Select Health Policies
Policy Development
Select Health medical, dental, and coding/reimbursement policies represent our determination of whether services or devices are standard medical practice, experimental/investigational, cosmetic, or within coding standards.
Medical policies are based on Select Health determination of whether services or devices are standard medical practice, experimental/investigational, cosmetic, or within coding standards. These conclusions reflect our review of currently available clinical information including:
- Research in peer-reviewed published medical literature
- Regulatory status of the technology
- Evidence-based guidelines of public health and health research agencies
- Evidence-based guidelines and positions of leading national health professional organizations
- Views of physicians practicing in relevant clinical areas
- Other relevant factors
Laboratory utilization policies reflect a partnership between Select Health and Avalon Healthcare. NOTE: Post-service automated policy adherence applies to outpatient laboratory services regardless of place of service. Learn more by accessing:
- Laboratory Utilization Policies: Part 1 and Part 2 (see links below)
- Frequently Asked Questions
Coding & Reimbursement policies (both medical and dental) are based on a review of coding standards, including:
- Centers for Medicare and Medicaid Services (CMS)
- Current Procedural Terminology (CPT®)
- Specialty societies (e.g., AAOS)
- Other expert sources
Pharmacy policies:
- Use PromptPA to obtain preauthorization for prescriptions and infusible drugs and to see pharmacy coverage requirements.
- To submit a pharmacy related appeal, please follow this simple process:
- Step 1: Access the online appeals form
- Step 2: Select plan, fill in required fields, and attach supporting documentation (if necessary)
- Step 3: Click the submit button
NOTE: By accessing and/or downloading Select Health policies, you automatically agree to the Medical and Coding/Reimbursement Policy Manual Terms and Conditions.
Select Health Medical Policies (by category)
Access Select Health Medical Policies as a collection (in PDF form) for each category below (or you can access individual policies via a searchable database on the Select Health Provider Portal, which requires a secure login).
Anesthesia
Behavioral Health
Cardiovascular
Dermatology
Durable Medical Equipment
Ear, Nose, & Throat
Endocrinology
Gastroenterology
General Surgery
Genetic Testing
Genitourinary
Hematology/Oncology
Laboratory Utilization Policies: Part 1, Part 2
Neurology/Neurosurgery
Obstetrics/Gynecology
Ophthalmology
Navigating Medical Policy Collections
Select Health may use additional coverage criteria where a medical policy is not available: InterQual Criteria
For Select Health Medicare Nevada: MCG Criteria
Find the exact policy you need within each collection.
Select Health Coding & Reimbursement Policies
Medical:
- 22 Modifier [#24]
- 59 Modifier [#05]
- After Hours and Urgent Care Charges [#02]
- Ambulatory Electroencephalography (EEG) [#89]
- Anesthesia (General & Mac) with Colonoscopies and Other Endoscopic Examinations [#51]
- Anesthesia Complicated by Emergency Conditions [#62]
- Appendectomy [#34]
- Arthrodesis with Additional Codes for Decompression [#69]
- Assistant Surgeons [#23]
- Autograft & Allograft for Spine Surgery [#57]
- Binocular Microscopy [#60]
- Bone and Tendon Grafts with Knee Surgery [#27]
- Breast Reconstruction [#44]
- Care Plan Oversight Services [#32]
- Cerumen Removal [#01]
- Chemotherapy and Other Highly Complex Drug or Biologic Agent Administration (Office Based) [#11]
- Comparison Films [#53]
- Conscious Sedation with Pain Management Procedures (#80)
