Anthem · Clinical Guideline · ANTHEM-CG-MED-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 |
|---|---|---|
| 00100 | CPT | Covered |
| 00102 | CPT | Covered |
| 00103 | CPT | Covered |
| 00104 | CPT | Covered |
| 00120 | CPT | Covered |
| 00124 | CPT | Covered |
| 00126 | CPT | Covered |
| 00140 | CPT | Covered |
| 00142 | CPT | Covered |
| 00144 | CPT | Covered |
| 00145 | CPT | Covered |
| 00147 | CPT | Covered |
| 00148 | CPT | Covered |
| 00160 | CPT | Covered |
| 00162 | CPT | Covered |
| 00164 | CPT | Covered |
| 00170 | CPT | Covered |
| 00172 | CPT | Covered |
| 00174 | CPT | Covered |
| 00176 | CPT | Covered |
| 00190 | CPT | Covered |
| 00192 | CPT | Covered |
| 00210 | CPT | Covered |
| 00211 | CPT | Covered |
| 00212 | CPT | Covered |
| 00214 | CPT | Covered |
| 00215 | CPT | Covered |
| 00216 | CPT | Covered |
| 00218 | CPT | Covered |
| 00220 | CPT | Covered |
| 00222 | CPT | Covered |
| 00300 | CPT | Covered |
| 00320 | CPT | Covered |
| 00322 | CPT | Covered |
| 00326 | CPT | Covered |
| 00350 | CPT | Covered |
| 00352 | CPT | Covered |
| 00400 | CPT | Covered |
| 00402 | CPT | Covered |
| 00404 | CPT | Covered |
| 00406 | CPT | Covered |
| 00410 | CPT | Covered |
| 00450 | CPT | Covered |
| 00452 | CPT | Covered |
| 00454 | CPT | Covered |
| 00470 | CPT | Covered |
| 00472 | CPT | Covered |
| 00474 | CPT | Covered |
| 00500 | CPT | Covered |
| 00520 | CPT | Covered |
| 00522 | CPT | Covered |
| 00524 | CPT | Covered |
| 00528 | CPT | Covered |
| 00529 | CPT | Covered |
| 00530 | CPT | Covered |
| 00532 | CPT | Covered |
| 00534 | CPT | Covered |
| 00537 | CPT | Covered |
| 00539 | CPT | Covered |
| 00540 | CPT | Covered |
| 00541 | CPT | Covered |
| 00542 | CPT | Covered |
| 00546 | CPT | Covered |
| 00548 | CPT | Covered |
| 00550 | CPT | Covered |
| 00560 | CPT | Covered |
| 00561 | CPT | Covered |
| 00562 | CPT | Covered |
| 00563 | CPT | Covered |
| 00566 | CPT | Covered |
| 00567 | CPT | Covered |
| 00580 | CPT | Covered |
| 00600 | CPT | Covered |
| 00604 | CPT | Covered |
| 00620 | CPT | Covered |
| 00622 | CPT | Covered |
| 00625 | CPT | Covered |
| 00626 | CPT | Covered |
| 00630 | CPT | Covered |
| 00632 | CPT | Covered |
| 00634 | CPT | Covered |
| 00635 | CPT | Covered |
| 00640 | CPT | Covered |
| 00670 | CPT | Covered |
| 00700 | CPT | Covered |
| 00702 | CPT | Covered |
| 00730 | CPT | Covered |
| 00750 | CPT | Covered |
| 00752 | CPT | Covered |
| 00754 | CPT | Covered |
| 00756 | CPT | Covered |
| 00770 | CPT | Covered |
| 00790 | CPT | Covered |
| 00792 | CPT | Covered |
| 00794 | CPT | Covered |
| 00796 | CPT | Covered |
| 00797 | CPT | Covered |
| 00800 | CPT | Covered |
| 00802 | CPT | Covered |
| 00820 | CPT | Covered |
| 00830 | CPT | Covered |
| 00832 | CPT | Covered |
| 00834 | CPT | Covered |
| 00836 | CPT | Covered |
| 00840 | CPT | Covered |
| 00842 | CPT | Covered |
| 00844 | CPT | Covered |
| 00846 | CPT | Covered |
| 00848 | CPT | Covered |
| 00851 | CPT | Covered |
| 00860 | CPT | Covered |
| 00862 | CPT | Covered |
| 00864 | CPT | Covered |
| 00865 | CPT | Covered |
| 00866 | CPT | Covered |
| 00868 | CPT | Covered |
| 00870 | CPT | Covered |
| 00872 | CPT | Covered |
| 00873 | CPT | Covered |
| 00880 | CPT | Covered |
| 00882 | CPT | Covered |
| 00902 | CPT | Covered |
| 00904 | CPT | Covered |
| 00906 | CPT | Covered |
| 00908 | CPT | Covered |
| 00910 | CPT | Covered |
| 00912 | CPT | Covered |
| 00914 | CPT | Covered |
| 00916 | CPT | Covered |
| 00918 | CPT | Covered |
| 00920 | CPT | Covered |
| 00921 | CPT | Covered |
| 00922 | CPT | Covered |
| 00924 | CPT | Covered |
| 00926 | CPT | Covered |
| 00928 | CPT | Covered |
| 00930 | CPT | Covered |
| 00932 | CPT | Covered |
| 00934 | CPT | Covered |
| 00936 | CPT | Covered |
| 00938 | CPT | Covered |
| 00940 | CPT | Covered |
| 00942 | CPT | Covered |
| 00944 | CPT | Covered |
| 00948 | CPT | Covered |
