Ambetter · PayerPolicy · AMBETTER-CP-MP-134
Summary of the payer’s published policy. Not a coverage determination — confirm with Ambetter 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 |
|---|---|---|
| 0333T | CPT | Covered |
| 92585 | CPT | Covered |
| 92652 | CPT | Covered |
| 92653 | CPT | Covered |
| 95925 | CPT | Covered |
| 95926 | CPT | Covered |
| 95927 | CPT | Covered |
| 95928 | CPT | Covered |
| 95929 | CPT | Covered |
| 95930 | CPT | Covered |
| 95938 | CPT | Covered |
| 95939 | CPT | Covered |
| 95940 | CPT | Covered |
| 95941 | CPT | Covered |
| G0453 | HCPCS | Covered |
| A17.0-A17.89 | ICD10CM | Covered |
| A39.82 | ICD10CM | Covered |
| C30.1 | ICD10CM | Covered |
| C41.0 | ICD10CM | Covered |
| C41.2 | ICD10CM | Covered |
| C70.0-C70.9 | ICD10CM | Covered |
| C71.0-C71.9 | ICD10CM | Covered |
| C72.0-C72.9 | ICD10CM | Covered |
| C79.31-C79.32 | ICD10CM | Covered |
| C79.49 | ICD10CM | Covered |
| D02.3 | ICD10CM | Covered |
| D14.0 | ICD10CM | Covered |
| D16.6 | ICD10CM | Covered |
| D18.02 | ICD10CM | Covered |
| D32.0-D32.9 | ICD10CM | Covered |
| D33.0-D33.9 | ICD10CM | Covered |
| D38.5 | ICD10CM | Covered |
| D42.0-D42.9 | ICD10CM | Covered |
| D43.0-D43.9 | ICD10CM | Covered |
| D44.3 | ICD10CM | Covered |
| D44.4 | ICD10CM | Covered |
| D44.5 | ICD10CM | Covered |
| D49.1 | ICD10CM | Covered |
| D49.6 | ICD10CM | Covered |
| E08.40 | ICD10CM | Covered |
| E08.41 | ICD10CM | Covered |
| E08.42 | ICD10CM | Covered |
| E08.43 | ICD10CM | Covered |
| E08.44 | ICD10CM | Covered |
| E08.49 | ICD10CM | Covered |
| E71.520 | ICD10CM | Covered |
| E71.521 | ICD10CM | Covered |
| E71.522 | ICD10CM | Covered |
| E71.528 | ICD10CM | Covered |
| E71.529 | ICD10CM | Covered |
| G06.0-G06.2 | ICD10CM | Covered |
| G11.10 | ICD10CM | Covered |
| G11.11 | ICD10CM | Covered |
| G11.19 | ICD10CM | Covered |
| G23.0 | ICD10CM | Covered |
| G23.1 | ICD10CM | Covered |
| G23.2 | ICD10CM | Covered |
| G23.8 | ICD10CM | Covered |
| G31.89 | ICD10CM | Covered |
| G31.9 | ICD10CM | Covered |
| G35 | ICD10CM | Covered |
| G36.0-G36.9 | ICD10CM | Covered |
| G37.0-G37.9 | ICD10CM | Covered |
| G50.0-G50.9 | ICD10CM | Covered |
| G52.0-G52.9 | ICD10CM | Covered |
| G54.0 | ICD10CM | Covered |
| G54.1 | ICD10CM | Covered |
| G54.2 | ICD10CM | Covered |
| G54.3 | ICD10CM | Covered |
| G54.4 | ICD10CM | Covered |
| G90.3 | ICD10CM | Covered |
| G90.8 | ICD10CM | Covered |
| G90.9 | ICD10CM | Covered |
| G93.0 | ICD10CM | Covered |
| G93.1 | ICD10CM | Covered |
| G93.5 | ICD10CM | Covered |
