Aetna · PayerPolicy · AETNA-CPB-0650
Summary of the payer’s published policy. Not a coverage determination — confirm with Aetna before submitting.
Free account. Policy pages stay open to everyone.
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 |
|---|---|---|
| 81291 | CPT | Covered |
| 81513 | CPT | Covered |
| 81514 | CPT | Covered |
| 87040 | CPT | Covered |
| 87472 | CPT | Covered |
| 87477 | CPT | Covered |
| 87481 | CPT | Covered |
| 87482 | CPT | Covered |
| 87483 | CPT | Covered |
| 87487 | CPT | Covered |
| 87497 | CPT | Covered |
| 87505 | CPT | Covered |
| 87506 | CPT | Covered |
| 87507 | CPT | Covered |
| 87511 | CPT | Covered |
| 87512 | CPT | Covered |
| 87517 | CPT | Covered |
| 87522 | CPT | Covered |
| 87527 | CPT | Covered |
| 87530 | CPT | Covered |
| 87533 | CPT | Covered |
| 87536 | CPT | Covered |
| 87539 | CPT | Covered |
| 87542 | CPT | Covered |
| 87562 | CPT | Covered |
| 87582 | CPT | Covered |
| 87592 | CPT | Covered |
| 87593 | CPT | Covered |
| 87631 | CPT | Covered |
| 87632 | CPT | Covered |
| 87633 | CPT | Covered |
| 87652 | CPT | Covered |
| 87799 | CPT | Covered |
| 87913 | CPT | Covered |
| C9803 | HCPCS | Covered |
| G2023 | HCPCS | Covered |
| G2024 | HCPCS | Covered |
| G2025 | HCPCS | Covered |
| A02.0 | ICD10CM | Covered |
| A02.9 | ICD10CM | Covered |
| A04.5 | ICD10CM | Covered |
| A04.6 | ICD10CM | Covered |
| A04.71 | ICD10CM | Covered |
| A04.72 | ICD10CM | Covered |
| A04.8 | ICD10CM | Covered |
| A05.3 | ICD10CM | Covered |
| A07.1 | ICD10CM | Covered |
| A07.2 | ICD10CM | Covered |
| A07.4 | ICD10CM | Covered |
| A08.32 | ICD10CM | Covered |
| A27.0 | ICD10CM | Covered |
| A27.9 | ICD10CM | Covered |
| A31.0 | ICD10CM | Covered |
| A31.9 | ICD10CM | Covered |
| A32.0 | ICD10CM | Covered |
| A32.9 | ICD10CM | Covered |
| A40.0 | ICD10CM | Covered |
| A40.3 | ICD10CM | Covered |
| A41.51 | ICD10CM | Covered |
| A41.52 | ICD10CM | Covered |
| A41.53 | ICD10CM | Covered |
| A41.81 | ICD10CM | Covered |
| A41.9 | ICD10CM | Covered |
| A44.0 | ICD10CM | Covered |
| A44.9 | ICD10CM | Covered |
| A48.1 | ICD10CM | Covered |
| A48.8 | ICD10CM | Covered |
| A49.01 | ICD10CM | Covered |
| A49.1 | ICD10CM | Covered |
| A49.3 | ICD10CM | Covered |
| A54.00 | ICD10CM | Covered |
| A54.9 | ICD10CM | Covered |
| A58 | ICD10CM | Covered |
| A69.20 | ICD10CM | Covered |
| A69.29 | ICD10CM | Covered |
| A74.89 | ICD10CM | Covered |
| A74.9 | ICD10CM | Covered |
| A81.00 | ICD10CM | Covered |
| A81.09 | ICD10CM | Covered |
| A98.5 | ICD10CM | Covered |
| B00.0 | ICD10CM | Covered |
| B00.9 | ICD10CM | Covered |
| B01.0 | ICD10CM | Covered |
| B01.9 | ICD10CM | Covered |
| B02.0 | ICD10CM | Covered |
| B02.9 | ICD10CM | Covered |
| B05.0 | ICD10CM | Covered |
| B05.9 | ICD10CM | Covered |
| B06.00 | ICD10CM | Covered |
| B06.9 | ICD10CM | Covered |
| B08.1 | ICD10CM | Covered |
| B08.20 | ICD10CM | Covered |
| B08.21 | ICD10CM | Covered |
