	Reflectance confocal microscopy (interpretation and report only), each additional lesion
97010	Hot or cold packs therapy
97012	Mechanical traction therapy
97014	Electric stimulation therapy

Physical medicine / rehabilitation codesCPT

97037	Low-level laser therapy (nonthermal and non-ablative) for post-operative reduction pain
97110	Therapeutic exercises
97116	Gait training therapy
97124	Massage therapy

Therapy, athletic training, wound careCPT

97169	Athletic training evaluation, low complexity
97170	Athletic training evaluation, moderate complexity
97171	Athletic training evaluation, high complexity
97551	Caregiver training in ADLs/IADLs
97602	Wound care non-selective
97610	Low frequency non-thermal ultrasound

Patient education and digital E/M codesCPT

98960	Education and training for patient self-management by qualified nonphysician
98961	Education and training for patient self-management (follow-up)
98970	Qualified nonphysician online digital E/M service (5-10 minutes)
98971	Qualified nonphysician online digital E/M service (longer duration)

Selected CPT/Codes from segmentCPTNot Covered

98015	Evaluation and management using total time; 40 minutes must be met or exceeded
98940	Chiropractic manipulation
98941	Chiropractic manipulation
98942	Chiropractic manipulation
98943	Chiropractic manipulation
98960	Education and training for patient self-management by a qualified nonphysician
98961	Education and training for patient self-management by a qualified nonphysician

Additional CPT codes in segmentCPTNot Covered

98970	Qualified nonphysician online digital E/M service, 5-10 minutes
98971	Qualified nonphysician online digital E/M service
99366	Medical team conference with interdisciplinary team, face-to-face with patient/family
99367	Medical team conference, patient/family not present
99450	Life/disability evaluation
99452	Care coordination by other qualified professional, 30 minutes

Home monitoring / pharmacist MTM / transport codesCPTNot Covered

99474	Self-measured blood pressure monitoring, 30-day reporting
99485	Supervision of interfacility transport
99605	Medication therapy management by pharmacist, individual face-to-face
99606	Medication therapy management by pharmacist, individual face-to-face

Quality/measure (G-codes / measure codes) in segmentmixed

0014F	Comprehensive preoperative assessment for cataract surgery with IOL placement
0015F	Melanoma follow-up completed
0500F	Initial prenatal care visit (quality measure)
0501F	Prenatal flow sheet documented in medical record by first prenatal visit
0502F	Subsequent prenatal care visit
0519F	Planned chemotherapy regimen documented prior to initiation

Selected F-codes (beginning series)CPTNot Covered

0502F	Subsequent prenatal care visit.
0507F	Peritoneal dialysis plan of care documented (ESRD).
0509F	Urinary incontinence plan of care documented (GER).
0514F	Plan of care for elevated hemoglobin level documented for patient receiving erythropoiesis-stimulating agent (ESA) therapy.
0517F	Glaucoma plan of care documented.
0519F	Planned chemotherapy regimen documented prior to initiation.

Respiratory / immunization related F-codesCPTNot Covered

1002F	Anginal symptoms and level of activity assessed.
1005F	Asthma symptoms evaluated (assessment tool).
1015F	COPD symptoms assessed.
1022F	Pneumococcus immunization status assessed.
1030F	Influenza immunization status assessed.

Stroke and GERD related F-codesCPTNot Covered

1065F	Ischemic stroke symptom onset < 3 hours prior to arrival.
1066F	Ischemic stroke symptom onset >= 3 hours prior to arrival.
1070F	Alarm symptoms for GERD assessed; none present.
1071F	Alarm symptoms for GERD assessed; one or more present.

Falls, discharge, and GERD F-codesCPTNot Covered

1100F	Patient screened for future fall risk; documentation of two or more falls in the past year or any fall with injury.
1101F	Patient screened for fall risk; no falls or only one fall without injury.
1110F	Patient discharged from an inpatient facility within [timeframe] (discharge medication reconciliation).
1118F	GERD symptoms assessed after 12 months of therapy.

