Anthem · Clinical Guideline · ANTHEM-CG-MED-97
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 |
|---|---|---|
| 00125 | CPT | Covered |
| 90875 | CPT | Covered |
| 90876 | CPT | Covered |
| 90901 | CPT | Covered |
| 90912 | CPT | Covered |
| 90913 | CPT | Covered |
| E0746 | HCPCS | Covered |
| S9002 | HCPCS | Covered |
| G43.001 | ICD10CM | Covered |
| G43.E19 | ICD10CM | Covered |
| G44.201 | ICD10CM | Covered |
| G44.229 | ICD10CM | Covered |
| G89.3 | ICD10CM | Covered |
| K59.00 | ICD10CM | Covered |
| K59.09 | ICD10CM | Covered |
| K59.4 | ICD10CM | Covered |
| K62.89 | ICD10CM | Covered |
| M54.00 | ICD10CM | Covered |
| M54.9 | ICD10CM | Covered |
| N39.3 | ICD10CM | Covered |
| N39.498 | ICD10CM | Covered |
| R15.0 | ICD10CM | Covered |
| R15.9 | ICD10CM | Covered |