| B08.22 | ICD10CM | Covered |
| B09 | ICD10CM | Covered |
| B10.01 | ICD10CM | Covered |
| B10.09 | ICD10CM | Covered |
| B10.81 | ICD10CM | Covered |
| B10.82 | ICD10CM | Covered |
| B10.89 | ICD10CM | Covered |
| B16.0 | ICD10CM | Covered |
| B16.9 | ICD10CM | Covered |
| B17.10 | ICD10CM | Covered |
| B17.11 | ICD10CM | Covered |
| B17.8 | ICD10CM | Covered |
| B18.0 | ICD10CM | Covered |
| B18.1 | ICD10CM | Covered |
| B18.2 | ICD10CM | Covered |
| B18.8 | ICD10CM | Covered |
| B18.9 | ICD10CM | Covered |
| B19 | ICD10CM | Covered |
| B19.10 | ICD10CM | Covered |
| B19.11 | ICD10CM | Covered |
| B19.20 | ICD10CM | Covered |
| B19.21 | ICD10CM | Covered |
| B20 | ICD10CM | Covered |
| B25.0 | ICD10CM | Covered |
| B25.9 | ICD10CM | Covered |
| B26.0 | ICD10CM | Covered |
| B26.9 | ICD10CM | Covered |
| B27 | ICD10CM | Covered |
| B29.9 | ICD10CM | Covered |
| B33.4 | ICD10CM | Covered |
| B34.0 | ICD10CM | Covered |
| B34.1 | ICD10CM | Covered |
| B34.3 | ICD10CM | Covered |
| B35.1 | ICD10CM | Covered |
| B35.3 | ICD10CM | Covered |
| B36.2 | ICD10CM | Covered |
| B37.0 | ICD10CM | Covered |
| B37.31 | ICD10CM | Covered |
| B37.32 | ICD10CM | Covered |
| B37.9 | ICD10CM | Covered |
| B38.0 | ICD10CM | Covered |
| B38.9 | ICD10CM | Covered |
| B39.0 | ICD10CM | Covered |
| B39.5 | ICD10CM | Covered |
| B40.0 | ICD10CM | Covered |
| B40.9 | ICD10CM | Covered |
| B42.0 | ICD10CM | Covered |
| B42.9 | ICD10CM | Covered |
| B44.0 | ICD10CM | Covered |
| B44.7 | ICD10CM | Covered |
| B44.89 | ICD10CM | Covered |
| B44.9 | ICD10CM | Covered |
| B45.0 | ICD10CM | Covered |
| B45.9 | ICD10CM | Covered |
| B47.1 | ICD10CM | Covered |
| B47.9 | ICD10CM | Covered |
| B48.8 | ICD10CM | Covered |
| B50.0 | ICD10CM | Covered |
| B54 | ICD10CM | Covered |
| B55.0 | ICD10CM | Covered |
| B55.9 | ICD10CM | Covered |
| B58.00 | ICD10CM | Covered |
| B58.9 | ICD10CM | Covered |
| B59 | ICD10CM | Covered |
| B60.0 | ICD10CM | Covered |
| B60.19 | ICD10CM | Covered |
| B95.0 | ICD10CM | Covered |
| B95.1 | ICD10CM | Covered |
| B95.2 | ICD10CM | Covered |
| B95.3 | ICD10CM | Covered |
| B95.5 | ICD10CM | Covered |
| B95.61 | ICD10CM | Covered |
| B95.62 | ICD10CM | Covered |
| B95.7 | ICD10CM | Covered |
| B95.8 | ICD10CM | Covered |
| B96.0 | ICD10CM | Covered |
| B96.20 | ICD10CM | Covered |
| B96.29 | ICD10CM | Covered |
| B96.3 | ICD10CM | Covered |
| B96.4 | ICD10CM | Covered |
| B96.5 | ICD10CM | Covered |
| B96.6 | ICD10CM | Covered |
| B96.81 | ICD10CM | Covered |
| B96.89 | ICD10CM | Covered |
| B97.0 | ICD10CM | Covered |
| B97.11 | ICD10CM | Covered |
| B97.12 | ICD10CM | Covered |
| B97.21 | ICD10CM | Covered |
| B97.29 | ICD10CM | Covered |
| B97.30 | ICD10CM | Covered |
| B97.35 | ICD10CM | Covered |
| B97.39 | ICD10CM | Covered |
| B97.6 | ICD10CM | Covered |
| B97.7 | ICD10CM | Covered |
| C00.0 | ICD10CM | Covered |
| C46.0 | ICD10CM | Covered |
| C46.9 | ICD10CM | Covered |