Musculoskeletal, palliative, dementia, epilepsy F-codesCPTNot Covered

1130F	Back pain and function assessed.
1134F	Episode of back pain lasting 6 weeks or less.
1137F	Episode of back pain lasting longer than 12 weeks.
1150F	Documentation that a patient has a substantial risk of death within [timeframe].
1175F	Functional status for dementia assessed and results reviewed.
1200F	Seizure type(s) and current seizure frequency documented.

Selected F-codes and measures appearing in this fragmentmixedNot Covered

1170F	Functional status assessed (coa/ra)
1175F	Functional status for dementia assessed and results reviewed (dem)
1200F	Seizure type(s) and current seizure frequency documented (epi)
2040F	Physical examination on the date of the initial visit for low back pain performed
2044F	Documentation of mental health assessment prior to intervention (back surgery or epidural steroid injection)
2050F	Wound characteristics documented prior to debridement (Cwc)
3017F	Colorectal cancer screening results documented and reviewed
3018F	Colonoscopy final report documentation (polyp details) documented
3020F	Left ventricular function assessment documented
3021F	Left ventricular ejection fraction <40% documented

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inv-62: preauth_after_rental_months

Rental-month threshold3 months (Preauth after 3rd rental month when criteria not met)

ContextApplies to durable medical equipment rentals when documented coverage criteria are not met

Source plan scopeSmall Employer and Individual (Nevada)

inv-63: Preauthorization visit/rental thresholds

Visit threshold note*Preauth needed after certain number of visits; limit depends on plan/provider type

Rental threshold note**Preauth after 3rd rental month when criteria not met

Effective date shownAs of: 09/25/25

inv-64: Preauthorization after rental period or visit limits

When preauthorization requiredAfter the 3rd rental month if coverage criteria are not met

Visit-based triggersPreauthorization may be needed after a plan-specific number of visits; limits vary by plan/provider type

Documentation noteOperational notes and footnotes accompany the code listings

inv-65: Preauthorization after rental month threshold

DME rental preauth rulePreauthorization required after the 3rd rental month when criteria are not met

Applies toDurable medical equipment rentals listed in the Nevada code table

Reference textContains operational footnote '**Preauth after 3rd rental month when doesn't met criteria.'

inv-66: Preauthorization trigger notes

Trigger typesSome services require preauthorization after certain visit counts or after the 3rd rental month for rentals

Limit variabilityThresholds depend on plan and provider type (plan-specific)

Where shownNoted in the code listing footnotes and adjacent to specific CPT/HCPCS entries

inv-67: Preauth visit threshold

Visit-based preauthPreauthorization required after a plan-specific number of visits (threshold varies by plan/provider type)

ExamplesSpeech/hearing therapy codes (92507/92508) show 'Preauthorization Required = X*' with visit-threshold footnote

Applies toServices listed under Small Employer and Individual columns in Nevada

inv-68: Preauthorization triggers/limits

Primary rulePreauth needed after certain number of visits or after the 3rd rental month when criteria not met

Plan variabilitySpecific thresholds are plan/provider dependent and may be indicated per-code

Footnote markersAsterisked notes in the document explain visit vs rental triggers

inv-69: Preauthorization after visit threshold

Visit threshold summaryPreauth may be required after a specified number of visits; limit depends on plan/provider type

DME rental threshold summaryPreauth after 3rd rental month when criteria not met

Notation placementNotes appear as footnotes and adjacent to relevant CPT/HCPCS codes in the listing

inv-70: DME rental preauthorization threshold

DME rental preauthorizationPreauthorization applies after the 3rd rental month when coverage criteria are not met

Operational noteDocument explicitly states '**Preauth after 3rd rental month when doesn't met criteria.'

