Anthem · Clinical Guideline · ANTHEM-CG-MED-23
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 |
|---|---|---|
| 99500 | CPT | Covered |
| 99503 | CPT | Covered |
| 99504 | CPT | Covered |
| 99505 | CPT | Covered |
| 99506 | CPT | Covered |
| 99507 | CPT | Covered |
| 99509 | CPT | Covered |
| 99510 | CPT | Covered |
| 99511 | CPT | Covered |
| 99512 | CPT | Covered |
| 99600 | CPT | Covered |
| 99601 | CPT | Covered |
| 99602 | CPT | Covered |
| G0068 | HCPCS | Covered |
| G0069 | HCPCS | Covered |
| G0070 | HCPCS | Covered |
| G0088 | HCPCS | Covered |
| G0089 | HCPCS | Covered |
| G0090 | HCPCS | Covered |
| G0151 | HCPCS | Covered |
| G0152 | HCPCS | Covered |
| G0153 | HCPCS | Covered |
| G0154 | HCPCS | Covered |
| G0155 | HCPCS | Covered |
| G0156 | HCPCS | Covered |
| G0157 | HCPCS | Covered |
| G0158 | HCPCS | Covered |
| G0159 | HCPCS | Covered |
| G0160 | HCPCS | Covered |
| G0161 | HCPCS | Covered |
| G0162 | HCPCS | Covered |
| G0163 | HCPCS | Covered |
| G0164 | HCPCS | Covered |
| G0299 | HCPCS | Covered |
| G0300 | HCPCS | Covered |
| G0320 | HCPCS | Covered |
| G0321 | HCPCS | Covered |
| G0322 | HCPCS | Covered |
| G0493 | HCPCS | Covered |
| G0494 | HCPCS | Covered |
| G0495 | HCPCS | Covered |
| G0496 | HCPCS | Covered |
| G2168 | HCPCS | Covered |
| G2169 | HCPCS | Covered |
| Q5001 | HCPCS | Covered |
| Q5002 | HCPCS | Covered |
| Q5009 | HCPCS | Covered |
| S5035 | HCPCS | Covered |
| S5036 | HCPCS | Covered |
| S5108 | HCPCS | Covered |
| S5109 | HCPCS | Covered |
| S5110 | HCPCS | Covered |
| S5111 | HCPCS | Covered |
| S5115 | HCPCS | Covered |
| S5116 | HCPCS | Covered |
| S5180 | HCPCS | Covered |
| S5181 | HCPCS | Covered |
| S5497 | HCPCS | Covered |
| S5498 | HCPCS | Covered |
| S5501 | HCPCS | Covered |
| S5502 | HCPCS | Covered |
| S5517 | HCPCS | Covered |
| S5518 | HCPCS | Covered |
| S5520 | HCPCS | Covered |
| S5521 | HCPCS | Covered |
| S5522 | HCPCS | Covered |
| S5523 | HCPCS | Covered |
| S9061 | HCPCS | Covered |
| S9097 | HCPCS | Covered |
| S9122 | HCPCS | Covered |
| S9123 | HCPCS | Covered |
| S9124 | HCPCS | Covered |
| S9127 | HCPCS | Covered |
| S9128 | HCPCS | Covered |
| S9129 | HCPCS | Covered |
| S9131 | HCPCS | Covered |
| S9209 | HCPCS | Covered |
| S9211 | HCPCS | Covered |
| S9212 | HCPCS | Covered |
| S9213 | HCPCS | Covered |
| S9214 | HCPCS | Covered |
| S9325 | HCPCS | Covered |
| S9326 | HCPCS | Covered |
| S9327 | HCPCS | Covered |
| S9328 | HCPCS | Covered |
| S9329 | HCPCS | Covered |
| S9330 | HCPCS | Covered |
| S9331 | HCPCS | Covered |
| S9336 | HCPCS | Covered |
| S9338 | HCPCS | Covered |
| S9345 | HCPCS | Covered |
| S9346 | HCPCS | Covered |
| S9348 | HCPCS | Covered |
| S9351 | HCPCS | Covered |
| S9353 | HCPCS | Covered |
| S9357 | HCPCS | Covered |
| S9361 | HCPCS | Covered |
| S9363 | HCPCS | Covered |
| S9364 | HCPCS | Covered |
| S9365 | HCPCS | Covered |
| S9366 | HCPCS | Covered |
| S9367 | HCPCS | Covered |
| S9368 | HCPCS | Covered |
| S9370 | HCPCS | Covered |
| S9372 | HCPCS | Covered |
| S9373 | HCPCS | Covered |
| S9374 | HCPCS | Covered |
| S9375 | HCPCS | Covered |
| S9376 | HCPCS | Covered |
| S9377 | HCPCS | Covered |
| S9379 | HCPCS | Covered |
| S9490 | HCPCS | Covered |
| S9494 | HCPCS | Covered |
| S9497 | HCPCS | Covered |
| S9500 | HCPCS | Covered |
| S9501 | HCPCS | Covered |
| S9502 | HCPCS | Covered |
| S9503 | HCPCS | Covered |
| S9504 | HCPCS | Covered |
| S9538 | HCPCS | Covered |
| S9542 | HCPCS | Covered |
| S9560 | HCPCS | Covered |
| S9590 | HCPCS | Covered |
| S9810 | HCPCS | Covered |
| T1001 | HCPCS | Covered |
| T1002 | HCPCS | Covered |
| T1003 | HCPCS | Covered |
| T1004 | HCPCS | Covered |
| T1021 | HCPCS | Covered |
| T1022 | HCPCS | Covered |
| T1030 | HCPCS | Covered |
| T1031 | HCPCS | Covered |