| C61 | ICD10CM | Covered |
| C94.80 | ICD10CM | Covered |
| C94.82 | ICD10CM | Covered |
| C96.9 | ICD10CM | Covered |
| D06.0 | ICD10CM | Covered |
| D06.9 | ICD10CM | Covered |
| D45 | ICD10CM | Covered |
| D47. | ICD10CM | Covered |
| D70.0 | ICD10CM | Covered |
| D77 | ICD10CM | Covered |
| D80.0 | ICD10CM | Covered |
| D89.40 | ICD10CM | Covered |
| D89.49 | ICD10CM | Covered |
| D89.810 | ICD10CM | Covered |
| D89.813 | ICD10CM | Covered |
| D89.82 | ICD10CM | Covered |
| D89.9 | ICD10CM | Covered |
| E08.00 | ICD10CM | Covered |
| E13.9 | ICD10CM | Covered |
| E40 | ICD10CM | Covered |
| E46 | ICD10CM | Covered |
| G00.0 | ICD10CM | Covered |
| G03.9 | ICD10CM | Covered |
| G04.00 | ICD10CM | Covered |
| G05.4 | ICD10CM | Covered |
| G20210A | ICD10CM | Covered |
| G30.0 | ICD10CM | Covered |
| G30.9 | ICD10CM | Covered |
| G35 | ICD10CM | Covered |
| G60.0 | ICD10CM | Covered |
| G60.9 | ICD10CM | Covered |
| G93.89 | ICD10CM | Covered |
| H00.93 | ICD10CM | Covered |
| H16.001 | ICD10CM | Covered |
| H16.079 | ICD10CM | Covered |
| H60.00 | ICD10CM | Covered |
| J02.0 | ICD10CM | Covered |
| J02.8 | ICD10CM | Covered |
| J02.9 | ICD10CM | Covered |
| J09. | ICD10CM | Covered |
| J10.00 | ICD10CM | Covered |
| J10.89 | ICD10CM | Covered |
| J11.00 | ICD10CM | Covered |
| J11.89 | ICD10CM | Covered |
| J12. | ICD10CM | Covered |
| J13 | ICD10CM | Covered |
| J15.0 | ICD10CM | Covered |
| J15.1 | ICD10CM | Covered |
| J15.212 | ICD10CM | Covered |
| J15.4 | ICD10CM | Covered |
| J15.7 | ICD10CM | Covered |
| J16.0 | ICD10CM | Covered |
| J18. | ICD10CM | Covered |
| J20.0 | ICD10CM | Covered |
| J20.1 | ICD10CM | Covered |
| J20.3 | ICD10CM | Covered |
| J20.7 | ICD10CM | Covered |
| J21.0 | ICD10CM | Covered |
| J31.2 | ICD10CM | Covered |
| J43.0 | ICD10CM | Covered |
| J43.9 | ICD10CM | Covered |
| J44.0 | ICD10CM | Covered |
| J44.9 | ICD10CM | Covered |
| J45.20 | ICD10CM | Covered |
| J45.998 | ICD10CM | Covered |
| J60 | ICD10CM | Covered |
| J70.9 | ICD10CM | Covered |
| J80 | ICD10CM | Covered |
| J81.0 | ICD10CM | Covered |
| J81.1 | ICD10CM | Covered |
| J82 | ICD10CM | Covered |
| J84.01 | ICD10CM | Covered |
| J84.9 | ICD10CM | Covered |
| J85.0 | ICD10CM | Covered |
| J86.9 | ICD10CM | Covered |
| J90 | ICD10CM | Covered |
| J94.9 | ICD10CM | Covered |
| J95.0 | ICD10CM | Covered |
| J95.89 | ICD10CM | Covered |
| J96 | ICD10CM | Covered |
| J96. | ICD10CM | Covered |
| J96.92 | ICD10CM | Covered |
| J98.01 | ICD10CM | Covered |
| J98.11 | ICD10CM | Covered |
| J98.19 | ICD10CM | Covered |
| J98.2 | ICD10CM | Covered |
| J98.3 | ICD10CM | Covered |
| K20.0 | ICD10CM | Covered |
| K25.0 | ICD10CM | Covered |
| K28.9 | ICD10CM | Covered |
| K51.20 | ICD10CM | Covered |
| K51.219 | ICD10CM | Covered |
| K62.6 | ICD10CM | Covered |
| K90.81 | ICD10CM | Covered |
| K91.2 | ICD10CM | Covered |
| L08.0 | ICD10CM | Covered |
| L29.2 | ICD10CM | Covered |