Effective dateAs of: 09/25/25 (document snapshot)

inv-71: Total time for E/M selection

Total-time E/M selectionWhen using total time for established patient E/M, 40 minutes must be met or exceeded

Code example98015 referenced in document for total-time E/M selection

ApplicabilityApplies to selection of appropriate E/M code when total time is used on the encounter date

inv-72: Preauthorization threshold

General preauth thresholdPreauthorization required after the 3rd rental month or after a certain number of visits depending on plan/provider type

Location in docStated in repeated footnotes and at the end of several sections of the Nevada listing

Plan scopeApplies to Small Employer and Individual commercial plans (Nevada) where indicated

inv-73: Preauthorization visit/rental thresholds

Combined thresholdsPreauth after 3rd rental month; preauth after certain number of visits depending on plan/provider type

Document styleThreshold rules repeated throughout the code listings as footnotes

Provider actionProviders should check per-code entries and footnotes for specific preauth requirements

Prior authorization and provider-facing notes

Prior Authorization

Preauthorization indicators for listed codes

Certain total disc arthroplasty and revision codes are marked as requiring prior authorization for Small Employer and Individual plans (e.g., 22856, 22860, 22861).

22856 — Preauthorization Required = X
22860 — Preauthorization Required = X
22861 — Preauthorization Required = X

Denial Risk

Not covered device codes

Several interlaminar/interspinous process stabilization device insertion codes are explicitly marked Not Covered for Small Employer and Individual plans.

22867 — Not Covered = X
22868 — Not Covered = X
22869 — Not Covered = X
22870 — Not Covered = X

Prior Authorization

Preauthorization flags for specific codes

The list flags specific procedure codes with differing coverage; for example, 36473 is marked Preauthorization Required while 37186 is marked Not Covered.

36473 — Preauthorization Required = X
37186 — Not Covered = X

Prior Authorization

General preauthorization notes

Operational notes state that preauthorization may be required after a plan-specific number of visits and that rental items may require preauthorization after the third rental month when criteria are not met.

* Preauth needed after certain number of visits; limit depends on plan/provider type.
** Preauth after 3rd rental month when criteria not met.

Prior Authorization

Prior authorization labels on codes

The coding tables include 'Not Covered' and 'Preauthorization Required' fields for Small Employer and Individual plans; many entries use an 'X' to indicate the applicable flag.

An 'X' in the Preauthorization Required field denotes prior authorization is required for that code under the listed plan types.
Files include both Not Covered and Preauthorization Required columns for plan-level status.

Prior Authorization

Preauthorization conditional rules

Footnotes clarify conditional preauthorization rules: preauth after a certain number of visits (plan-dependent) and preauth after the 3rd rental month if criteria are unmet.

*Preauth needed after certain number of visits. Limit depends on plan/provider type.
**Preauth after 3rd rental month when doesn't meet criteria.

Prior Authorization

Preauthorization indicators for listed CPT/procedure codes (Nevada commercial)

A set of CPT/procedure codes in the Nevada commercial list are marked with Preauthorization Required flags (X) for Small Employer and Individual plans; providers must obtain authorization where indicated.

Examples shown with Preauthorization Required = X include 50327, 50328, 60660, 61630, 61635, 61640, 61641 (see list).

Prior Authorization

Timing/limits for preauthorization

Timing notes reiterate that preauthorization may be triggered after a specific number of visits and that rentals require preauthorization after the 3rd rental month if criteria are not met.

Preauth after 3rd rental month when criteria not met.
Preauth needed after certain number of visits; limit depends on plan/provider type.

Prior Authorization

Preauthorization — selected codes

CPT 60660 (radiofrequency ablation) is listed as requiring preauthorization (marked 'X') for Small Employer and Individual plans in this extract.

60660 — Preauthorization Required = X

Prior Authorization

Preauthorization — additional selected codes

A group of additional CPT codes are flagged as requiring preauthorization (marked 'X') for Small Employer and Individual plans in this extract; obtain prior approval before service.

Examples include 61799, 61800, 62263, 62264, 62287, 62380, 63621, 64490–64495, 64628–64629, 64633–64634, 65757, 69727, 69728.

Prior Authorization

Prior authorization required for some codes

The document uses 'Preauthorization Required = X' for numerous listed codes, indicating prior authorization is required for those services under the Small Employer and Individual plan columns.

Multiple imaging, radiation therapy, and laboratory/genetic codes are marked with Preauthorization Required = X in the extract (see lines for examples).

