CurrentSharp-Health-PlanPolicy N/A

Medical services prior authorization & benefit routing list

Lists medical services and associated administrative routing (Prior authorization required, Provider-directed, No prior authorization, or Not a covered benefit) with code ranges to guide providers submitting claims or prior authorization requests.

Policy Summary

PayerSharp-Health-Plan

PolicyMedical services prior authorization & benefit routing list

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for any service labeled 'P' before providing or billing the service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

manylisted service/procedure entries

P/D/X/NCBauthorization categories used

acupuncture→ASHspecial routing note

12 evalsdirect referral pattern

numerousCPT/HCPCS code ranges

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Coverage & Authorization Matrix

Administrative coverage categorization

Coverage administrative stance is indicated by category labels; specific clinical medical necessity criteria are not present in this part of the document.

Authorization category determination: If a service is labeled 'P' then prior authorization is required; if labeled 'D' then provider-directed/in-network without prior authorization; if labeled 'X' then no prior authorization or referral form is needed; 'NCB' denotes not a covered benefit.

Administrative routing only; clinical medical necessity criteria are documented elsewhere.

Authorization designations and coverage stance

Coverage and authorization rules by designation

Prior Authorization Required (P): Services marked P require prior authorization before coverage. This includes a broad set of surgical, imaging, transplant, specialty procedures, and therapies (see listed codes and service line items). Examples in the table include abortions (59840-59866), aquatic/physical therapies beyond initial direct-referral sessions, bone marrow transplant (38230-38243), neurostimulator generators (95970-95975), nuclear scans (78012-79999), transplants except corneal, and many other codes listed across the document.see code groups and thresholds for therapy session limits

Prior authorization is required for further treatments when direct referral limits are exceeded (see therapy continuation rules).

Provider-directed (D): Services marked D are provider-directed and do not require prior authorization or a referral form. Many routine, in-network services and initial evaluations (for example newborn care, certain maternal-fetal services, in-network audiometry, and some ambulatory services) are designated D.

Several therapy services are D for an initial evaluation and limited direct referral sessions; further sessions may require prior authorization (D,P entries).

Not a Covered Benefit (NCB): Items marked NCB are not covered benefits. Document examples include tubal ligation reversal and vasectomy reversal (code 55400), orthoptic training (92065), and postmortem examinations (88000-88099).

NCB entries are administrative determinations; claims for these services are not covered.

The plan designates certain services as Not a Covered Benefit (NCB). Per the administrative table, custodial care is explicitly listed as a NCB and is not covered by medical insurance. The document also identifies travel or employment immunizations (including codes in the 90476 - 90749 range and related entries) as NCB; immunizations required for travel or by employers are not covered benefits.

The table lists several procedures as Not a Covered Benefit (NCB). Examples called out include Orthoptic Training (CPT 92065), postmortem/examination ranges (88000–88099 are noted elsewhere in the document as NCB class examples), and reproductive reversal procedures such as tubal ligation reversal and vasectomy reversal (CPT 55400), which are explicitly marked NCB.

Related CPT / HCPCS Codes

Examples of Prior Authorization (P)CPTCovered

59840-59866	Abortions
97810-97814	Acupuncture

Mixed examples (P / D / X)mixed

97113	Aquatic Therapy
A0021-A099	Ambulance services (gurney and wheelchair non-emergent) including A0080, A0130, A0210, A0390, A0998

Further P-coded proceduresCPTCovered

38230-38243	Bone Marrow Transplant
20974-20979	Bone electrical stimulation to aid in healing / non-invasive
95004-95199	Allergen immunotherapy services

Examples across documentmixed

58321-58322	Artificial insemination
69930-69949	Cochlear device implant
A0021-A0999	Ambulance emergent services

Infertility / ARTmixedCovered

58321-58323, 76948, 55870, 58970-58999, 84830, 58750-58770, 89250-89398, 99203, 99241-99245

Infertility and Assisted Reproductive Technology (ART) (check benefit/supplemental)

Infertility / related codesCPTCovered

58321-58323	Infertility and Assisted Reproductive Technology (ART)
76948	Ultrasound Aspirations of Ova
55870	Electroejaculation
58970-58999
84830	Ovulation Testing
58750-58770	Repair of Oviduct / Ovary-Tubotubal Anastomosis etc.
89250-89398
99203
99241-99245

Injectable medication-specific codeHCPCSCovered

J1055

Depo-Provera Injections

Mixed services with codesmixedCovered

57155	Insertion of Heyman Capsules (Intrauterine)
58346
58300-58301	IUD Insertion, Removal
21141-21160	Lefort I, II, III
21345-21348
21421-21436
61586
92071-92072	Standard Intraocular Lenses Post-Cataract Surgery
47133-47147	Liver Transplant
32850-32856	Lung Transplant

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Not covered (NCB) examplesCPTNot Covered

92065	Orthoptic Training - Ophthalmology
55400	Vasectomy Reversal

Initial therapy sessions

Initial approved evaluationEvaluation is approved as the initial therapy session before the treatment series

Allowed initial treatments (lymphedema)Initial approval for treatment of lymphedema = evaluation plus 10 treatments

Allowed initial treatments (physiotherapy/OT)Initial approval for physiotherapy / occupational therapy = evaluation plus 8 to 10 treatments (direct referral for evaluation and 12 treatments noted for some OT/hand therapy entries)

Continuation requirementFurther treatments beyond the initial evaluation + specified treatments require prior authorization

What Providers Must Do

Prior Authorization

Services requiring prior authorization — provider responsibilities

Certain services in this policy require prior authorization. Providers must verify authorization requirements before scheduling or delivering P-designated services to avoid denials or retroactive nonpayment.

P = Prior authorization required
D = Provider-directed care; no prior authorization or referral form needed
X = No prior authorization or referral form needed
NCB = Not a covered benefit

Prior Authorization

Therapy continuation prior authorization

Prior authorization is required for continuation of therapy services beyond the direct-referral evaluation period. For therapies with direct referral allowances (e.g., physical therapy, occupational therapy, aquatic therapy, pool therapy, vestibular rehab, pulmonary and cardiac rehabilitation), initial coverage is limited to the evaluation plus a limited number of visits (typically 8–12 visits depending on service). Providers must obtain prior authorization for further treatments to ensure continued coverage.

Legend & Terms

Authorization legend (short)

PPrior authorization required

DProvider-directed care; no prior authorization or referral form needed

XNo prior authorization or referral form needed

NCBNot a covered benefit

P / D / X / NCB (definitions)

PPrior authorization required

DProvider-directed care; no prior authorization or referral form needed

Policy Scope & Notes

This document functions as an administrative coverage and prior authorization matrix mapping many services to an administrative action: P (prior authorization required), D (provider-directed; no prior authorization or referral form needed), X (no prior authorization or referral form needed), or NCB (not a covered benefit). The matrix includes code-level entries and service notes used by operations to determine whether to submit a prior authorization before scheduling or claim submission. For example, many specialty procedures and imaging/transplant services are marked P and require prior authorization, certain routine in‑network services are D, and specific items such as orthoptic training or sterilization reversal are NCB.