Anthem · Clinical Guideline · ANTHEM-CG-RAD-26
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 |
|---|---|---|
| 76801 | CPT | Covered |
| 76802 | CPT | Covered |
| 76805 | CPT | Covered |
| 76810 | CPT | Covered |
| 76811 | CPT | Covered |
| 76812 | CPT | Covered |
| 76815 | CPT | Covered |
| 76816 | CPT | Covered |
| 76817 | CPT | Covered |
| A92.5 | ICD10CM | Covered |
| D25.0 | ICD10CM | Covered |
| D25.9 | ICD10CM | Covered |
| O00.00 | ICD10CM | Covered |
| O00.91 | ICD10CM | Covered |
| O01.0 | ICD10CM | Covered |
| O01.9 | ICD10CM | Covered |
| O02.0 | ICD10CM | Covered |
| O02.9 | ICD10CM | Covered |
| O03.4 | ICD10CM | Covered |
| O03.9 | ICD10CM | Covered |
| O07.4 | ICD10CM | Covered |
| O09.00 | ICD10CM | Covered |
| O09.03 | ICD10CM | Covered |
| O09.10 | ICD10CM | Covered |
| O09.13 | ICD10CM | Covered |
| O09.211 | ICD10CM | Covered |
| O09.219 | ICD10CM | Covered |
| O09.291 | ICD10CM | Covered |
| O09.299 | ICD10CM | Covered |
| O09.30 | ICD10CM | Covered |
| O09.33 | ICD10CM | Covered |
| O09.511 | ICD10CM | Covered |
| O09.529 | ICD10CM | Covered |
| O09.811 | ICD10CM | Covered |
| O09.93 | ICD10CM | Covered |
| O09.A0 | ICD10CM | Covered |
| O09.A3 | ICD10CM | Covered |
| O10.011 | ICD10CM | Covered |
| O10.019 | ICD10CM | Covered |
| O10.111 | ICD10CM | Covered |
| O10.119 | ICD10CM | Covered |
| O10.211 | ICD10CM | Covered |
| O10.219 | ICD10CM | Covered |
| O10.311 | ICD10CM | Covered |
| O10.319 | ICD10CM | Covered |
| O10.411 | ICD10CM | Covered |
| O10.419 | ICD10CM | Covered |
| O10.911 | ICD10CM | Covered |
| O10.919 | ICD10CM | Covered |
| O11.1 | ICD10CM | Covered |
| O11.3 | ICD10CM | Covered |
| O11.9 | ICD10CM | Covered |
| O14.00 | ICD10CM | Covered |
| O14.03 | ICD10CM | Covered |
| O14.10 | ICD10CM | Covered |
| O14.13 | ICD10CM | Covered |
| O14.20 | ICD10CM | Covered |
| O14.23 | ICD10CM | Covered |
| O14.90 | ICD10CM | Covered |
| O14.93 | ICD10CM | Covered |
| O16.1 | ICD10CM | Covered |
| O16.3 | ICD10CM | Covered |
| O16.9 | ICD10CM | Covered |
| O20.0 | ICD10CM | Covered |
| O20.9 | ICD10CM | Covered |
| O21.0 | ICD10CM | Covered |
| O21.9 | ICD10CM | Covered |
| O24.011 | ICD10CM | Covered |
| O24.019 | ICD10CM | Covered |
| O24.111 | ICD10CM | Covered |
| O24.119 | ICD10CM | Covered |
| O24.311 | ICD10CM | Covered |
| O24.319 | ICD10CM | Covered |
| O24.410 | ICD10CM | Covered |
| O24.419 | ICD10CM | Covered |
| O24.811 | ICD10CM | Covered |
| O24.819 | ICD10CM | Covered |
| O24.911 | ICD10CM | Covered |
| O24.919 | ICD10CM | Covered |
| O26.20 | ICD10CM | Covered |
| O26.23 | ICD10CM | Covered |
| O26.30 | ICD10CM | Covered |
| O26.33 | ICD10CM | Covered |
| O26.841 | ICD10CM | Covered |
