Aetna · PayerPolicy · AETNA-CPB-0604
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 |
|---|---|---|
| 46930 | CPT | Covered |
| 97026 | CPT | Covered |
| A4639 | HCPCS | Covered |
| E0221 | HCPCS | Covered |
| B35.1 | ICD10CM | Covered |
| C00.0 | ICD10CM | Covered |
| D09.9 | ICD10CM | Covered |
| E08.00 | ICD10CM | Covered |
| E13.9 | ICD10CM | Covered |
| F01. | ICD10CM | Covered |
| F01.50 | ICD10CM | Covered |
| F02.80 | ICD10CM | Covered |
| F02.81 | ICD10CM | Covered |
| F03.90 | ICD10CM | Covered |
| F03.91 | ICD10CM | Covered |
| F33.0 | ICD10CM | Covered |
| F33.9 | ICD10CM | Covered |
| G11.1 | ICD10CM | Covered |
| G20. | ICD10CM | Covered |
| G21.9 | ICD10CM | Covered |
| G43.001 | ICD10CM | Covered |
| G43.901 | ICD10CM | Covered |
| G51.0 | ICD10CM | Covered |
| G60.0 | ICD10CM | Covered |
| G62.9 | ICD10CM | Covered |
| G91.0 | ICD10CM | Covered |
| G91.9 | ICD10CM | Covered |
| G92 | ICD10CM | Covered |
| G93.1 | ICD10CM | Covered |
| G93.9 | ICD10CM | Covered |
| H35.30 | ICD10CM | Covered |
| H35.466 | ICD10CM | Covered |
| J45.20 | ICD10CM | Covered |
| J45.22 | ICD10CM | Covered |
| J45.30 | ICD10CM | Covered |
| J45.32 | ICD10CM | Covered |
| J45.40 | ICD10CM | Covered |
| J45.42 | ICD10CM | Covered |
| J45.50 | ICD10CM | Covered |
| J45.52 | ICD10CM | Covered |
| J45.901 | ICD10CM | Covered |
| J45.909 | ICD10CM | Covered |
| J45.990 | ICD10CM | Covered |
| J45.998 | ICD10CM | Covered |
| K62.82 | ICD10CM | Covered |
| K64.0 | ICD10CM | Covered |
| K64.1 | ICD10CM | Covered |
| L70.0 | ICD10CM | Covered |
| L70.9 | ICD10CM | Covered |
| L89.000 | ICD10CM | Covered |
| L89.95 | ICD10CM | Covered |
| M15.0 | ICD10CM | Covered |
| M19.93 | ICD10CM | Covered |
| M26.601 | ICD10CM | Covered |
| M26.609 | ICD10CM | Covered |
| M54.2 | ICD10CM | Covered |
| M54.50 | ICD10CM | Covered |
| M54.59 | ICD10CM | Covered |
| M54.6 | ICD10CM | Covered |
| M54.9 | ICD10CM | Covered |
| M67.00 | ICD10CM | Covered |
| M67.99 | ICD10CM | Covered |
| M80.00 | ICD10CM | Covered |
| M81.8 | ICD10CM | Covered |
| M85.80 | ICD10CM | Covered |
| M85.9 | ICD10CM | Covered |
| N18.1 | ICD10CM | Covered |
| N18.9 | ICD10CM | Covered |
| Q82.0 | ICD10CM | Covered |
| R40.0 | ICD10CM | Covered |
| R40.4 | ICD10CM | Covered |
| R68.2 | ICD10CM | Covered |
| S02. | ICD10CM | Covered |
| S06. | ICD10CM | Covered |
| S12. | ICD10CM | Covered |
| S12.000 | ICD10CM | Covered |
| S14. | ICD10CM | Covered |
| S14.9 | ICD10CM | Covered |
| S22.000 | ICD10CM | Covered |
| S22.089 | ICD10CM | Covered |
| S24. | ICD10CM | Covered |
| S24.9 | ICD10CM | Covered |
| S32. | ICD10CM | Covered |
| S32.000 | ICD10CM | Covered |
| S34. | ICD10CM | Covered |
| T81.30X | ICD10CM | Covered |
| T81.33X | ICD10CM | Covered |
| T81.89X | ICD10CM | Covered |