Anthem · Clinical Guideline · ANTHEM-CG-SURG-127
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 |
|---|---|---|
| 15011 | CPT | Covered |
| 15012 | CPT | Covered |
| 15013 | CPT | Covered |
| 15014 | CPT | Covered |
| 15015 | CPT | Covered |
| 15016 | CPT | Covered |
| 15017 | CPT | Covered |
| 15018 | CPT | Covered |
| 15150 | CPT | Covered |
| 15151 | CPT | Covered |
| 15152 | CPT | Covered |
| 15155 | CPT | Covered |
| 15156 | CPT | Covered |
| 15157 | CPT | Covered |
| 15271 | CPT | Covered |
| 15272 | CPT | Covered |
| 15273 | CPT | Covered |
| 15274 | CPT | Covered |
| 15275 | CPT | Covered |
| 15276 | CPT | Covered |
| 15277 | CPT | Covered |
| 15278 | CPT | Covered |
| 15777 | CPT | Covered |
| 17999 | CPT | Covered |
| 65778 | CPT | Covered |
| 65779 | CPT | Covered |
| 65780 | CPT | Covered |
| A4100 | HCPCS | Covered |
| C1832 | HCPCS | Covered |
| C5271 | HCPCS | Covered |
| C5272 | HCPCS | Covered |
| C5273 | HCPCS | Covered |
| C5274 | HCPCS | Covered |
| C5275 | HCPCS | Covered |
| C5276 | HCPCS | Covered |
| C5277 | HCPCS | Covered |
| C5278 | HCPCS | Covered |
| C8002 | HCPCS | Covered |
| C9358 | HCPCS | Covered |
| C9360 | HCPCS | Covered |
| C9363 | HCPCS | Covered |
| C9399 | HCPCS | Covered |
| Q4100 | HCPCS | Covered |
| Q4101 | HCPCS | Covered |
| Q4102 | HCPCS | Covered |
| Q4104 | HCPCS | Covered |
| Q4105 | HCPCS | Covered |
| Q4106 | HCPCS | Covered |
| Q4107 | HCPCS | Covered |
| Q4110 | HCPCS | Covered |
| Q4115 | HCPCS | Covered |
| Q4116 | HCPCS | Covered |
| Q4121 | HCPCS | Covered |
| Q4122 | HCPCS | Covered |
| Q4124 | HCPCS | Covered |
| Q4128 | HCPCS | Covered |
| Q4130 | HCPCS | Covered |
| Q4133 | HCPCS | Covered |
| Q4136 | HCPCS | Covered |
| Q4151 | HCPCS | Covered |
| Q4154 | HCPCS | Covered |
| Q4158 | HCPCS | Covered |
| Q4160 | HCPCS | Covered |
| Q4186 | HCPCS | Covered |
| Q4187 | HCPCS | Covered |
| Q4283 | HCPCS | Covered |
| Q4334 | HCPCS | Covered |
| Q4335 | HCPCS | Covered |
| Q4369 | HCPCS | Covered |
| Q4391 | HCPCS | Covered |
| S0305 | HCPCS | Covered |
| S0748 | HCPCS | Covered |
| V2790 | HCPCS | Covered |
| C69.00 | ICD10CM | Covered |
| C69.02 | ICD10CM | Covered |
| C69.10 | ICD10CM | Covered |
| C69.12 | ICD10CM | Covered |
| E08.00 | ICD10CM | Covered |
| E13.9 | ICD10CM | Covered |
| H11.001 | ICD10CM | Covered |
| H11.069 | ICD10CM | Covered |
| H16.001 | ICD10CM | Covered |
| H16.079 | ICD10CM | Covered |
| H16.231 | ICD10CM | Covered |
| H16.239 | ICD10CM | Covered |
| H18.10 | ICD10CM | Covered |
| H18.13 | ICD10CM | Covered |
| H18.40 | ICD10CM | Covered |
| H18.599 | ICD10CM | Covered |
| H18.831 | ICD10CM | Covered |
| H18.839 | ICD10CM | Covered |
| H59.091 | ICD10CM | Covered |
| H59.099 | ICD10CM | Covered |
| L51.1 | ICD10CM | Covered |
| Q81.0 | ICD10CM | Covered |
| Q81.9 | ICD10CM | Covered |
| T20.20XA | ICD10CM | Covered |
| T20.39XS | ICD10CM | Covered |
| T20.60XA | ICD10CM | Covered |
| T20.79XS | ICD10CM | Covered |
| T21.20XA | ICD10CM | Covered |
| T21.39XS | ICD10CM | Covered |
| T21.60XA | ICD10CM | Covered |
| T21.79XS | ICD10CM | Covered |
| T22.20XA | ICD10CM | Covered |
| T22.399S | ICD10CM | Covered |
| T22.60XA | ICD10CM | Covered |
| T22.799S | ICD10CM | Covered |
| T23.201A | ICD10CM | Covered |
| T23.399S | ICD10CM | Covered |
| T23.601A | ICD10CM | Covered |
| T23.799S | ICD10CM | Covered |
| T24.201A | ICD10CM | Covered |
| T24.399S | ICD10CM | Covered |
| T24.601A | ICD10CM | Covered |
| T24.799S | ICD10CM | Covered |
| T25.211A | ICD10CM | Covered |
| T25.399S | ICD10CM | Covered |
| T25.611A | ICD10CM | Covered |
| T25.799S | ICD10CM | Covered |
| T26.10XA | ICD10CM | Covered |
| T26.12XS | ICD10CM | Covered |
| T26.60XA | ICD10CM | Covered |
| T26.62XS | ICD10CM | Covered |
| T31.0 | ICD10CM | Covered |
| T31.99 | ICD10CM | Covered |
| T32.0 | ICD10CM | Covered |
| T32.99 | ICD10CM | Covered |