Prior Authorization

General preauthorization notes

Notes repeat that preauthorization thresholds depend on plan/provider type and that rentals may require preauthorization after the third rental month when criteria are not met.

Preauth needed after certain number of visits; limit depends on plan/provider type.
Preauth after 3rd rental month when criteria not met.

Prior Authorization

Preauthorization indicators for listed codes

Many molecular and genetic procedure codes listed for Nevada are marked with Preauthorization Required = X for Small Employer and Individual plans; providers should request prior authorization where 'X' appears.

Examples: 81120, 81121, 81162, 81163, 81164 — Preauthorization Required = X

Prior Authorization

Examples of codes requiring preauthorization

Examples of molecular/genetic and cytogenomic codes throughout the list show Preauthorization Required = X for Small Employer and Individual plans; obtain authorization accordingly.

81228 — Preauthorization Required = X
81262, 81263, 81264 — Preauthorization Required = X (see molecular code listings)

Prior Authorization

Preauthorization flag for molecular/genetic codes (partial)

The Nevada section contains numerous molecular/genetic codes that include a 'Preauthorization Required = X' indicator; providers must follow plan-specific preauthorization rules for these tests.

Multiple gene/molecular procedure codes are marked Preauthorization Required = X in the listing (see gene panels and targeted analyses).

Documentation Required

Coverage variability and disclaimer

The document includes a disclaimer that coverage may vary by plan type and that coding lists are updated quarterly; immunizations, injectable drugs, and specialty medications are not reflected and should be directed to Pharmacy resources.

Coverage may vary by plan type; coding lists updated quarterly.
Coding lists do not reflect immunizations, injectable drugs, or specialty medications — consult Pharmacy.

Prior Authorization

Preauthorization required for selected genomic/molecular codes

Certain genomic panels and molecular tests (including several solid organ and hematolymphoid panels) are specifically marked as requiring preauthorization (Preauthorization Required = X).

81419, 81432, 81439–81441, 81449, 81450, 81451, 81455–81458, 81462–81463 — Preauthorization Required = X

Prior Authorization

Preauthorization required for tumor/genomic panels

Multiple tumor and genomic panel codes used for oncology diagnostics are flagged with Preauthorization Required = X; prior authorization must be obtained for these assays.

81449, 81450, 81451, 81456–81458, 81523, 81536, 81554 — Preauthorization Required = X

Prior Authorization

Oncology and diagnostic tests prior authorization

Selected oncology and diagnostic gene expression panels and functional assays are flagged for prior authorization (examples include several 815xx codes).

81517 — Not Covered = X
81523, 81525, 81529, 81536, 81554, 81595 — Preauthorization Required = X

Documentation Required

Plan variation and disclaimer

The coding lists and preauthorization requirements may vary by plan type; the document reiterates the quarterly update cadence and the Pharmacy exclusion for drug-related items.

Coverage may vary by plan type; lists updated quarterly.
Pharmacy link should be used for immunization/injectable/specialty medication coverage.

Prior Authorization

Preauthorization for therapy services

Speech/hearing therapy codes (e.g., 92507, 92508) are marked with an asterisk indicating preauthorization is required after a plan-specific number of visits; providers must request authorization when thresholds are met.

92507 — Preauthorization Required = X* (preauth after plan-specific visit threshold)
92508 — Preauthorization Required = X*

Prior Authorization

Preauthorization timing notes

Timing notes confirm some services require preauthorization after the third rental month when criteria are not met (applies to rental items) and that other services have plan-specific preauthorization triggers.

Preauth after 3rd rental month when criteria not met (DME/rental items).
Preauth thresholds for visits are plan/provider dependent.

Prior Authorization

Preauthorization required/marked

Audiology code 92596 is shown with an 'X' for Small Employer and Individual plans, indicating preauthorization is marked for this code in the table.

92596 — Marked X (preauth indicated)

Prior Authorization

AAC device evaluation/therapy preauthorization

Evaluation and therapeutic services for speech‑generating AAC devices (92607–92609) are marked with Preauthorization Required = X*, indicating prior authorization is required (notes reference visit thresholds).