| 00950 | CPT | Covered |
| 00952 | CPT | Covered |
| 01112 | CPT | Covered |
| 01120 | CPT | Covered |
| 01130 | CPT | Covered |
| 01140 | CPT | Covered |
| 01150 | CPT | Covered |
| 01160 | CPT | Covered |
| 01170 | CPT | Covered |
| 01173 | CPT | Covered |
| 01180 | CPT | Covered |
| 01190 | CPT | Covered |
| 01200 | CPT | Covered |
| 01202 | CPT | Covered |
| 01210 | CPT | Covered |
| 01212 | CPT | Covered |
| 01214 | CPT | Covered |
| 01215 | CPT | Covered |
| 01220 | CPT | Covered |
| 01230 | CPT | Covered |
| 01232 | CPT | Covered |
| 01234 | CPT | Covered |
| 01250 | CPT | Covered |
| 01260 | CPT | Covered |
| 01270 | CPT | Covered |
| 01272 | CPT | Covered |
| 01274 | CPT | Covered |
| 01320 | CPT | Covered |
| 01340 | CPT | Covered |
| 01360 | CPT | Covered |
| 01380 | CPT | Covered |
| 01382 | CPT | Covered |
| 01390 | CPT | Covered |
| 01392 | CPT | Covered |
| 01400 | CPT | Covered |
| 01402 | CPT | Covered |
| 01404 | CPT | Covered |
| 01420 | CPT | Covered |
| 01430 | CPT | Covered |
| 01432 | CPT | Covered |
| 01440 | CPT | Covered |
| 01442 | CPT | Covered |
| 01444 | CPT | Covered |
| 01462 | CPT | Covered |
| 01464 | CPT | Covered |
| 01470 | CPT | Covered |
| 01472 | CPT | Covered |
| 01474 | CPT | Covered |
| 01480 | CPT | Covered |
| 01482 | CPT | Covered |
| 01484 | CPT | Covered |
| 01486 | CPT | Covered |
| 01490 | CPT | Covered |
| 01500 | CPT | Covered |
| 01502 | CPT | Covered |
| 01520 | CPT | Covered |
| 01522 | CPT | Covered |
| 01610 | CPT | Covered |
| 01620 | CPT | Covered |
| 01622 | CPT | Covered |
| 01630 | CPT | Covered |
| 01632 | CPT | Covered |
| 01634 | CPT | Covered |
| 01636 | CPT | Covered |
| 01638 | CPT | Covered |
| 01650 | CPT | Covered |
| 01652 | CPT | Covered |
| 01654 | CPT | Covered |
| 01656 | CPT | Covered |
| 01670 | CPT | Covered |
| 01680 | CPT | Covered |
| 01682 | CPT | Covered |
| 01710 | CPT | Covered |
| 01712 | CPT | Covered |
| 01714 | CPT | Covered |
| 01716 | CPT | Covered |
| 01730 | CPT | Covered |
| 01732 | CPT | Covered |
| 01740 | CPT | Covered |
| 01742 | CPT | Covered |
| 01744 | CPT | Covered |
| 01756 | CPT | Covered |
| 01758 | CPT | Covered |
| 01760 | CPT | Covered |
| 01770 | CPT | Covered |
| 01772 | CPT | Covered |
| 01780 | CPT | Covered |
| 01782 | CPT | Covered |
| 01810 | CPT | Covered |
| 01820 | CPT | Covered |
| 01829 | CPT | Covered |
| 01830 | CPT | Covered |
| 01832 | CPT | Covered |
| 01840 | CPT | Covered |
| 01842 | CPT | Covered |
| 01844 | CPT | Covered |
| 01850 | CPT | Covered |
| 01852 | CPT | Covered |
| 01860 | CPT | Covered |
| 01905 | CPT | Covered |
| 01916 | CPT | Covered |
| 01920 | CPT | Covered |
| 01922 | CPT | Covered |
| 01924 | CPT | Covered |
| 01925 | CPT | Covered |
| 01926 | CPT | Covered |
| 01930 | CPT | Covered |
| 01931 | CPT | Covered |
| 01932 | CPT | Covered |
| 01933 | CPT | Covered |
| 01935 | CPT | Covered |
| 01936 | CPT | Covered |
| 01937 | CPT | Covered |
| 01938 | CPT | Covered |
| 01951 | CPT | Covered |
| 01952 | CPT | Covered |
| 01953 | CPT | Covered |
| 01958 | CPT | Covered |
| 01960 | CPT | Covered |
| 01961 | CPT | Covered |
| 01962 | CPT | Covered |
| 01963 | CPT | Covered |
| 01965 | CPT | Covered |
| 01966 | CPT | Covered |
| 01967 | CPT | Covered |
| 01968 | CPT | Covered |
| 01969 | CPT | Covered |
| 01990 | CPT | Covered |
| 01991 | CPT | Covered |
| 01992 | CPT | Covered |
| 01996 | CPT | Covered |
| 01999 | CPT | Covered |
| 64412 | CPT | Covered |
| 99100 | CPT | Covered |
| 99116 | CPT | Covered |
| 99135 | CPT | Covered |
| 99140 | CPT | Covered |
| 99143 | CPT | Covered |
| 99144 | CPT | Covered |
| 99145 | CPT | Covered |
| 99148 | CPT | Covered |
| 99149 | CPT | Covered |
| 99150 | CPT | Covered |
| 99151 | CPT | Covered |
| 99152 | CPT | Covered |
| 99153 | CPT | Covered |
| 99155 | CPT | Covered |
| 99156 | CPT | Covered |
| 99157 | CPT | Covered |
| G0500 | HCPCS | Covered |