Anthem · Clinical Guideline · ANTHEM-CG-MED-68
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 |
|---|---|---|
| 00113 | CPT | Covered |
| 36511 | CPT | Covered |
| 36512 | CPT | Covered |
| 36513 | CPT | Covered |
| 36514 | CPT | Covered |
| 36515 | CPT | Covered |
| 36516 | CPT | Covered |
| S2120 | HCPCS | Covered |
| B60.0 | ICD10CM | Covered |
| B60.00 | ICD10CM | Covered |
| B60.09 | ICD10CM | Covered |
| B95.0 | ICD10CM | Covered |
| B95.1 | ICD10CM | Covered |
| C88.0 | ICD10CM | Covered |
| C88.00 | ICD10CM | Covered |
| C88.01 | ICD10CM | Covered |
| C90.00 | ICD10CM | Covered |
| C90.02 | ICD10CM | Covered |
| D47.2 | ICD10CM | Covered |
| D47.3 | ICD10CM | Covered |
| D56.1 | ICD10CM | Covered |
| D57.00 | ICD10CM | Covered |
| D57.819 | ICD10CM | Covered |
| D59.0 | ICD10CM | Covered |
| D59.1 | ICD10CM | Covered |
| D59.12 | ICD10CM | Covered |
| D59.3 | ICD10CM | Covered |
| D59.30 | ICD10CM | Covered |
| D59.39 | ICD10CM | Covered |
| D68.61 | ICD10CM | Covered |
| D89.1 | ICD10CM | Covered |
| D89.89 | ICD10CM | Covered |
| E78.00 | ICD10CM | Covered |
| E78.01 | ICD10CM | Covered |
| E78.010 | ICD10CM | Covered |
| E78.011 | ICD10CM | Covered |
| E78.019 | ICD10CM | Covered |
| E80.0 | ICD10CM | Covered |
| E80.1 | ICD10CM | Covered |
| E83.01 | ICD10CM | Covered |
| E83.110 | ICD10CM | Covered |
| F42.8 | ICD10CM | Covered |
| G04.81 | ICD10CM | Covered |
| G13.1 | ICD10CM | Covered |
| G35.A | ICD10CM | Covered |
| G35.D | ICD10CM | Covered |
| G36.0 | ICD10CM | Covered |
| G37.0 | ICD10CM | Covered |
| G37.9 | ICD10CM | Covered |
| G60.8 | ICD10CM | Covered |
| G61.0 | ICD10CM | Covered |
| G61.81 | ICD10CM | Covered |
| G61.89 | ICD10CM | Covered |
| G61.9 | ICD10CM | Covered |
| G70.00 | ICD10CM | Covered |
| G70.01 | ICD10CM | Covered |
| G71.19 | ICD10CM | Covered |
| M31.0 | ICD10CM | Covered |
| M31.1 | ICD10CM | Covered |
| M31.10 | ICD10CM | Covered |
| M31.19 | ICD10CM | Covered |
| M31.31 | ICD10CM | Covered |
| M31.7 | ICD10CM | Covered |
| M32.0 | ICD10CM | Covered |
| M32.9 | ICD10CM | Covered |
| N01.0 | ICD10CM | Covered |
| N01.A | ICD10CM | Covered |
| N03.0 | ICD10CM | Covered |
| N03.A | ICD10CM | Covered |
| N04.0 | ICD10CM | Covered |
| N04.A | ICD10CM | Covered |
| N04.B2 | ICD10CM | Covered |
| N17.0 | ICD10CM | Covered |
| N17.9 | ICD10CM | Covered |
| N18.1 | ICD10CM | Covered |
| N18.9 | ICD10CM | Covered |
| O99.011 | ICD10CM | Covered |
| O99.03 | ICD10CM | Covered |
| T86.00 | ICD10CM | Covered |
| T86.09 | ICD10CM | Covered |
| T86.10 | ICD10CM | Covered |
| T86.19 | ICD10CM | Covered |
| T86.21 | ICD10CM | Covered |
| T86.40 | ICD10CM | Covered |
| T86.49 | ICD10CM | Covered |
| T86.5 | ICD10CM | Covered |
| Z83.42 | ICD10CM | Covered |
| Z94.0 | ICD10CM | Covered |
| Z94.1 | ICD10CM | Covered |
| Z94.4 | ICD10CM | Covered |
| Z94.81 | ICD10CM | Covered |
| Z94.84 | ICD10CM | Covered |