Anthem · Clinical Guideline · ANTHEM-CG-MED-73
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 |
|---|---|---|
| 99183 | CPT | Covered |
| A4575 | HCPCS | Covered |
| G0277 | HCPCS | Covered |
| A42.0 | ICD10CM | Covered |
| A42.9 | ICD10CM | Covered |
| A48.0 | ICD10CM | Covered |
| B36.0 | ICD10CM | Covered |
| B36.9 | ICD10CM | Covered |
| B37.0 | ICD10CM | Covered |
| B37.9 | ICD10CM | Covered |
| B46.0 | ICD10CM | Covered |
| B46.9 | ICD10CM | Covered |
| B48.0 | ICD10CM | Covered |
| B48.8 | ICD10CM | Covered |
| E08.00 | ICD10CM | Covered |
| E11.A | ICD10CM | Covered |
| E13.00 | ICD10CM | Covered |
| E13.9 | ICD10CM | Covered |
| G06.0 | ICD10CM | Covered |
| H34.10 | ICD10CM | Covered |
| H34.13 | ICD10CM | Covered |
| H70.201 | ICD10CM | Covered |
| H70.229 | ICD10CM | Covered |
| H90.3 | ICD10CM | Covered |
| H90.A32 | ICD10CM | Covered |
| I73.89 | ICD10CM | Covered |
| I73.9 | ICD10CM | Covered |
| I74.2 | ICD10CM | Covered |
| I74.9 | ICD10CM | Covered |
| I99.9 | ICD10CM | Covered |
| K62.7 | ICD10CM | Covered |
| L08.0 | ICD10CM | Covered |
| L08.9 | ICD10CM | Covered |
| L59.8 | ICD10CM | Covered |
| L59.9 | ICD10CM | Covered |
| L89.000 | ICD10CM | Covered |
| L89.95 | ICD10CM | Covered |
| L97.101 | ICD10CM | Covered |
| L97.929 | ICD10CM | Covered |
| L98.411 | ICD10CM | Covered |
| L98.499 | ICD10CM | Covered |
| L98.A111 | ICD10CM | Covered |
| L98.A399 | ICD10CM | Covered |
| M27.2 | ICD10CM | Covered |
| M72.6 | ICD10CM | Covered |
| M79.9 | ICD10CM | Covered |
| M79.A11 | ICD10CM | Covered |
| M79.A9 | ICD10CM | Covered |
| M86.30 | ICD10CM | Covered |
| M86.69 | ICD10CM | Covered |
| M86.8X0 | ICD10CM | Covered |
| M86.8X9 | ICD10CM | Covered |
| M86.9 | ICD10CM | Covered |
| N30.40 | ICD10CM | Covered |
| N30.41 | ICD10CM | Covered |
| S01.00XS | ICD10CM | Covered |
| S01.95XS | ICD10CM | Covered |
| S07.0XXA | ICD10CM | Covered |
| S07.9XXS | ICD10CM | Covered |
| S11.011S | ICD10CM | Covered |
| S11.95XS | ICD10CM | Covered |
| S17.0XXA | ICD10CM | Covered |
| S17.9XXS | ICD10CM | Covered |
| S21.001S | ICD10CM | Covered |
| S21.95XS | ICD10CM | Covered |
| S28.0XXA | ICD10CM | Covered |
| S28.0XXS | ICD10CM | Covered |
| S31.000S | ICD10CM | Covered |
| S31.839S | ICD10CM | Covered |
| S38.001A | ICD10CM | Covered |
| S38.1XXS | ICD10CM | Covered |
| S41.001S | ICD10CM | Covered |
| S41.159S | ICD10CM | Covered |
| S45.001A | ICD10CM | Covered |
| S45.099S | ICD10CM | Covered |
| S45.801A | ICD10CM | Covered |
| S45.999S | ICD10CM | Covered |
| S47.1XXA | ICD10CM | Covered |
| S47.9XXS | ICD10CM | Covered |
| S51.001S | ICD10CM | Covered |
| S51.859S | ICD10CM | Covered |
| T20.20XA | ICD10CM | Covered |
| T20.29XS | ICD10CM | Covered |
| T20.30XA | ICD10CM | Covered |
| T20.39XS | ICD10CM | Covered |
| T21.20XA | ICD10CM | Covered |
| T21.29XS | ICD10CM | Covered |
| T21.30XA | ICD10CM | Covered |
| T21.39XS | ICD10CM | Covered |
| T22.20XA | ICD10CM | Covered |
| T22.299S | ICD10CM | Covered |
| T22.30XA | ICD10CM | Covered |
| T22.399S | ICD10CM | Covered |
| T23.201A | ICD10CM | Covered |
| T23.299S | ICD10CM | Covered |
| T23.301A | ICD10CM | Covered |
| T23.399S | ICD10CM | Covered |
| T24.201A | ICD10CM | Covered |
| T24.299S | ICD10CM | Covered |
| T24.301A | ICD10CM | Covered |
| T24.399S | ICD10CM | Covered |
| T25.211A | ICD10CM | Covered |
| T25.299S | ICD10CM | Covered |
| T25.311A | ICD10CM | Covered |
| T25.399S | ICD10CM | Covered |
| T31.0 | ICD10CM | Covered |
| T31.99 | ICD10CM | Covered |
| T57.3X1A | ICD10CM | Covered |
| T57.3X4S | ICD10CM | Covered |
| T58.01XA | ICD10CM | Covered |
| T58.94XS | ICD10CM | Covered |
| T65.0X1A | ICD10CM | Covered |
| T65.0X4S | ICD10CM | Covered |
| T66.XXXA | ICD10CM | Covered |
| T66.XXXS | ICD10CM | Covered |
| T70.3XXA | ICD10CM | Covered |
| T70.3XXS | ICD10CM | Covered |
| T79.0XXA | ICD10CM | Covered |
| T79.0XXS | ICD10CM | Covered |
| T79.A0XA | ICD10CM | Covered |
| T79.A0XS | ICD10CM | Covered |
| T79.A11A | ICD10CM | Covered |
| T79.A9XS | ICD10CM | Covered |
| T86.820 | ICD10CM | Covered |
| T86.829 | ICD10CM | Covered |