Aetna · PayerPolicy · AETNA-CPB-0784
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 |
|---|---|---|
| 15771 | CPT | Covered |
| 15772 | CPT | Covered |
| 15773 | CPT | Covered |
| 15774 | CPT | Covered |
| 38205 | CPT | Covered |
| 38206 | CPT | Covered |
| 38232 | CPT | Covered |
| 38241 | CPT | Covered |
| 64490 | CPT | Covered |
| 64491 | CPT | Covered |
| 64492 | CPT | Covered |
| 64493 | CPT | Covered |
| 64494 | CPT | Covered |
| 64495 | CPT | Covered |
| G0460 | HCPCS | Covered |
| P9020 | HCPCS | Covered |
| S9055 | HCPCS | Covered |
| E08.621 | ICD10CM | Covered |
| E09.621 | ICD10CM | Covered |
| E10.621 | ICD10CM | Covered |
| E11.621 | ICD10CM | Covered |
| E13.621 | ICD10CM | Covered |
| G80.0 | ICD10CM | Covered |
| G80.9 | ICD10CM | Covered |
| K05.30 | ICD10CM | Covered |
| K05.329 | ICD10CM | Covered |
| K50.00 | ICD10CM | Covered |
| K50.919 | ICD10CM | Covered |
| K60.3 | ICD10CM | Covered |
| K60.4 | ICD10CM | Covered |
| K60.5 | ICD10CM | Covered |
| L50.8 | ICD10CM | Covered |
| L63.0 | ICD10CM | Covered |
| L63.9 | ICD10CM | Covered |
| L80 | ICD10CM | Covered |
| M12.88 | ICD10CM | Covered |
| M12.9 | ICD10CM | Covered |
| M15.0 | ICD10CM | Covered |
| M17.0 | ICD10CM | Covered |
| M17.9 | ICD10CM | Covered |
| M18.0 | ICD10CM | Covered |
| M18.9 | ICD10CM | Covered |
| M19.93 | ICD10CM | Covered |
| M22.40 | ICD10CM | Covered |
| M22.42 | ICD10CM | Covered |
| M26.621 | ICD10CM | Covered |
| M26.629 | ICD10CM | Covered |
| M26.69 | ICD10CM | Covered |
| M34.0 | ICD10CM | Covered |
| M34.9 | ICD10CM | Covered |
| M46.86 | ICD10CM | Covered |
| M46.96 | ICD10CM | Covered |
| M53.86 | ICD10CM | Covered |
| M54.12 | ICD10CM | Covered |
| M54.16 | ICD10CM | Covered |
| M54.50 | ICD10CM | Covered |
| M54.59 | ICD10CM | Covered |
| M62.251 | ICD10CM | Covered |
| M62.279 | ICD10CM | Covered |
| M70.031 | ICD10CM | Covered |
| M76.50 | ICD10CM | Covered |
| M76.52 | ICD10CM | Covered |
| M77.10 | ICD10CM | Covered |
| M77.12 | ICD10CM | Covered |
| M79.9 | ICD10CM | Covered |
| M84.459 | ICD10CM | Covered |
| M84.559 | ICD10CM | Covered |
| M84.659 | ICD10CM | Covered |
| M84.750 | ICD10CM | Covered |
| M84.759 | ICD10CM | Covered |
| M87.011 | ICD10CM | Covered |
| M87.029 | ICD10CM | Covered |
| M87.051 | ICD10CM | Covered |
| M87.059 | ICD10CM | Covered |
| M87.08 | ICD10CM | Covered |
| M87.180 | ICD10CM | Covered |
| M89.70 | ICD10CM | Covered |
| M89.79 | ICD10CM | Covered |
| N35.010 | ICD10CM | Covered |
| N35.92 | ICD10CM | Covered |
| S31.000 | ICD10CM | Covered |
| S31.839 | ICD10CM | Covered |
| S43.421 | ICD10CM | Covered |
| S43.429 | ICD10CM | Covered |
| S46.021A | ICD10CM | Covered |
| S46.029S | ICD10CM | Covered |
| S72.001 | ICD10CM | Covered |
| S72.046 | ICD10CM | Covered |
| S76.301 | ICD10CM | Covered |
| S76.319 | ICD10CM | Covered |
| S83. | ICD10CM | Covered |
| S83.401 | ICD10CM | Covered |
| S83.409 | ICD10CM | Covered |
| S86.111 | ICD10CM | Covered |
| S86.119 | ICD10CM | Covered |
| S86.211 | ICD10CM | Covered |
| S86.219 | ICD10CM | Covered |
| S86.311 | ICD10CM | Covered |
| S86.319 | ICD10CM | Covered |
| S86.811 | ICD10CM | Covered |
| S86.819 | ICD10CM | Covered |
| S93.401 | ICD10CM | Covered |
| S93.499 | ICD10CM | Covered |