Anthem · Clinical Guideline · ANTHEM-CG-SURG-51
Summary of the payer’s published policy. Not a coverage determination — confirm with Anthem before submitting.
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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 |
|---|---|---|
| 52000 | CPT | Covered |
| 52001 | CPT | Covered |
| 52005 | CPT | Covered |
| 52007 | CPT | Covered |
| 52010 | CPT | Covered |
| 52204 | CPT | Covered |
| 52214 | CPT | Covered |
| 52224 | CPT | Covered |
| 52234 | CPT | Covered |
| 52235 | CPT | Covered |
| 52240 | CPT | Covered |
| 52250 | CPT | Covered |
| 52260 | CPT | Covered |
| 52265 | CPT | Covered |
| 52270 | CPT | Covered |
| 52275 | CPT | Covered |
| C7550 | HCPCS | Covered |
| C7554 | HCPCS | Covered |
| C51.0 | ICD10CM | Covered |
| C57.9 | ICD10CM | Covered |
| C64.1 | ICD10CM | Covered |
| C68.9 | ICD10CM | Covered |
| C79.00 | ICD10CM | Covered |
| C79.19 | ICD10CM | Covered |
| D09.0 | ICD10CM | Covered |
| D09.19 | ICD10CM | Covered |
| D17.71 | ICD10CM | Covered |
| D17.72 | ICD10CM | Covered |
| D30.00 | ICD10CM | Covered |
| D30.9 | ICD10CM | Covered |
| D41.00 | ICD10CM | Covered |
| D41.9 | ICD10CM | Covered |
| D49.4 | ICD10CM | Covered |
| D49.5 | ICD10CM | Covered |
| N02.0 | ICD10CM | Covered |
| N02.A | ICD10CM | Covered |
| N02.B9 | ICD10CM | Covered |
| N13.1 | ICD10CM | Covered |
| N13.9 | ICD10CM | Covered |
| N20.0 | ICD10CM | Covered |
| N21.9 | ICD10CM | Covered |
| N30.00 | ICD10CM | Covered |
| N30.91 | ICD10CM | Covered |
| N32.0 | ICD10CM | Covered |
| N34.0 | ICD10CM | Covered |
| N34.3 | ICD10CM | Covered |
| N35.010 | ICD10CM | Covered |
| N35.92 | ICD10CM | Covered |
| N39.0 | ICD10CM | Covered |
| R80.0 | ICD10CM | Covered |
| R82.99 | ICD10CM | Covered |
| Z85.50 | ICD10CM | Covered |
| Z85.59 | ICD10CM | Covered |
| Z87.440 | ICD10CM | Covered |
| Z87.448 | ICD10CM | Covered |