Anthem · Clinical Guideline · ANTHEM-CG-LAB-21
Summary of the payer’s published policy. Not a coverage determination — confirm with Anthem 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 |
|---|---|---|
| 82728 | CPT | Covered |
| 83540 | CPT | Covered |
| 83550 | CPT | Covered |
| 84466 | CPT | Covered |
| A01.00 | ICD10CM | Covered |
| A02.9 | ICD10CM | Covered |
| A04.0 | ICD10CM | Covered |
| A04.9 | ICD10CM | Covered |
| A06.0 | ICD10CM | Covered |
| A15.0 | ICD10CM | Covered |
| A18.01 | ICD10CM | Covered |
| A18.89 | ICD10CM | Covered |
| B15.0 | ICD10CM | Covered |
| B19.9 | ICD10CM | Covered |
| B25.1 | ICD10CM | Covered |
| B52.0 | ICD10CM | Covered |
| C00.0 | ICD10CM | Covered |
| C96.9 | ICD10CM | Covered |
| D00.00 | ICD10CM | Covered |
| D09.9 | ICD10CM | Covered |
| D10.0 | ICD10CM | Covered |
| D36.9 | ICD10CM | Covered |
| D37.01 | ICD10CM | Covered |
| D48.9 | ICD10CM | Covered |
| D49.0 | ICD10CM | Covered |
| D49.9 | ICD10CM | Covered |
| D50.0 | ICD10CM | Covered |
| D53.9 | ICD10CM | Covered |
| D56.0 | ICD10CM | Covered |
| D57.819 | ICD10CM | Covered |
| D64.9 | ICD10CM | Covered |
| D69.9 | ICD10CM | Covered |
| D75.838 | ICD10CM | Covered |
| D75.839 | ICD10CM | Covered |
| E08.00 | ICD10CM | Covered |
| E13.9 | ICD10CM | Covered |
| E23.0 | ICD10CM | Covered |
| E23.1 | ICD10CM | Covered |
| E23.6 | ICD10CM | Covered |
| E24.1 | ICD10CM | Covered |
| E28.310 | ICD10CM | Covered |
| E28.39 | ICD10CM | Covered |
| E29.1 | ICD10CM | Covered |
| E61.1 | ICD10CM | Covered |
| E64.0 | ICD10CM | Covered |
| E75.26 | ICD10CM | Covered |
| E79.0 | ICD10CM | Covered |
| E80.0 | ICD10CM | Covered |
| E80.29 | ICD10CM | Covered |
| E83.10 | ICD10CM | Covered |
| E83.19 | ICD10CM | Covered |
| E88.02 | ICD10CM | Covered |
| E89.3 | ICD10CM | Covered |
| F45.8 | ICD10CM | Covered |
| F50.00 | ICD10CM | Covered |
| F50.9 | ICD10CM | Covered |
| F98.21 | ICD10CM | Covered |
| F98.29 | ICD10CM | Covered |
| F98.3 | ICD10CM | Covered |
| I12.0 | ICD10CM | Covered |
| I13.11 | ICD10CM | Covered |
| I13.2 | ICD10CM | Covered |
| I27.83 | ICD10CM | Covered |
| I42.0 | ICD10CM | Covered |
| I44.0 | ICD10CM | Covered |
| I49.9 | ICD10CM | Covered |
| I50.1 | ICD10CM | Covered |
| I50.9 | ICD10CM | Covered |
| K22.6 | ICD10CM | Covered |
| K22.81 | ICD10CM | Covered |
| K22.89 | ICD10CM | Covered |
| K25.0 | ICD10CM | Covered |
| K28.9 | ICD10CM | Covered |
| K29.00 | ICD10CM | Covered |
| K31.9 | ICD10CM | Covered |
| K50.00 | ICD10CM | Covered |
| K52.839 | ICD10CM | Covered |
| K55.011 | ICD10CM | Covered |
| K55.33 | ICD10CM | Covered |
| K56.699 | ICD10CM | Covered |
| K57.00 | ICD10CM | Covered |
| K57.93 | ICD10CM | Covered |
| K62.5 | ICD10CM | Covered |
| K63.5 | ICD10CM | Covered |
| K63.81 | ICD10CM | Covered |
| K70.0 | ICD10CM | Covered |
| K90.0 | ICD10CM | Covered |
| K90.9 | ICD10CM | Covered |
| K91.2 | ICD10CM | Covered |
| K92.0 | ICD10CM | Covered |
| K92.2 | ICD10CM | Covered |
| K94.20 | ICD10CM | Covered |
| K94.29 | ICD10CM | Covered |
| L28.0 | ICD10CM | Covered |
| L28.2 | ICD10CM | Covered |
