Aetna · PayerPolicy · AETNA-CPB-0452
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 |
|---|---|---|
| 94726 | CPT | Covered |
| A4468 | HCPCS | Covered |
| B91 | ICD10CM | Covered |
| E66.2 | ICD10CM | Covered |
| G12.0 | ICD10CM | Covered |
| G12.9 | ICD10CM | Covered |
| G14 | ICD10CM | Covered |
| G47.31 | ICD10CM | Covered |
| G47.33 | ICD10CM | Covered |
| G47.35 | ICD10CM | Covered |
| G47.36 | ICD10CM | Covered |
| G47.37 | ICD10CM | Covered |
| G54.0 | ICD10CM | Covered |
| G54.9 | ICD10CM | Covered |
| G55 | ICD10CM | Covered |
| G70.00 | ICD10CM | Covered |
| G73.7 | ICD10CM | Covered |
| G93.31 | ICD10CM | Covered |
| G93.39 | ICD10CM | Covered |
| H20 | ICD10CM | Covered |
| J10.00 | ICD10CM | Covered |
| J18.9 | ICD10CM | Covered |
| J21.0 | ICD10CM | Covered |
| J21.9 | ICD10CM | Covered |
| J39.8 | ICD10CM | Covered |
| J40 | ICD10CM | Covered |
| J44.9 | ICD10CM | Covered |
| J45.20 | ICD10CM | Covered |
| J45.998 | ICD10CM | Covered |
| J47.0 | ICD10CM | Covered |
| J47.9 | ICD10CM | Covered |
| J67.0 | ICD10CM | Covered |
| J67.9 | ICD10CM | Covered |
| J80 | ICD10CM | Covered |
| J96.00 | ICD10CM | Covered |
| J96.92 | ICD10CM | Covered |
| J98.4 | ICD10CM | Covered |
| M41.00 | ICD10CM | Covered |
| M41.9 | ICD10CM | Covered |
| M95.4 | ICD10CM | Covered |
| M96.5 | ICD10CM | Covered |
| Q32.0 | ICD10CM | Covered |
| Q67.8 | ICD10CM | Covered |
| R06.00 | ICD10CM | Covered |
| R06.9 | ICD10CM | Covered |
| R09.02 | ICD10CM | Covered |
| R53.0 | ICD10CM | Covered |
| R53.1 | ICD10CM | Covered |
| R53.81 | ICD10CM | Covered |
| R58.83 | ICD10CM | Covered |
| S21.309 | ICD10CM | Covered |
| S27.301 | ICD10CM | Covered |
| S27.399 | ICD10CM | Covered |