| G93.6 | ICD10CM | Covered |
| G93.82 | ICD10CM | Covered |
| G95.9 | ICD10CM | Covered |
| G96.89 | ICD10CM | Covered |
| H35.54 | ICD10CM | Covered |
| H46.0-H46.9 | ICD10CM | Covered |
| H47.011-H47.649 | ICD10CM | Covered |
| H53.001-H53.9 | ICD10CM | Covered |
| H54.3 | ICD10CM | Covered |
| H54.60-H54.62 | ICD10CM | Covered |
| H54.60-H54.7 | ICD10CM | Covered |
| H54.7 | ICD10CM | Covered |
| H81.01-H81.09 | ICD10CM | Covered |
| H81.391-H81.399 | ICD10CM | Covered |
| H81.4 | ICD10CM | Covered |
| H81.41 | ICD10CM | Covered |
| H81.42 | ICD10CM | Covered |
| H81.43 | ICD10CM | Covered |
| H81.49 | ICD10CM | Covered |
| H90.0-H90.72 | ICD10CM | Covered |
| H91.01-H91.93 | ICD10CM | Covered |
| H93.3x1-H93.3x9 | ICD10CM | Covered |
| I60.00-I60.8 | ICD10CM | Covered |
| I61.0-I61.8 | ICD10CM | Covered |
| I62.00-I62.1 | ICD10CM | Covered |
| I63.00-I63.9 | ICD10CM | Covered |
| I65.01-I65.9 | ICD10CM | Covered |
| I66.01-I66.9 | ICD10CM | Covered |
| I67.0-I67.7 | ICD10CM | Covered |
| I71.00-I71.9 | ICD10CM | Covered |
| I72.0 | ICD10CM | Covered |
| I77.71 | ICD10CM | Covered |
| I77.74 | ICD10CM | Covered |
| M40.00-M40.57 | ICD10CM | Covered |
| M41.00-M41.9 | ICD10CM | Covered |
| M43.00-M43.09 | ICD10CM | Covered |
| M43.10-M43.19 | ICD10CM | Covered |
| M47.011-M47.9 | ICD10CM | Covered |
| M48.00-M48.08 | ICD10CM | Covered |
| M50.00-M50.93 | ICD10CM | Covered |
| M51.04-M51.9 | ICD10CM | Covered |
| P10.0-P10.9 | ICD10CM | Covered |
| P11.0-P11.9 | ICD10CM | Covered |
| P14.0-P14.9 | ICD10CM | Covered |
| Q01.0-Q01.9 | ICD10CM | Covered |
| Q04.0-Q04.9 | ICD10CM | Covered |
| Q05.0-Q05.9 | ICD10CM | Covered |
| Q07.00-Q07.03 | ICD10CM | Covered |
| Q28.0-Q28.9 | ICD10CM | Covered |
| Q76.2 | ICD10CM | Covered |
| Q85.00-Q85.09 | ICD10CM | Covered |
| R40.2 | ICD10CM | Covered |
| R40.20-R40.2444 | ICD10CM | Covered |
| R40.3 | ICD10CM | Covered |
| R42 | ICD10CM | Covered |
| R44.1 | ICD10CM | Covered |
| R47.01 | ICD10CM | Covered |
| R48.3 | ICD10CM | Covered |
| R94.110-R94.138 | ICD10CM | Covered |
| S02.0XX-S02.42X | ICD10CM | Covered |
| S04.011-S04.9XX | ICD10CM | Covered |
| S06 | ICD10CM | Covered |
| S06.0X0-S06.899 | ICD10CM | Covered |
| S07.0XX-S07.9XX | ICD10CM | Covered |
| S12.000-S12.9XX | ICD10CM | Covered |
| S14.0XX-S14.9XX | ICD10CM | Covered |
| S22.000-S22.089 | ICD10CM | Covered |
| S24.101-S24.9XX | ICD10CM | Covered |
| S34.01X-S34.9XX | ICD10CM | Covered |
| Z01.110 | ICD10CM | Covered |
| Z08 | ICD10CM | Covered |
| Z87.710-Z87.798 | ICD10CM | Covered |