| L29.3 | ICD10CM | Covered |
| L37713 | ICD10CM | Covered |
| L60.2 | ICD10CM | Covered |
| L70.8 | ICD10CM | Covered |
| L98. | ICD10CM | Covered |
| L98.411 | ICD10CM | Covered |
| L98.499 | ICD10CM | Covered |
| L98.8 | ICD10CM | Covered |
| L98.9 | ICD10CM | Covered |
| M00.10 | ICD10CM | Covered |
| M00.19 | ICD10CM | Covered |
| M02.30 | ICD10CM | Covered |
| M02.39 | ICD10CM | Covered |
| M25.40 | ICD10CM | Covered |
| M25.48 | ICD10CM | Covered |
| M30.3 | ICD10CM | Covered |
| M32.0 | ICD10CM | Covered |
| M32.9 | ICD10CM | Covered |
| M34.0 | ICD10CM | Covered |
| M34.9 | ICD10CM | Covered |
| M35.00 | ICD10CM | Covered |
| M35.9 | ICD10CM | Covered |
| M43.6 | ICD10CM | Covered |
| N18.5 | ICD10CM | Covered |
| N18.6 | ICD10CM | Covered |
| N34.1 | ICD10CM | Covered |
| N34.2 | ICD10CM | Covered |
| N39.0 | ICD10CM | Covered |
| N39.9 | ICD10CM | Covered |
| N41.0 | ICD10CM | Covered |
| N41.9 | ICD10CM | Covered |
| N72 | ICD10CM | Covered |
| N76.0 | ICD10CM | Covered |
| N76.1 | ICD10CM | Covered |
| N76.2 | ICD10CM | Covered |
| N76.3 | ICD10CM | Covered |
| N76.5 | ICD10CM | Covered |
| N76.6 | ICD10CM | Covered |
| N77.1 | ICD10CM | Covered |
| N87.0 | ICD10CM | Covered |
| N87.9 | ICD10CM | Covered |
| N89.8 | ICD10CM | Covered |
| P28.40 | ICD10CM | Covered |
| P28.41 | ICD10CM | Covered |
| P28.42 | ICD10CM | Covered |
| P28.43 | ICD10CM | Covered |
| P28.49 | ICD10CM | Covered |
| P35.0 | ICD10CM | Covered |
| P35.1 | ICD10CM | Covered |
| P35.4 | ICD10CM | Covered |
| P450 | ICD10CM | Covered |
| Q02 | ICD10CM | Covered |
| Q84.5 | ICD10CM | Covered |
| R00.0 | ICD10CM | Covered |
| R05. | ICD10CM | Covered |
| R05.1 | ICD10CM | Covered |
| R05.9 | ICD10CM | Covered |
| R06.02 | ICD10CM | Covered |
| R11.10 | ICD10CM | Covered |
| R11.2 | ICD10CM | Covered |
| R13.10 | ICD10CM | Covered |
| R13.19 | ICD10CM | Covered |
| R19.7 | ICD10CM | Covered |
| R21 | ICD10CM | Covered |
| R23.1 | ICD10CM | Covered |
| R30.0 | ICD10CM | Covered |
| R34 | ICD10CM | Covered |
| R40.20 | ICD10CM | Covered |
| R40.244 | ICD10CM | Covered |
| R41.0 | ICD10CM | Covered |
| R41.82 | ICD10CM | Covered |
| R44.0 | ICD10CM | Covered |
| R44.3 | ICD10CM | Covered |
| R45.1 | ICD10CM | Covered |
| R50.9 | ICD10CM | Covered |
| R51 | ICD10CM | Covered |
| R53.0 | ICD10CM | Covered |
| R53.1 | ICD10CM | Covered |
| R53.82 | ICD10CM | Covered |
| R53.83 | ICD10CM | Covered |
| R55 | ICD10CM | Covered |
| R56.9 | ICD10CM | Covered |
| R61 | ICD10CM | Covered |
| R68.0 | ICD10CM | Covered |
| R75 | ICD10CM | Covered |
| R87.610 | ICD10CM | Covered |
| R87.613 | ICD10CM | Covered |
| R87.619 | ICD10CM | Covered |
| R87.810 | ICD10CM | Covered |
| S10. | ICD10CM | Covered |
| S20. | ICD10CM | Covered |
| S20.161A | ICD10CM | Covered |
| S20.169S | ICD10CM | Covered |
| S20.361A | ICD10CM | Covered |
| S20.369S | ICD10CM | Covered |
| S20.461A | ICD10CM | Covered |
| S20.469S | ICD10CM | Covered |
