Anthem · Clinical Guideline · ANTHEM-CG-LAB-24
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 |
|---|---|---|
| 87086 | CPT | Covered |
| 87088 | CPT | Covered |
| A02.1 | ICD10CM | Covered |
| A02.25 | ICD10CM | Covered |
| A18.11 | ICD10CM | Covered |
| A18.14 | ICD10CM | Covered |
| A40.0 | ICD10CM | Covered |
| A41.9 | ICD10CM | Covered |
| A42.7 | ICD10CM | Covered |
| A56.00 | ICD10CM | Covered |
| A56.2 | ICD10CM | Covered |
| C64.1 | ICD10CM | Covered |
| C68.9 | ICD10CM | Covered |
| D29.1 | ICD10CM | Covered |
| D30.00 | ICD10CM | Covered |
| D30.9 | ICD10CM | Covered |
| D40.0 | ICD10CM | Covered |
| D41.00 | ICD10CM | Covered |
| D41.9 | ICD10CM | Covered |
| D49.4 | ICD10CM | Covered |
| D49.59 | ICD10CM | Covered |
| D70.0 | ICD10CM | Covered |
| D70.9 | ICD10CM | Covered |
| D72.89 | ICD10CM | Covered |
| E08.21 | ICD10CM | Covered |
| E08.29 | ICD10CM | Covered |
| E09.21 | ICD10CM | Covered |
| E09.29 | ICD10CM | Covered |
| E10.10 | ICD10CM | Covered |
| E10.29 | ICD10CM | Covered |
| E11.10 | ICD10CM | Covered |
| E11.29 | ICD10CM | Covered |
| E13.21 | ICD10CM | Covered |
| E13.29 | ICD10CM | Covered |
| E87.20 | ICD10CM | Covered |
| E87.29 | ICD10CM | Covered |
| E87.4 | ICD10CM | Covered |
| F45.8 | ICD10CM | Covered |
| G93.31 | ICD10CM | Covered |
| G93.39 | ICD10CM | Covered |
| I50.1 | ICD10CM | Covered |
| I50.9 | ICD10CM | Covered |
| K72.00 | ICD10CM | Covered |
| K72.01 | ICD10CM | Covered |
| K76.2 | ICD10CM | Covered |
| M04.1 | ICD10CM | Covered |
| M32.14 | ICD10CM | Covered |
| M32.15 | ICD10CM | Covered |
| M35.04 | ICD10CM | Covered |
| M35.0A | ICD10CM | Covered |
| M54.89 | ICD10CM | Covered |
| M54.9 | ICD10CM | Covered |
| N00.0 | ICD10CM | Covered |
| N17.0 | ICD10CM | Covered |
| N25.0 | ICD10CM | Covered |
| N30.00 | ICD10CM | Covered |
| N39.9 | ICD10CM | Covered |
| N40.0 | ICD10CM | Covered |
| N42.9 | ICD10CM | Covered |
| N43.40 | ICD10CM | Covered |
| N43.42 | ICD10CM | Covered |
| N44.00 | ICD10CM | Covered |
| N45.4 | ICD10CM | Covered |
| N49.0 | ICD10CM | Covered |
| N53.11 | ICD10CM | Covered |
| N53.9 | ICD10CM | Covered |
| N70.01 | ICD10CM | Covered |
| N77.1 | ICD10CM | Covered |
| N82.0 | ICD10CM | Covered |
| N82.9 | ICD10CM | Covered |
| N83.511 | ICD10CM | Covered |
| N83.53 | ICD10CM | Covered |
| N99.0 | ICD10CM | Covered |
| N99.538 | ICD10CM | Covered |
| O08.0 | ICD10CM | Covered |
| O08.9 | ICD10CM | Covered |
| O09.00 | ICD10CM | Covered |
| O09.93 | ICD10CM | Covered |
| O10.011 | ICD10CM | Covered |
| O16.9 | ICD10CM | Covered |
