Kidney Stones: Selected Interventions | Aetna | Backwork

Kidney Stones: Selected Interventions

Aetna · PayerPolicy · AETNA-CPB-0392

Status: Active
Effective: June 6, 2023
Last reviewed by Aetna: June 23, 2026
Last checked by Backwork: August 1, 2026

Summary of the payer’s published policy. Not a coverage determination — confirm with Aetna before submitting.

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Codes in this policy

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.

Codes this policy lists and each code’s status in the policy
Code	Code system	Status in this policy
72192	CPT	Covered
72193	CPT	Covered
72194	CPT	Covered
72195	CPT	Covered
72196	CPT	Covered
72197	CPT	Covered
N20.0	ICD10CM	Covered
R82.991	ICD10CM	Covered
R82.998	ICD10CM	Covered
Z87.442	ICD10CM	Covered