| L29.0 | ICD10CM | Covered |
| L29.9 | ICD10CM | Covered |
| L57.3 | ICD10CM | Covered |
| L63.0 | ICD10CM | Covered |
| L66.9 | ICD10CM | Covered |
| L81.0 | ICD10CM | Covered |
| L81.9 | ICD10CM | Covered |
| L98.1 | ICD10CM | Covered |
| M07.60 | ICD10CM | Covered |
| M07.69 | ICD10CM | Covered |
| M12.80 | ICD10CM | Covered |
| M12.9 | ICD10CM | Covered |
| M13.0 | ICD10CM | Covered |
| M13.179 | ICD10CM | Covered |
| M14.80 | ICD10CM | Covered |
| M25.50 | ICD10CM | Covered |
| M25.59 | ICD10CM | Covered |
| M79.641 | ICD10CM | Covered |
| M79.646 | ICD10CM | Covered |
| M84.750A | ICD10CM | Covered |
| M84.759S | ICD10CM | Covered |
| M97.01XA | ICD10CM | Covered |
| M97.9XXS | ICD10CM | Covered |
| N02.0 | ICD10CM | Covered |
| N02.B9 | ICD10CM | Covered |
| N04.0 | ICD10CM | Covered |
| N04.B2 | ICD10CM | Covered |
| N18.1 | ICD10CM | Covered |
| N18.9 | ICD10CM | Covered |
| N50.0 | ICD10CM | Covered |
| N89.7 | ICD10CM | Covered |
| N91.0 | ICD10CM | Covered |
| N93.9 | ICD10CM | Covered |
| N95.0 | ICD10CM | Covered |
| N99.116 | ICD10CM | Covered |
| O09.A0 | ICD10CM | Covered |
| O09.A3 | ICD10CM | Covered |
| O11.4 | ICD10CM | Covered |
| O11.5 | ICD10CM | Covered |
| O90.81 | ICD10CM | Covered |
| O99.011 | ICD10CM | Covered |
| O99.03 | ICD10CM | Covered |
| O99.891 | ICD10CM | Covered |
| O99.893 | ICD10CM | Covered |
| P50.0 | ICD10CM | Covered |
| P57.9 | ICD10CM | Covered |
| Q85.00 | ICD10CM | Covered |
| Q85.09 | ICD10CM | Covered |
| R00.1 | ICD10CM | Covered |
| R11.10 | ICD10CM | Covered |
| R11.2 | ICD10CM | Covered |
| R63.8 | ICD10CM | Covered |
| R71.0 | ICD10CM | Covered |
| R71.8 | ICD10CM | Covered |
| R74.01 | ICD10CM | Covered |
| R74.9 | ICD10CM | Covered |
| R78.71 | ICD10CM | Covered |
| R78.79 | ICD10CM | Covered |
| R78.89 | ICD10CM | Covered |
| R79.0 | ICD10CM | Covered |
| R79.9 | ICD10CM | Covered |
| T40.411A | ICD10CM | Covered |
| T40.415S | ICD10CM | Covered |
| T40.421A | ICD10CM | Covered |
| T40.425S | ICD10CM | Covered |
| T40.491A | ICD10CM | Covered |
| T40.495S | ICD10CM | Covered |
| T43.641A | ICD10CM | Covered |
| T43.644S | ICD10CM | Covered |
| T45.4X1A | ICD10CM | Covered |
| T45.4X4S | ICD10CM | Covered |
| T50.911A | ICD10CM | Covered |
| T50.915S | ICD10CM | Covered |
| T56.0X1A | ICD10CM | Covered |
| T56.0X4S | ICD10CM | Covered |
| T80.89XA | ICD10CM | Covered |
| T80.910A | ICD10CM | Covered |
| T80.919S | ICD10CM | Covered |
| T80.92XA | ICD10CM | Covered |
| T86.00 | ICD10CM | Covered |
| T86.09 | ICD10CM | Covered |
| Z31.7 | ICD10CM | Covered |
| Z49.31 | ICD10CM | Covered |
| Z49.32 | ICD10CM | Covered |
| Z83.430 | ICD10CM | Covered |
| Z83.438 | ICD10CM | Covered |
| Z84.82 | ICD10CM | Covered |
| Z86.2 | ICD10CM | Covered |
| Z86.39 | ICD10CM | Covered |
| Z95.0 | ICD10CM | Covered |
| Z95.812 | ICD10CM | Covered |
| Z95.818 | ICD10CM | Covered |
| Z95.9 | ICD10CM | Covered |
| Z96.60 | ICD10CM | Covered |
| Z98.870 | ICD10CM | Covered |
| Z98.871 | ICD10CM | Covered |
| Z98.890 | ICD10CM | Covered |
| Z98.891 | ICD10CM | Covered |