| O23.00 | ICD10CM | Covered |
| O24.93 | ICD10CM | Covered |
| O26.831 | ICD10CM | Covered |
| O26.839 | ICD10CM | Covered |
| O28.0 | ICD10CM | Covered |
| O28.9 | ICD10CM | Covered |
| O30.001 | ICD10CM | Covered |
| O30.93 | ICD10CM | Covered |
| O33.7XX0 | ICD10CM | Covered |
| O33.7XX9 | ICD10CM | Covered |
| O34.80 | ICD10CM | Covered |
| O34.93 | ICD10CM | Covered |
| O36.8310 | ICD10CM | Covered |
| O36.8399 | ICD10CM | Covered |
| O44.20 | ICD10CM | Covered |
| O44.53 | ICD10CM | Covered |
| O86.11 | ICD10CM | Covered |
| O86.89 | ICD10CM | Covered |
| P36.0 | ICD10CM | Covered |
| P36.9 | ICD10CM | Covered |
| P39.3 | ICD10CM | Covered |
| R00.0 | ICD10CM | Covered |
| R10.0 | ICD10CM | Covered |
| R10.A3 | ICD10CM | Covered |
| R30.0 | ICD10CM | Covered |
| R36.9 | ICD10CM | Covered |
| R39.0 | ICD10CM | Covered |
| R39.9 | ICD10CM | Covered |
| R40.2410 | ICD10CM | Covered |
| R40.2444 | ICD10CM | Covered |
| R40.4 | ICD10CM | Covered |
| R41.0 | ICD10CM | Covered |
| R41.9 | ICD10CM | Covered |
| R45.84 | ICD10CM | Covered |
| R45.88 | ICD10CM | Covered |
| R50.2 | ICD10CM | Covered |
| R50.9 | ICD10CM | Covered |
| R53.83 | ICD10CM | Covered |
| R57.0 | ICD10CM | Covered |
| R57.9 | ICD10CM | Covered |
| R65.21 | ICD10CM | Covered |
| R68.0 | ICD10CM | Covered |
| R68.89 | ICD10CM | Covered |
| R73.03 | ICD10CM | Covered |
| R78.81 | ICD10CM | Covered |
| R80.0 | ICD10CM | Covered |
| R82.998 | ICD10CM | Covered |
| T19.0XXA | ICD10CM | Covered |
| T19.1XXS | ICD10CM | Covered |
| T19.4XXA | ICD10CM | Covered |
| T19.4XXS | ICD10CM | Covered |
| T83.010A | ICD10CM | Covered |
| T83.098S | ICD10CM | Covered |
| T83.113A | ICD10CM | Covered |
| T83.113S | ICD10CM | Covered |
| T83.123A | ICD10CM | Covered |
| T83.123S | ICD10CM | Covered |
| T83.193A | ICD10CM | Covered |
| T83.193S | ICD10CM | Covered |
| T83.24XA | ICD10CM | Covered |
| T83.25XS | ICD10CM | Covered |
| T83.510A | ICD10CM | Covered |
| T83.598S | ICD10CM | Covered |
| T83.61XA | ICD10CM | Covered |
| T83.79XS | ICD10CM | Covered |
| Z05.0 | ICD10CM | Covered |
| Z05.9 | ICD10CM | Covered |
| Z19.1 | ICD10CM | Covered |
| Z19.2 | ICD10CM | Covered |
| Z31.7 | ICD10CM | Covered |
| Z34.00 | ICD10CM | Covered |
| Z34.93 | ICD10CM | Covered |
| Z36.89 | ICD10CM | Covered |
| Z43.5 | ICD10CM | Covered |
| Z43.6 | ICD10CM | Covered |
| Z79.01 | ICD10CM | Covered |
| Z79.899 | ICD10CM | Covered |
| Z84.82 | ICD10CM | Covered |
| Z93.50 | ICD10CM | Covered |
| Z93.59 | ICD10CM | Covered |
| Z93.6 | ICD10CM | Covered |