| S30.860A | ICD10CM | Covered |
| S30.867S | ICD10CM | Covered |
| S40.261A | ICD10CM | Covered |
| S40.269S | ICD10CM | Covered |
| S40.861A | ICD10CM | Covered |
| S40.869S | ICD10CM | Covered |
| S50.361A | ICD10CM | Covered |
| S50.369S | ICD10CM | Covered |
| S50.861A | ICD10CM | Covered |
| S50.869S | ICD10CM | Covered |
| S60.361A | ICD10CM | Covered |
| S60.369S | ICD10CM | Covered |
| S60.460A | ICD10CM | Covered |
| S60.469S | ICD10CM | Covered |
| S60.561A | ICD10CM | Covered |
| S60.569S | ICD10CM | Covered |
| S60.861A | ICD10CM | Covered |
| S60.869S | ICD10CM | Covered |
| S70.261A | ICD10CM | Covered |
| S70.269S | ICD10CM | Covered |
| S70.361A | ICD10CM | Covered |
| S70.369S | ICD10CM | Covered |
| S80.261A | ICD10CM | Covered |
| S80.269S | ICD10CM | Covered |
| S80.861A | ICD10CM | Covered |
| S80.869S | ICD10CM | Covered |
| S90.461A | ICD10CM | Covered |
| S90.466S | ICD10CM | Covered |
| S90.561A | ICD10CM | Covered |
| S90.569S | ICD10CM | Covered |
| S90.861A | ICD10CM | Covered |
| S90.869S | ICD10CM | Covered |
| T86.00 | ICD10CM | Covered |
| T86.10 | ICD10CM | Covered |
| T86.19 | ICD10CM | Covered |
| T86.99 | ICD10CM | Covered |
| W57. | ICD10CM | Covered |
| Z00.00 | ICD10CM | Covered |
| Z00.01 | ICD10CM | Covered |
| Z01. | ICD10CM | Covered |
| Z01.411 | ICD10CM | Covered |
| Z01.419 | ICD10CM | Covered |
| Z01.42 | ICD10CM | Covered |
| Z11. | ICD10CM | Covered |
| Z11.1 | ICD10CM | Covered |
| Z11.2 | ICD10CM | Covered |
| Z11.3 | ICD10CM | Covered |
| Z11.4 | ICD10CM | Covered |
| Z11.51 | ICD10CM | Covered |
| Z11.59 | ICD10CM | Covered |
| Z11.6 | ICD10CM | Covered |
| Z11.8 | ICD10CM | Covered |
| Z13.6 | ICD10CM | Covered |
| Z13.89 | ICD10CM | Covered |
| Z16.11 | ICD10CM | Covered |
| Z16.21 | ICD10CM | Covered |
| Z16.22 | ICD10CM | Covered |
| Z20.2 | ICD10CM | Covered |
| Z20.4 | ICD10CM | Covered |
| Z20.5 | ICD10CM | Covered |
| Z20.6 | ICD10CM | Covered |
| Z20.820 | ICD10CM | Covered |
| Z20.821 | ICD10CM | Covered |
| Z20.828 | ICD10CM | Covered |
| Z20.89 | ICD10CM | Covered |
| Z21 | ICD10CM | Covered |
| Z22.4 | ICD10CM | Covered |
| Z22.51 | ICD10CM | Covered |
| Z22.52 | ICD10CM | Covered |
| Z30. | ICD10CM | Covered |
| Z30.40 | ICD10CM | Covered |
| Z30.9 | ICD10CM | Covered |
| Z34. | ICD10CM | Covered |
| Z34.00 | ICD10CM | Covered |
| Z34.93 | ICD10CM | Covered |
| Z36.85 | ICD10CM | Covered |
| Z48.21 | ICD10CM | Covered |
| Z48.298 | ICD10CM | Covered |
| Z49.01 | ICD10CM | Covered |
| Z49.32 | ICD10CM | Covered |
| Z51.11 | ICD10CM | Covered |
| Z51.12 | ICD10CM | Covered |
| Z72.51 | ICD10CM | Covered |
| Z72.52 | ICD10CM | Covered |
| Z72.53 | ICD10CM | Covered |
| Z77.128 | ICD10CM | Covered |
| Z77.21 | ICD10CM | Covered |
| Z79.52 | ICD10CM | Covered |
| Z85.41 | ICD10CM | Covered |
| Z87.11 | ICD10CM | Covered |
| Z94.0 | ICD10CM | Covered |
| Z94.84 | ICD10CM | Covered |
| Z99.2 | ICD10CM | Covered |