Aetna · PayerPolicy · AETNA-CPB-0344
Summary of the payer’s published policy. Not a coverage determination — confirm with Aetna before submitting.
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Each code’s status is what the policy records for it. This page does not show the policy’s criteria. Read them in the payer’s source.
| Code | Code system | Status in this policy |
|---|---|---|
| 92133 | CPT | Covered |
| 92134 | CPT | Covered |
| A28.1 | ICD10CM | Covered |
| B39.4 | ICD10CM | Covered |
| B50.0 | ICD10CM | Covered |
| B54 | ICD10CM | Covered |
| B58.01 | ICD10CM | Covered |
| C69.20 | ICD10CM | Covered |
| C69.32 | ICD10CM | Covered |
| C71.0 | ICD10CM | Covered |
| C71.9 | ICD10CM | Covered |
| D18.09 | ICD10CM | Covered |
| D31.20 | ICD10CM | Covered |
| D31.32 | ICD10CM | Covered |
| E05.00 | ICD10CM | Covered |
| E05.01 | ICD10CM | Covered |
| E08.311 | ICD10CM | Covered |
| E08.3599 | ICD10CM | Covered |
| E09.311 | ICD10CM | Covered |
| E09.3599 | ICD10CM | Covered |
| E10.311 | ICD10CM | Covered |
| E10.3599 | ICD10CM | Covered |
| E11.311 | ICD10CM | Covered |
| E11.3599 | ICD10CM | Covered |
| E13.311 | ICD10CM | Covered |
| E13.3599 | ICD10CM | Covered |
| F20.00 | ICD10CM | Covered |
| F20.9 | ICD10CM | Covered |
| G31.01 | ICD10CM | Covered |
| G31.09 | ICD10CM | Covered |
| G31.9 | ICD10CM | Covered |
| G35 | ICD10CM | Covered |
| G40.201 | ICD10CM | Covered |
| G40.219 | ICD10CM | Covered |
| G40.401 | ICD10CM | Covered |
| G40.419 | ICD10CM | Covered |
| G40.821 | ICD10CM | Covered |
| G40.824 | ICD10CM | Covered |
| G93.2 | ICD10CM | Covered |
| H04.121 | ICD10CM | Covered |
| H04.129 | ICD10CM | Covered |
| H04.561 | ICD10CM | Covered |
| H04.569 | ICD10CM | Covered |
| H11.141 | ICD10CM | Covered |
| H11.149 | ICD10CM | Covered |
| H16.221 | ICD10CM | Covered |
| H16.239 | ICD10CM | Covered |
| H20.821 | ICD10CM | Covered |
| H20.829 | ICD10CM | Covered |
| H25.011 | ICD10CM | Covered |
| H28 | ICD10CM | Covered |
| H30.001 | ICD10CM | Covered |
| H31.9 | ICD10CM | Covered |
| H32 | ICD10CM | Covered |
| H33.001 | ICD10CM | Covered |
| H36 | ICD10CM | Covered |
| H40.001 | ICD10CM | Covered |
| H40.9 | ICD10CM | Covered |
| H43.10 | ICD10CM | Covered |
| H43.13 | ICD10CM | Covered |
| H43.821 | ICD10CM | Covered |
| H43.829 | ICD10CM | Covered |
| H46.00 | ICD10CM | Covered |
| H47.399 | ICD10CM | Covered |
| H47.9 | ICD10CM | Covered |
| H53.40 | ICD10CM | Covered |
| H53.489 | ICD10CM | Covered |
| H53.8 | ICD10CM | Covered |
| H59.031 | ICD10CM | Covered |
| H59.039 | ICD10CM | Covered |
| L93.0 | ICD10CM | Covered |
| L93.2 | ICD10CM | Covered |
| M05.0 | ICD10CM | Covered |
| M06.9 | ICD10CM | Covered |
| M32.0 | ICD10CM | Covered |
| M32.9 | ICD10CM | Covered |
| M35.00 | ICD10CM | Covered |
| M35.09 | ICD10CM | Covered |
| Q12.0 | ICD10CM | Covered |
| Q12.9 | ICD10CM | Covered |
| Q14.0 | ICD10CM | Covered |
| Q14.9 | ICD10CM | Covered |
| Q15.0 | ICD10CM | Covered |
| Q85.00 | ICD10CM | Covered |
| Q85.01 | ICD10CM | Covered |
| T37. | ICD10CM | Covered |
| T85. | ICD10CM | Covered |
| Z13.5 | ICD10CM | Covered |