92607 — Preauthorization Required = X*
92608 — Preauthorization Required = X*
92609 — Preauthorization Required = X*

Denial Risk

Pulmonary/home ventilator coverage flags

Some pulmonary function and home ventilator management codes are marked Not Covered for Small Employer and Individual plans (examples: 94005, 94011, 94012 shown in the list).

94005 — Not Covered = X (home ventilator management care plan oversight)
94011, 94012 — examples of pulmonary testing entries flagged

Prior Authorization

Preauthorization threshold note

Therapy and other services (e.g., 97129) include a preauthorization threshold note indicating authorization may be required after a certain number of visits; limits depend on plan/provider type.

97129 — Preauthorization Required = X* (preauth after visit threshold as noted)

Prior Authorization

General preauthorization note repeated

The document repeats that preauthorization may be needed after a plan-specific number of visits; providers should monitor visit counts and request authorization when thresholds are reached.

Preauth needed after certain number of visits; limit depends on plan/provider type.

Prior Authorization

Durable medical equipment rental preauth note

Durable medical equipment rentals are subject to preauthorization after the third rental month when criteria are not met; providers should submit prior authorization requests before month four if criteria remain unmet.

Preauth after 3rd rental month when criteria not met (DME rental rule).

Prior Authorization

Preauthorization notes

The listing reiterates the preauthorization footnotes: preauth after a certain number of visits (plan-dependent) and preauth after rental month three if criteria are unmet — providers must follow these rules when billing.

* Preauth needed after certain number of visits. Limit depends on plan/provider type.
** Preauth after 3rd rental month when criteria not met.

Prior Authorization

Preauthorization rules (general statement)

A general statement repeated across the document: preauthorization is required after a certain number of visits (plan-dependent) and after the 3rd rental month for rentals when criteria are not met.

Preauth needed after certain number of visits; limit depends on plan/provider type.
Preauth after 3rd rental month when criteria not met.

Prior Authorization

Preauthorization rules repeated

The same preauthorization rule language is reiterated in a repeated section: providers must obtain preauthorization per plan thresholds (visit limits) and for rentals after month three if criteria remain unmet.

Preauth needed after certain number of visits; limit depends on plan/provider type.
Preauth after 3rd rental month when criteria not met.

Prior Authorization

Preauthorization rules footer

Footer language restates that preauthorization may be required after a plan-specific number of visits and after the third rental month when criteria have not been met.

Preauth needed after certain number of visits; limit depends on plan/provider type.
Preauth after 3rd rental month when criteria not met.

Prior Authorization

Preauthorization rental-month rule

A threshold rule in the document explicitly notes that preauthorization is required after the third rental month when criteria are not met for rental equipment.

Preauth after 3rd rental month when criteria not met.

Prior Authorization

Visit-limit preauthorization note

Notes repeated in multiple sections caution that preauthorization may be needed after a certain number of visits and that the applicable limit depends on plan and provider type; providers should confirm plan-specific thresholds.

Preauth needed after certain number of visits; limit depends on plan/provider type.

Definitions and scope notes

inv-108: Not Covered

Definition - Not CoveredCodes marked as Not Covered indicate the payer will not reimburse these services for the specified plan type or population as listed.

Update frequencyCoding lists are updated quarterly

Geographic scopeThis list applies to Nevada (Small Employer and Individual)

inv-109: Preauthorization Required

Definition - Preauthorization RequiredCodes marked as Preauthorization Required require prior approval from the payer before services are rendered to be eligible for coverage consideration.

Indicator conventionAn 'X' in the 'Preauthorization Required' field denotes prior authorization is required for that code under the listed plan type.

Example codesExamples in the list: 22856, 22860, 22861 are shown with Preauthorization Required = X

inv-110: pharmacy_exclusion

Pharmacy exclusionsCoding lists do not reflect immunizations, injectable drugs, or specialty medications; direct drug-related inquiries to the Pharmacy link

Quarterly updatesPharmacy-related coverage is handled outside these code lists; lists are updated quarterly

Scope reminderRefer to pharmacy resources for drug and vaccine coverage details

inv-111: preauth_note

Preauthorization timing notePreauthorization may be required after a certain number of visits; limits depend on plan/provider type

Rental-month noteFootnote specifies '**Preauth after 3rd rental month when doesn't met criteria.'

