Cigna · PayerPolicy · CIGNA-CPG143
Summary of the payer’s published policy. Not a coverage determination — confirm with Cigna 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 |
|---|---|---|
| 29200 | CPT | Not covered |
| 29240 | CPT | Not covered |
| 29260 | CPT | Not covered |
| 29280 | CPT | Covered |
| 29520 | CPT | Not covered |
| 29530 | CPT | Not covered |
| 29540 | CPT | Covered |
| 29550 | CPT | Covered |
| 29799 | CPT | Not covered |
| 97110 | CPT | Covered with conditions |
| 97112 | CPT | Covered with conditions |
| G57.51 | ICD10CM | Covered |
| G57.52 | ICD10CM | Covered |
| G57.53 | ICD10CM | Covered |
| G57.61 | ICD10CM | Covered |
| G57.62 | ICD10CM | Covered |
| G57.63 | ICD10CM | Covered |
| G57.81 | ICD10CM | Covered |
| G57.82 | ICD10CM | Covered |
| M20.10 | ICD10CM | Covered |
| M20.11 | ICD10CM | Covered |
| M20.12 | ICD10CM | Covered |
| M20.40 | ICD10CM | Covered |
| M20.41 | ICD10CM | Covered |
| M20.42 | ICD10CM | Covered |
| M20.5X1 | ICD10CM | Covered |
| M20.5X2 | ICD10CM | Covered |
| M20.5X9 | ICD10CM | Covered |
| M21.611 | ICD10CM | Covered |
| M21.612 | ICD10CM | Covered |
| M21.619 | ICD10CM | Covered |
| M21.621 | ICD10CM | Covered |
| M21.622 | ICD10CM | Covered |
| M21.629 | ICD10CM | Covered |
| M24.441 | ICD10CM | Covered |
| M24.442 | ICD10CM | Covered |
| M24.443 | ICD10CM | Covered |
| M24.444 | ICD10CM | Covered |
| M24.445 | ICD10CM | Covered |
| M24.446 | ICD10CM | Covered |
| M65.261 | ICD10CM | Covered |
| M65.262 | ICD10CM | Covered |
| M65.271 | ICD10CM | Covered |
| M65.272 | ICD10CM | Covered |
| M65.29 | ICD10CM | Covered |
| M65.861 | ICD10CM | Covered |
| M65.862 | ICD10CM | Covered |
| M65.871 | ICD10CM | Covered |
| M65.872 | ICD10CM | Covered |
| M65.879 | ICD10CM | Covered |
| M66.271 | ICD10CM | Covered |
| M66.272 | ICD10CM | Covered |
| M66.361 | ICD10CM | Covered |
| M66.362 | ICD10CM | Covered |
| M67.01 | ICD10CM | Covered |
| M67.02 | ICD10CM | Covered |
| M67.371 | ICD10CM | Covered |
| M67.372 | ICD10CM | Covered |
| M67.379 | ICD10CM | Covered |
| M67.871 | ICD10CM | Covered |
| M67.872 | ICD10CM | Covered |
| M67.873 | ICD10CM | Covered |
| M67.874 | ICD10CM | Covered |
| M67.88 | ICD10CM | Covered |
| M72.2 | ICD10CM | Covered |
| M76.60 | ICD10CM | Covered |
| M76.61 | ICD10CM | Covered |
| M76.62 | ICD10CM | Covered |
| M76.71 | ICD10CM | Covered |
| M76.72 | ICD10CM | Covered |
| M76.811 | ICD10CM | Covered |
| M76.812 | ICD10CM | Covered |
| M76.819 | ICD10CM | Covered |
| M76.821 | ICD10CM | Covered |
| M76.822 | ICD10CM | Covered |
| M76.829 | ICD10CM | Covered |
| M84.374A | ICD10CM | Covered |
| M84.374D | ICD10CM | Covered |
| M84.375A | ICD10CM | Covered |
| M84.375D | ICD10CM | Covered |
| M84.376A | ICD10CM | Covered |
| M84.376D | ICD10CM | Covered |
| M84.377A | ICD10CM | Covered |
| M84.377D | ICD10CM | Covered |
| M84.378A | ICD10CM | Covered |
| M84.378D | ICD10CM | Covered |
| M84.379A | ICD10CM | Covered |
| M84.379D | ICD10CM | Covered |
| Q66.89 | ICD10CM | Covered |
| S61.009A | ICD10CM | Covered |
| S61.209A | ICD10CM | Covered |
| S61.409A | ICD10CM | Covered |
| S62.501A-S62.509B | ICD10CM | Covered |
| S62.511A-S62.516B | ICD10CM | Covered |
