1 commercial payer policy lists K04.01. See each policy's status for the code and its official source. Listing a code is not a coverage decision: read each policy’s source for the requirements that apply.
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1 policy from 1 payer
Summary of the payer’s published policy. Not a coverage determination — confirm with the payer before submitting.
| Policy | Effective | Status of K04.01 |
|---|---|---|
| Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting | Jul 1, 2026 | Covered |