Action for providersCheck per-code entries and footnotes for visit- or rental-based preauth triggers

inv-112: Not Covered / Preauthorization Required (field meaning)

Field meaningsTable fields indicate whether a code is 'Not Covered' or 'Preauthorization Required' for specified plan types (e.g., Small Employer and Individual)

Notation conventionAn 'X' adjacent to a plan column flags the code status for that plan type

Per-code displaySome codes show '.' or blank for a field when not applicable

inv-113: Disclaimer/Scope

Scope disclaimerCoverage may vary by plan type; coding lists are updated quarterly and do not reflect immunizations, injectable drugs, or specialty medications

Where to find drug coverageConsult the Pharmacy link for immunizations, injectables, and specialty medications

Document applicabilityApplies to SelectHealth commercial plans in Nevada (Small Employer and Individual)

inv-114: Preauthorization timing

Preauthorization timing summaryFootnotes indicate preauthorization timing: after a certain number of visits or after the 3rd rental month when criteria are not met

Plan dependenceThresholds depend on plan and provider type and are described in per-code notes

Document dateAs of: 09/25/25 appears with these timing notes

inv-115: Disclaimer / scope of coding lists

Coding lists scopeCoding lists are updated quarterly and do not reflect immunizations, injectable drugs, or specialty medications (refer to Pharmacy)

Plan variabilityCoverage may vary by plan type; check specific plan details

Update cadenceLists maintained with quarterly updates

inv-116: Preauthorization timing notes

Timing note repeatedSome services require preauthorization after rental month 3 when criteria not met; other plan-specific preauth rules noted with annotations

Where notedThese timing notes appear near molecular and other sections as repeated footnotes

Provider actionVerify per-code footnotes for timing triggers before service delivery

inv-117: Coverage may vary by plan type; codes updated quarterly and lists do not reflect immunizations, injectable drugs, or specialty medications which should be directed to the Pharmacy link.

Plan-variation disclaimerCoverage may vary by plan type; coding lists are updated quarterly and do not reflect immunizations, injectable drugs, or specialty medications

Quarterly updatesLists are maintained on a quarterly schedule

Pharmacy directionDirect drug/immunization questions to Pharmacy resources on the website

inv-118: Disclaimer / scope note

Scope reminderCoding lists exclude immunizations, injectables, and specialty medications; see Pharmacy for those items

UpdatesLists updated quarterly; entries may change each quarter

Geographic scopeThis document section applies to Nevada Small Employer and Individual plans

inv-119: Preauthorization footnotes

Preauthorization footnotes (text)*Preauth needed after certain number of visits; limit depends on plan/provider type. **Preauth after 3rd rental month when criteria not met.

UsageFootnotes accompany code listings to explain conditional preauth triggers

Effective snapshotAppears repeatedly with 'As of: 09/25/25'

inv-120: Disclaimer / Coverage variance

Coverage variance noteCoverage may vary by plan type and may not follow the listed services; coding lists are updated quarterly

ActionConfirm coverage with plan documents or Pharmacy for drug-related items

ApplicabilityApplies to Small Employer and Individual (Nevada) listings

inv-121: Preauthorization indicator

X notation meaningAn 'X' adjacent to a plan column indicates the code is flagged for that plan type (e.g., Not Covered or Preauthorization Required)

Where usedUsed in the per-code tables for Small Employer and Individual columns

InterpretationCheck both 'Not Covered' and 'Preauthorization Required' columns for the 'X' indicator

inv-122: Disclaimer / plan variation

Plan-variation disclaimerCoverage may vary by plan type; coding lists are updated quarterly and do not include immunizations, injectables, or specialty medications

Referencing PharmacyPharmacy link handles drug/immunization coverage specifics

Document maintenanceQuarterly updates may change code status

inv-123: Preauthorization Required = X

'Preauthorization Required = X' definitionAn 'X' in the 'Preauthorization Required' field indicates prior authorization is required for that specific code under the listed plan type.

