Anthem · Clinical Guideline · ANTHEM-CG-MED-47
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 |
|---|---|---|
| 92250 | CPT | Covered |
| 92499 | CPT | Covered |
| A18.50 | ICD10CM | Covered |
| A18.59 | ICD10CM | Covered |
| A50.01 | ICD10CM | Covered |
| A50.30 | ICD10CM | Covered |
| A50.44 | ICD10CM | Covered |
| A51.43 | ICD10CM | Covered |
| A52.15 | ICD10CM | Covered |
| A52.71 | ICD10CM | Covered |
| B25.0 | ICD10CM | Covered |
| B25.9 | ICD10CM | Covered |
| B39.4 | ICD10CM | Covered |
| B39.9 | ICD10CM | Covered |
| B50.0 | ICD10CM | Covered |
| B52.9 | ICD10CM | Covered |
| B58.00 | ICD10CM | Covered |
| B58.09 | ICD10CM | Covered |
| C69.00 | ICD10CM | Covered |
| C69.92 | ICD10CM | Covered |
| C79.49 | ICD10CM | Covered |
| D09.20 | ICD10CM | Covered |
| D09.22 | ICD10CM | Covered |
| D31.00 | ICD10CM | Covered |
| D31.92 | ICD10CM | Covered |
| D33.3 | ICD10CM | Covered |
| D49.81 | ICD10CM | Covered |
| D57.00 | ICD10CM | Covered |
| D57.819 | ICD10CM | Covered |
| E08.00 | ICD10CM | Covered |
| E13.9 | ICD10CM | Covered |
| E50.7 | ICD10CM | Covered |
| E70.310 | ICD10CM | Covered |
| E70.329 | ICD10CM | Covered |
| G35.A | ICD10CM | Covered |
| G35.D | ICD10CM | Covered |
| G45.3 | ICD10CM | Covered |
| G93.2 | ICD10CM | Covered |
| H15.031 | ICD10CM | Covered |
| H15.039 | ICD10CM | Covered |
| H16.241 | ICD10CM | Covered |
| H16.249 | ICD10CM | Covered |
| H20.821 | ICD10CM | Covered |
| H20.829 | ICD10CM | Covered |
| H21.331 | ICD10CM | Covered |
| H21.339 | ICD10CM | Covered |
| H27.111 | ICD10CM | Covered |
| H27.139 | ICD10CM | Covered |
| H30.001 | ICD10CM | Covered |
| H30.811 | ICD10CM | Covered |
| H30.93 | ICD10CM | Covered |
| H31.001 | ICD10CM | Covered |
| H31.9 | ICD10CM | Covered |
| H33.001 | ICD10CM | Covered |
| H33.8 | ICD10CM | Covered |
| H34.00 | ICD10CM | Covered |
| H34.9 | ICD10CM | Covered |
| H35.00 | ICD10CM | Covered |
| H35.9 | ICD10CM | Covered |
| H36.811 | ICD10CM | Covered |
| H36.89 | ICD10CM | Covered |
| H40.001 | ICD10CM | Covered |
| H40.9 | ICD10CM | Covered |
| H43.00 | ICD10CM | Covered |
| H43.9 | ICD10CM | Covered |
| H44.001 | ICD10CM | Covered |
| H44.9 | ICD10CM | Covered |
| H46.00 | ICD10CM | Covered |
| H46.9 | ICD10CM | Covered |
| H47.011 | ICD10CM | Covered |
| H47.9 | ICD10CM | Covered |
| H53.121 | ICD10CM | Covered |
| H53.15 | ICD10CM | Covered |
| H53.40 | ICD10CM | Covered |
| H53.489 | ICD10CM | Covered |
| H53.50 | ICD10CM | Covered |
| H53.59 | ICD10CM | Covered |
| H53.63 | ICD10CM | Covered |
| H53.71 | ICD10CM | Covered |
| H53.9 | ICD10CM | Covered |
| L93.0 | ICD10CM | Covered |
| L93.2 | ICD10CM | Covered |
| M05.00 | ICD10CM | Covered |
| M05.A | ICD10CM | Covered |
| M06.00 | ICD10CM | Covered |
| M06.0A | ICD10CM | Covered |
| M06.9 | ICD10CM | Covered |
| M08.00 | ICD10CM | Covered |
| M08.9A | ICD10CM | Covered |
| M32.19 | ICD10CM | Covered |
| M32.8 | ICD10CM | Covered |
| M32.9 | ICD10CM | Covered |
| P35.0 | ICD10CM | Covered |
| P35.9 | ICD10CM | Covered |
| P37.0 | ICD10CM | Covered |
| P37.9 | ICD10CM | Covered |
| Q14.0 | ICD10CM | Covered |
| Q14.9 | ICD10CM | Covered |
| Q15.0 | ICD10CM | Covered |
| Q85.1 | ICD10CM | Covered |
| Q85.9 | ICD10CM | Covered |
| Q87.0 | ICD10CM | Covered |
| Q87.89 | ICD10CM | Covered |
| R44.1 | ICD10CM | Covered |
| R48.3 | ICD10CM | Covered |
| R94.110 | ICD10CM | Covered |
| R94.118 | ICD10CM | Covered |
| S05.00XA | ICD10CM | Covered |
| S05.92XS | ICD10CM | Covered |
| T37.2X1A | ICD10CM | Covered |
| T37.2X5S | ICD10CM | Covered |
| T74.12XA | ICD10CM | Covered |
| T74.12XS | ICD10CM | Covered |
| T74.4XXA | ICD10CM | Covered |
| T74.4XXS | ICD10CM | Covered |
| T76.12XA | ICD10CM | Covered |
| T76.12XS | ICD10CM | Covered |
| Z01.00 | ICD10CM | Covered |
| Z13.5 | ICD10CM | Covered |
| Z79.899 | ICD10CM | Covered |
| Z85.840 | ICD10CM | Covered |