Aetna · PayerPolicy · AETNA-CPB-0530
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 |
|---|---|---|
| 76817 | CPT | Covered |
| 76830 | CPT | Covered |
| C53.0 | ICD10CM | Covered |
| C55 | ICD10CM | Covered |
| C56.1 | ICD10CM | Covered |
| C56.9 | ICD10CM | Covered |
| C57.4 | ICD10CM | Covered |
| C79.60 | ICD10CM | Covered |
| C79.63 | ICD10CM | Covered |
| C79.82 | ICD10CM | Covered |
| D07.0 | ICD10CM | Covered |
| D25.0 | ICD10CM | Covered |
| D25.9 | ICD10CM | Covered |
| D26.1 | ICD10CM | Covered |
| D27.0 | ICD10CM | Covered |
| D27.9 | ICD10CM | Covered |
| D39.0 | ICD10CM | Covered |
| D39.10 | ICD10CM | Covered |
| D39.12 | ICD10CM | Covered |
| N39.3 | ICD10CM | Covered |
| N39.9 | ICD10CM | Covered |
| N70.01 | ICD10CM | Covered |
| N77.1 | ICD10CM | Covered |
| N80.00 | ICD10CM | Covered |
| N80.03 | ICD10CM | Covered |
| N80.50 | ICD10CM | Covered |
| N80.569 | ICD10CM | Covered |
| N83.201 | ICD10CM | Covered |
| N83.299 | ICD10CM | Covered |
| N91.0 | ICD10CM | Covered |
| N94.0 | ICD10CM | Covered |
| N94.89 | ICD10CM | Covered |
| N94.9 | ICD10CM | Covered |
| N95.0 | ICD10CM | Covered |
| N97.0 | ICD10CM | Covered |
| N97.9 | ICD10CM | Covered |
| Q51.0 | ICD10CM | Covered |
| Q51.5 | ICD10CM | Covered |
| Q51.810 | ICD10CM | Covered |
| Q51.818 | ICD10CM | Covered |
| Q51.9 | ICD10CM | Covered |
| R10.0 | ICD10CM | Covered |
| R10.829 | ICD10CM | Covered |
| R10.84 | ICD10CM | Covered |
| R10.9 | ICD10CM | Covered |
| R14.0 | ICD10CM | Covered |
| R19.00 | ICD10CM | Covered |
| R19.09 | ICD10CM | Covered |
| R35.0 | ICD10CM | Covered |
| R39.15 | ICD10CM | Covered |
| R68.81 | ICD10CM | Covered |
| T83. | ICD10CM | Covered |
| Z01.411 | ICD10CM | Covered |
| Z01.419 | ICD10CM | Covered |
| Z12.73 | ICD10CM | Covered |
| Z12.79 | ICD10CM | Covered |
| Z15.02 | ICD10CM | Covered |
| Z30.431 | ICD10CM | Covered |
| Z97.5 | ICD10CM | Covered |