PlacementDisplayed in the per-code Small Employer and Individual columns next to the code

ExampleMultiple molecular/genetic codes show 'Preauthorization Required = X' in the list

inv-124: Coverage may vary by plan type; coding lists are updated quarterly and do not reflect immunizations, injectable drugs, or specialty medications (those are handled via the Pharmacy link).

Quarterly update & pharmacy exclusionCoding lists updated quarterly and do not reflect immunizations, injectable drugs, or specialty medications (handled via Pharmacy link)

Plan variabilityCoverage may vary by plan type; check plan-specific resources

Document scopeThis statement repeats throughout the Nevada listing

inv-125: Preauthorization note (visits / rental month)

Preauth note for visits/rental monthsPreauthorization may be required after a certain number of visits or after the 3rd rental month if criteria are not met; limits depend on plan/provider type.

ExamplesSpeech/hearing therapy (92507/92508) and therapeutic interventions (97129) have visit-based preauth notes

Provider instructionVerify per-code notation and seek prior authorization when thresholds are met

inv-126: Disclaimer / Coverage variance

Coverage variability disclaimerCoverage may vary by plan type; coding lists are updated quarterly and do not reflect immunizations, injectable drugs, or specialty medications

ActionConsult plan documents or Pharmacy resources for exceptions or drug items

Applies toSmall Employer and Individual commercial plans in Nevada

inv-127: X notation

'X' notation summary'X' marks a code field for that plan type (Not Covered or Preauthorization Required) in the per-code table

Interpretation tipAn 'X' under 'Not Covered' means no reimbursement; under 'Preauthorization Required' means prior auth needed

Where to checkSee Small Employer and Individual columns in the Nevada listing

inv-128: coverage may vary by plan type

Plan-variability reminderCoverage may vary by plan type — verify with plan-specific resources

Document noteThis disclaimer appears repeatedly in the Nevada listing

Quarterly updatesLists are updated quarterly and may change per quarter

inv-129: preauthorization threshold

Preauthorization threshold summaryPreauthorization thresholds apply after a certain number of visits or rental months depending on plan/provider type

Where indicatedShown as footnotes and per-code annotations in the Nevada listing

Provider actionRequest prior auth once visit or rental thresholds are reached or as indicated per code

inv-130: Preauth needed after certain number of visits. Limit depends on plan/provider type.

Visit-limit preauth notePreauth needed after certain number of visits; limit depends on plan/provider type

NotationAppears as asterisked footnote in the listing ('*Preauth needed after certain number of visits')

ActionCheck per-code asterisks and plan-level rules before exceeding visit thresholds

inv-131: Coverage may vary by plan type; lists do not include immunizations, injectable drugs, or specialty medications.

Coverage disclaimer (pharmacy note)Coverage may vary by plan type; lists do not include immunizations, injectable drugs, or specialty medications — refer to Pharmacy

Update cadenceLists updated quarterly

Geographic scopeNevada Small Employer and Individual plans

inv-132: Disclaimer / scope

Disclaimer / scope summaryCoverage may vary by plan type; lists are updated quarterly and do not reflect immunizations, injectable drugs, or specialty medications (see Pharmacy)

Provider instructionUse Pharmacy resources for drug-related coverage questions

Document maintenanceQuarterly updates may change code statuses

inv-133: Disclaimer / scope of coding lists

Coding list scopeCoding lists are updated quarterly and do not reflect immunizations, injectable drugs, or specialty medications (handled via Pharmacy)

Action for providersDirect medication and immunization questions to Pharmacy; verify code status each quarter

ApplicabilityApplies to the Nevada Small Employer and Individual code listing

Policy Summary

PayerSelectHealth

PolicyCommercial CPT/HCPCS codes not covered or requiring preauthorization (Nevada)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 25, 2025

Last ReviewSep 25, 2025

Next Review DateN/A

Key ActionObtain prior authorization when a code in the list is marked 'Preauthorization Required' or follow plan-specific visit/rental thresholds before submitting claims.

SourceLink

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