| S62.521A-S62.526B | ICD10CM | Covered |
| S62.600A-S62.609B | ICD10CM | Covered |
| S62.610A-S62.619B | ICD10CM | Covered |
| S62.620A-S62.629B | ICD10CM | Covered |
| S62.630A-S62.639B | ICD10CM | Covered |
| S62.640A-S62.649B | ICD10CM | Covered |
| S62.650A-S62.659B | ICD10CM | Covered |
| S62.660A-S62.669B | ICD10CM | Covered |
| S62.90XA-S62.92XB | ICD10CM | Covered |
| S63.101A-S63.106A | ICD10CM | Covered |
| S63.111A-S63.116A | ICD10CM | Covered |
| S63.121A-S63.126A | ICD10CM | Covered |
| S63.200A-S63.209A | ICD10CM | Covered |
| S63.210A-S63.219A | ICD10CM | Covered |
| S63.220A-S63.229A | ICD10CM | Covered |
| S63.230A-S63.239A | ICD10CM | Covered |
| S63.240A-S63.249A | ICD10CM | Covered |
| S63.250A-S63.259A | ICD10CM | Covered |
| S63.260A-S63.269A | ICD10CM | Covered |
| S63.270A-S63.279A | ICD10CM | Covered |
| S63.280A-S63.289A | ICD10CM | Covered |
| S63.290A-S63.299A | ICD10CM | Covered |
| S82.51XA | ICD10CM | Covered |
| S82.51XD | ICD10CM | Covered |
| S82.52XA | ICD10CM | Covered |
| S82.52XD | ICD10CM | Covered |
| S82.54XA | ICD10CM | Covered |
| S82.54XD | ICD10CM | Covered |
| S82.55XA | ICD10CM | Covered |
| S82.55XD | ICD10CM | Covered |
| S82.61XA-S82.66XD | ICD10CM | Covered |
| S86.011A-S86.019D | ICD10CM | Covered |
| S86.311A | ICD10CM | Covered |
| S86.311D | ICD10CM | Covered |
| S86.312A | ICD10CM | Covered |
| S86.312D | ICD10CM | Covered |
| S86.391A | ICD10CM | Covered |
| S86.391D | ICD10CM | Covered |
| S86.392A | ICD10CM | Covered |
| S86.392D | ICD10CM | Covered |
| S91.109A | ICD10CM | Covered |
| S91.109D | ICD10CM | Covered |
| S91.309A | ICD10CM | Covered |
| S91.309D | ICD10CM | Covered |
| S92.011A-S92.016D | ICD10CM | Covered |
| S92.021A-S92.026D | ICD10CM | Covered |
| S92.031A-S92.036D | ICD10CM | Covered |
| S92.041A-S92.046D | ICD10CM | Covered |
| S92.051A-S92.056D | ICD10CM | Covered |
| S92.061A | ICD10CM | Covered |
| S92.061D | ICD10CM | Covered |
| S92.062A | ICD10CM | Covered |
| S92.062D | ICD10CM | Covered |
| S92.063A | ICD10CM | Covered |
| S92.063D | ICD10CM | Covered |
| S92.064A | ICD10CM | Covered |
| S92.064D | ICD10CM | Covered |
| S92.065A | ICD10CM | Covered |
| S92.065D | ICD10CM | Covered |
| S92.111A-S92.116D | ICD10CM | Covered |
| S92.121A-S92.126D | ICD10CM | Covered |
| S92.131A-S92.136D | ICD10CM | Covered |
| S92.141A-S92.146D | ICD10CM | Covered |
| S92.151A-S92.156D | ICD10CM | Covered |
| S92.191A | ICD10CM | Covered |
| S92.191D | ICD10CM | Covered |
| S92.192A | ICD10CM | Covered |
| S92.192D | ICD10CM | Covered |
| S92.201A-S92.209D | ICD10CM | Covered |
| S92.211A | ICD10CM | Covered |
| S92.211B | ICD10CM | Covered |
| S92.211D | ICD10CM | Covered |
| S92.212A | ICD10CM | Covered |
| S92.212B | ICD10CM | Covered |
| S92.212D | ICD10CM | Covered |
| S92.213A | ICD10CM | Covered |
| S92.213B | ICD10CM | Covered |
| S92.213D | ICD10CM | Covered |
| S92.214A | ICD10CM | Covered |
| S92.214B | ICD10CM | Covered |
| S92.214D | ICD10CM | Covered |
| S92.215A | ICD10CM | Covered |
| S92.215B | ICD10CM | Covered |
| S92.215D | ICD10CM | Covered |
| S92.221A-S92.226D | ICD10CM | Covered |
| S92.231A-S92.236D | ICD10CM | Covered |
