Ambetter · PayerPolicy · AMBETTER-CP-MP-97
Summary of the payer’s published policy. Not a coverage determination — confirm with Ambetter 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 |
|---|---|---|
| 0330U | CPT | Covered |
| 0352U | CPT | Covered |
| 0353U | CPT | Covered |
| 81513 | CPT | Covered |
| 81514 | CPT | Covered |
| 82120 | CPT | Covered |
| 83986 | CPT | Covered |
| 87210 | CPT | Covered |
| 87480 | CPT | Covered |
| 87481 | CPT | Covered |
| 87510 | CPT | Covered |
| 87511 | CPT | Covered |
| 87660 | CPT | Covered |
| 87798 | CPT | Covered |
| 87905 | CPT | Covered |
| A59.01 | ICD10CM | Covered |
| B37.3 | ICD10CM | Covered |
| B37.31 | ICD10CM | Covered |
| B37.32 | ICD10CM | Covered |
| F11.10-F11.19 | ICD10CM | Covered |
| F11.20-F11.29 | ICD10CM | Covered |
| F14.10-F14.19 | ICD10CM | Covered |
| F14.20-F14.29 | ICD10CM | Covered |
| F15.10-F15.19 | ICD10CM | Covered |
| F15.20-F15.29 | ICD10CM | Covered |
| F18.10-F18.19 | ICD10CM | Covered |
| F18.20-F18.29 | ICD10CM | Covered |
| F19.10-F19.19 | ICD10CM | Covered |
| F19.20-F19.29 | ICD10CM | Covered |
| L29.2 | ICD10CM | Covered |
| L29.3 | ICD10CM | Covered |
| N39.0 | ICD10CM | Covered |
| N72 | ICD10CM | Covered |
| N76.0 | ICD10CM | Covered |
| N76.0-N76.3 | ICD10CM | Covered |
| N76.1 | ICD10CM | Covered |
| N76.2 | ICD10CM | Covered |
| N76.3 | ICD10CM | Covered |
| N76.81 | ICD10CM | Covered |
| N76.89 | ICD10CM | Covered |
| N77.1 | ICD10CM | Covered |
| N89.8 | ICD10CM | Covered |
| N89.9 | ICD10CM | Covered |
| N90.89 | ICD10CM | Covered |
| N90.9 | ICD10CM | Covered |
| N91.0-N91.5 | ICD10CM | Covered |
| N92.0 | ICD10CM | Covered |
| N93.0 | ICD10CM | Covered |
| N93.8 | ICD10CM | Covered |
| N93.9 | ICD10CM | Covered |
| N94.3 | ICD10CM | Covered |
| N94.4-N94.6 | ICD10CM | Covered |
| N94.89 | ICD10CM | Covered |
| N94.9 | ICD10CM | Covered |
| O09.00-O09.03 | ICD10CM | Covered |
| O09.10-O09.13 | ICD10CM | Covered |
| O09.211-O09.219 | ICD10CM | Covered |
| O09.291-O09.299 | ICD10CM | Covered |
| O09.30-O09.33 | ICD10CM | Covered |
| O09.40-O09.43 | ICD10CM | Covered |
| O09.511-O09.519 | ICD10CM | Covered |
| O09.521-O09.529 | ICD10CM | Covered |
| O09.611-O09.619 | ICD10CM | Covered |
| O09.621-O09.629 | ICD10CM | Covered |
| O09.70-O09.73 | ICD10CM | Covered |
| O09.811-O09.819 | ICD10CM | Covered |
| O09.821-O09.829 | ICD10CM | Covered |
| O09.891-O09.899 | ICD10CM | Covered |
| O09.90-O09.93 | ICD10CM | Covered |
| O09.A0-O09.A3 | ICD10CM | Covered |
| O23.0-O23.03 | ICD10CM | Covered |
| O23.00 | ICD10CM | Covered |
| O23.01 | ICD10CM | Covered |
| O23.02 | ICD10CM | Covered |
| O23.03 | ICD10CM | Covered |
| O23.1-O23.13 | ICD10CM | Covered |
| O23.10 | ICD10CM | Covered |
| O23.11 | ICD10CM | Covered |
| O23.12 | ICD10CM | Covered |
| O23.13 | ICD10CM | Covered |
| O23.2-O23.23 | ICD10CM | Covered |
| O23.20 | ICD10CM | Covered |
| O23.21 | ICD10CM | Covered |
| O23.22 | ICD10CM | Covered |
| O23.23 | ICD10CM | Covered |
| O23.3-O23.43 | ICD10CM | Covered |
| O23.30-O23.43 | ICD10CM | Covered |
| O23.511-O23.93 | ICD10CM | Covered |
| Z00.00 | ICD10CM | Covered |
| Z00.8 | ICD10CM | Covered |
| Z01.419 | ICD10CM | Covered |
| Z11.2 | ICD10CM | Covered |
| Z11.3 | ICD10CM | Covered |
| Z11.51 | ICD10CM | Covered |
| Z11.8 | ICD10CM | Covered |
| Z13.89 | ICD10CM | Covered |
| Z13.9 | ICD10CM | Covered |
| Z22.330 | ICD10CM | Covered |
| Z23 | ICD10CM | Covered |
| Z30.011-Z30.019 | ICD10CM | Covered |
| Z30.02 | ICD10CM | Covered |
| Z30.09 | ICD10CM | Covered |
| Z30.40-Z30.9 | ICD10CM | Covered |
| Z32.00 | ICD10CM | Covered |
| Z33.1 | ICD10CM | Covered |
| Z34.00-Z34.03 | ICD10CM | Covered |
| Z34.80-Z34.83 | ICD10CM | Covered |
| Z34.90-Z34.93 | ICD10CM | Covered |
| Z36.0-Z36.5 | ICD10CM | Covered |
| Z36.3 | ICD10CM | Covered |
| Z36.81-Z36.9 | ICD10CM | Covered |
| Z38.00-Z38.01 | ICD10CM | Covered |
| Z38.30-Z38.31 | ICD10CM | Covered |
| Z38.61-Z38.69 | ICD10CM | Covered |
| Z39.0-Z39.2 | ICD10CM | Covered |
| Z3A.00-Z3A.49 | ICD10CM | Covered |
| Z72.51-Z72.53 | ICD10CM | Covered |
| Z86.19 | ICD10CM | Covered |
| Z97.5 | ICD10CM | Covered |