- Critical Care (Not including Neonatal or Pediatric Critical Care) [#15]
- Determining Allowed Amounts for Out-of-Network Claims for Commercial Plans [#96]
- Durable Medical Equipment (DME) [#41]
- Evaluation Visits for Excluded Medical Diagnosis Codes [#33]
- Exploration of Spinal Fusion with Other Surgery [#21]
- Facet Injection with Epidural Injection [#39]
- Fetal Non-Stress Test with or without Ultrasound [#37]
- Formulas and Other Enteral Nutrition [#95]
- Global Surgery [#12]
- Hierarchy of Sources [#63]
- Home Health Aide [#82}
- Hospital Beds [#90]
- Hydration (Office-Based)*[#09]
- "Incident to Physician's Professional Services" and Split/Shared E/M Service [#03]
- In-Network Coverage of Medical Services with an Out-of-Network Provider [#88]
- In-Office Procedures [#79]
- Inpatient Readmissions
- Insertion, Non-Biodegradable Drug Delivery Implant to Report Joint or Ophthalmologic Spacers or Prosthesis [#71]
- Intraoperative Neurophysiological Monitoring (IONM) [#56]
- IV Moderate Conscious Sedation [#07]
- Lipoma Removal [#58]
- Lysis of Adhesions [#36]
- Medical Necessity - Geographic Considerations [#97]
- Medical Record Documentation [#35]
- Modifiers [#17]
- Molecular Genetic Testing Guidelines [#83]
- Multiple Procedure Reduction for Diagnostic Cardiology Procedures [#73]
- Multiple Procedure Reduction for Diagnostic Ophthalmology Procedures [#74]
- Multiple Procedure Reduction for Radiology Procedures [#61]
- Multiple Procedure Reduction Therapy [#59]
- Multiple Surgeries [#13]
- Mumford Procedure [#40]
- Obstetrical Services [#16]
- Ocular Imaging [#92]
- Operating Microscope [#46]
- Ophthalmic Biometry [#54]
- Postoperative Continuous Local Delivery of Medication for Pain Control [#48]
- Post-Operative Debridement Following FESS [#50]
- Preventative and Problem-Oriented Evaluation and Management Services [#42]
- Preventive Care and Screening Guidelines [#06]
- Pulse Oximetry [#19]
- Robotic Assisted Surgery [#66]
- Scope Procedures Converted to Open Procedures [#38]
- Screening Pap-Smear with a Preventive Eval [#76]
- Screening Visual Acuity with E/M Services [#31]
- Shoulder Debridement [#72]
- Specimen Validity Testing [#65]
- Spinal Cord Stimulation-Test Trial Portion [#47]
- Spravato (Esketamine) for Treatment Resistant Depression [#91]
- State-supplied Immunization [#22]
- Supervised Anesthesia [#75]
- Supervision for Physical Therapy Services [#52]
- Surgical Trays and Supplies [#14]
- Telehealth and Telemedicine [#85]
- Temporomandibular Joint (TMJ)Disorders (TMD) [#43]
- Testing Serum Vitamin D Levels [#77]
- Therapeutic, Prophylactic, and Diagnostic and Infusions Policy(Office Based) [#10]
- Travel Allowance for Organ Transplants [#86]
- Unlisted/Unspecified Codes [#08]
- Urine Drug Testing in the Outpatient Setting [#87]
- Venipuncture and/or Collection of Specimens [#78]
*See also, Chemotherapy, and Therapeutic, Prophylactic, and Diagnostic Injections and Infusions Policies
Dental:
- Anterior Crowns and Labial Veneers (D001)
- Unspecified Procedures (D002)
- Periodontal Codes (D003)
- Crown, Inlay, Onlay, and Veneer Repairs (D004)
- Fixed Partial Dental Procedures: Pontics and Crowns (D005)
- Treatment for Post-Surgical Complications (D006)
- Crown Revisions (D007)
- Dental Anesthesia Coverage (D008)
- Crown/Veneer Placement Date (D009)
- Crown Lengthening (D010)
- Treatment of Root Canal Obstruction: Non-Surgical Access (D011)
- Inraoral-Occlusal Radiographic Image (D012)
- Pulp Caps (D013)
- Anterior Multiple Surface Fillings (D014)
- Scaling and Debridement of a Single Implant (D015)
- Core Buildup (D016)
- Collection and Application of Autologous Blood Concentrate Product (D017)
- Complicated Suturing (D018)
- Guided Tissue Regeneration (D019)
- Dental Record Documentation (D020)