| S92.241A-S92.246D | ICD10CM | Covered |
| S92.251A-S92.256D | ICD10CM | Covered |
| S92.301A-S92.309D | ICD10CM | Covered |
| S92.311A-S92.316D | ICD10CM | Covered |
| S92.321A-S92.326D | ICD10CM | Covered |
| S92.331A-S92.336D | ICD10CM | Covered |
| S92.341A-S92.346D | ICD10CM | Covered |
| S92.351A-S92.356D | ICD10CM | Covered |
| S92.401A-S92.406D | ICD10CM | Covered |
| S92.411A-S92.416D | ICD10CM | Covered |
| S92.421A-S92.426D | ICD10CM | Covered |
| S92.491A-S92.499D | ICD10CM | Covered |
| S92.501A-S92.506D | ICD10CM | Covered |
| S92.511A-S92.516D | ICD10CM | Covered |
| S92.521A-S92.526D | ICD10CM | Covered |
| S92.531A-S92.536D | ICD10CM | Covered |
| S92.591A-S92.599D | ICD10CM | Covered |
| S92.811A-S92.819D | ICD10CM | Covered |
| S92.911A-S92.919D | ICD10CM | Covered |
| S93.01XA | ICD10CM | Covered |
| S93.01XD | ICD10CM | Covered |
| S93.02XA | ICD10CM | Covered |
| S93.02XD | ICD10CM | Covered |
| S93.101A-S93.106D | ICD10CM | Covered |
| S93.111A-S93.119D | ICD10CM | Covered |
| S93.121A-S93.129D | ICD10CM | Covered |
| S93.131A-S93.139D | ICD10CM | Covered |
| S93.141A-S93.149D | ICD10CM | Covered |
| S93.301A-S93.306D | ICD10CM | Covered |
| S93.311A-S93.316D | ICD10CM | Covered |
| S93.321A-S93.326D | ICD10CM | Covered |
| S93.331A-S93.336D | ICD10CM | Covered |
| S93.401A-S93.409D | ICD10CM | Covered |
| S93.411A-S93.419D | ICD10CM | Covered |
| S93.421A-S93.429D | ICD10CM | Covered |
| S93.431A-S93.439D | ICD10CM | Covered |
| S93.491A-S93.499D | ICD10CM | Covered |
| S93.501A | ICD10CM | Covered |
| S93.501A-S93.509D | ICD10CM | Covered |
| S93.501D | ICD10CM | Covered |
| S93.502A | ICD10CM | Covered |
| S93.502D | ICD10CM | Covered |
| S93.504A | ICD10CM | Covered |
| S93.504D | ICD10CM | Covered |
| S93.505A | ICD10CM | Covered |
| S93.505D | ICD10CM | Covered |
| S93.506A | ICD10CM | Covered |
| S93.506D | ICD10CM | Covered |
| S93.509A | ICD10CM | Covered |
| S93.509D | ICD10CM | Covered |
| S93.511A-S93.519D | ICD10CM | Covered |
| S93.521A-S93.529D | ICD10CM | Covered |
| S93.601A-S93.609D | ICD10CM | Covered |
| S93.611A-S93.619D | ICD10CM | Covered |
| S93.621A-S93.629D | ICD10CM | Covered |
| S93.691A-S93.699D | ICD10CM | Covered |
| S96.011A | ICD10CM | Covered |
| S96.011D | ICD10CM | Covered |
| S96.012A | ICD10CM | Covered |
| S96.012D | ICD10CM | Covered |
| S96.019A | ICD10CM | Covered |
| S96.019D | ICD10CM | Covered |
| S96.111A-S96.119D | ICD10CM | Covered |
| S96.211A-S96.219D | ICD10CM | Covered |
| S96.811A-S96.819D | ICD10CM | Covered |
| S96.911A-S96.919D | ICD10CM | Covered |
| S99.001A-S99.009D | ICD10CM | Covered |
| S99.011A-S99.019D | ICD10CM | Covered |
| S99.021A-S99.029D | ICD10CM | Covered |
| S99.101A-S99.109D | ICD10CM | Covered |
| S99.111A-S99.119D | ICD10CM | Covered |
| S99.121A-S99.129D | ICD10CM | Covered |
| S99.131A-S99.139D | ICD10CM | Covered |
| S99.141A-S99.149D | ICD10CM | Covered |
| S99.191A-S99.199D | ICD10CM | Covered |
| S99.201A-S99.209D | ICD10CM | Covered |
| S99.211A-S99.219D | ICD10CM | Covered |
| S99.221A-S99.229D | ICD10CM | Covered |
| S99.231A-S99.239D | ICD10CM | Covered |
| S99.241A-S99.249D | ICD10CM | Covered |
| S99.291A-S99.299D | ICD10CM | Covered |