| O26.849 | ICD10CM | Covered |
| O26.851 | ICD10CM | Covered |
| O26.859 | ICD10CM | Covered |
| O26.872 | ICD10CM | Covered |
| O26.879 | ICD10CM | Covered |
| O30.001 | ICD10CM | Covered |
| O30.93 | ICD10CM | Covered |
| O31.00X0 | ICD10CM | Covered |
| O31.8X99 | ICD10CM | Covered |
| O32.0XX0 | ICD10CM | Covered |
| O32.9XX9 | ICD10CM | Covered |
| O33.0 | ICD10CM | Covered |
| O33.9 | ICD10CM | Covered |
| O34.00 | ICD10CM | Covered |
| O34.93 | ICD10CM | Covered |
| O35.00X0 | ICD10CM | Covered |
| O35.9XX9 | ICD10CM | Covered |
| O36.0110 | ICD10CM | Covered |
| O36.0999 | ICD10CM | Covered |
| O36.20X0 | ICD10CM | Covered |
| O36.23X9 | ICD10CM | Covered |
| O36.4XX0 | ICD10CM | Covered |
| O36.4XX9 | ICD10CM | Covered |
| O36.5110 | ICD10CM | Covered |
| O36.5999 | ICD10CM | Covered |
| O36.60X0 | ICD10CM | Covered |
| O36.63X9 | ICD10CM | Covered |
| O36.70X0 | ICD10CM | Covered |
| O36.73X9 | ICD10CM | Covered |
| O36.80X0 | ICD10CM | Covered |
| O36.80X9 | ICD10CM | Covered |
| O36.8120 | ICD10CM | Covered |
| O36.8199 | ICD10CM | Covered |
| O36.8310 | ICD10CM | Covered |
| O36.8399 | ICD10CM | Covered |
| O36.8910 | ICD10CM | Covered |
| O36.8999 | ICD10CM | Covered |
| O36.90X0 | ICD10CM | Covered |
| O36.93X9 | ICD10CM | Covered |
| O40.1XX0 | ICD10CM | Covered |
| O40.9XX9 | ICD10CM | Covered |
| O41.00X0 | ICD10CM | Covered |
| O41.93X9 | ICD10CM | Covered |
| O42.00 | ICD10CM | Covered |
| O42.92 | ICD10CM | Covered |
| O43.021 | ICD10CM | Covered |
| O43.029 | ICD10CM | Covered |
| O43.101 | ICD10CM | Covered |
| O43.199 | ICD10CM | Covered |
| O43.211 | ICD10CM | Covered |
| O43.93 | ICD10CM | Covered |
| O44.00 | ICD10CM | Covered |
| O44.53 | ICD10CM | Covered |
| O45.001 | ICD10CM | Covered |
| O45.93 | ICD10CM | Covered |
| O46.001 | ICD10CM | Covered |
| O46.93 | ICD10CM | Covered |
| O47.00 | ICD10CM | Covered |
| O47.9 | ICD10CM | Covered |
| O48.0 | ICD10CM | Covered |
| O48.1 | ICD10CM | Covered |
| O60.00 | ICD10CM | Covered |
| O60.03 | ICD10CM | Covered |
| O73.0 | ICD10CM | Covered |
| O73.1 | ICD10CM | Covered |
| O98.111 | ICD10CM | Covered |
| O98.119 | ICD10CM | Covered |
| O99.210 | ICD10CM | Covered |
| O99.213 | ICD10CM | Covered |
| O99.310 | ICD10CM | Covered |
| O99.313 | ICD10CM | Covered |
| O99.320 | ICD10CM | Covered |
| O99.323 | ICD10CM | Covered |
| O99.330 | ICD10CM | Covered |
| O99.333 | ICD10CM | Covered |
| O99.810 | ICD10CM | Covered |
| O99.891 | ICD10CM | Covered |
| Q51.21 | ICD10CM | Covered |
| Q51.28 | ICD10CM | Covered |
| Z20.821 | ICD10CM | Covered |
| Z34.00 | ICD10CM | Covered |
| Z34.93 | ICD10CM | Covered |
| Z36.0 | ICD10CM | Covered |
| Z36.9 | ICD10CM | Covered |