EviCore by Evernorth · PayerPolicy · EVICORE-MEDICAL_DRUG-85C35C32FFD7
Summary of the payer’s published policy. Not a coverage determination — confirm with EviCore by Evernorth 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 |
|---|---|---|
| J0172 | HCPCS | Covered with conditions |
| G300 | ICD10CM | Covered with conditions |
| G301 | ICD10CM | Covered with conditions |
| G308 | ICD10CM | Covered with conditions |
| G309 | ICD10CM | Covered with conditions |