Check Medicare coverage for a code and diagnosis

1. Check the diagnosis code (any plan)Copy Anchor Link

Send the full billable ICD-10-CM code. A category such as B35 matches only where a document lists the category itself, so check first that the code is billable:

curl https://api.healthcare.dev/v1/codes/icd10cm/B35.1 \
  -H "Authorization: Bearer $HDEV_API_KEY" | jq '.data | {code, display, billable, status}'

2. Ask for coverage supportCopy Anchor Link

curl "https://api.healthcare.dev/v1/coverage/medicare?code=11720&dx=B35.1&state=TX&view=compact" \
  -H "Authorization: Bearer $HDEV_API_KEY"

{
  "data": {
    "code": "11720",
    "dx": "B35.1",
    "state": "TX",
    "disclaimer": "Reference data, not a coverage determination.",
    "coverage": {
      "answer": "supported",
      "confidence": 1,
      "derivation": "source_stated",
      "evidence": [
        {
          "url": "https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=56640&ver=16",
          "anchor": "h3Icd10SupportHeader"
        }
      ],
      "as_of": "2026-10-19T06:55:00.000Z"
    },
    "basis": "documents_agree"
  }
}

Leave out view=compact (the default is full) to get results: one entry per LCD or billing article that lists the code, each with its own answer, basis and document.

TypeScript

import { HealthcareDev, PlanUpgradeRequiredError } from "@healthcare.dev/sdk";

const hdev = new HealthcareDev();

try {
  const { data } = await hdev.coverage.medicare({ code: "11720", dx: "B35.1", state: "TX" });
  const { answer, derivation, confidence, evidence } = data.coverage;
  console.log(answer, derivation, confidence, evidence[0]?.url);
  for (const r of data.results ?? []) console.log(r.document.id, r.coverage.answer, r.basis);
  console.log(data.disclaimer); // show it with the answer
} catch (err) {
  if (err instanceof PlanUpgradeRequiredError) console.log(`Needs the ${err.requiredPlan} plan`);
  else throw err;
}

Python

from healthcare_dev import HealthcareDev

hdev = HealthcareDev()

cov = hdev.coverage.medicare(code="11720", dx="B35.1", state="TX")["data"]
c = cov["coverage"]
print(c["answer"], c["derivation"], c["confidence"], [e["url"] for e in c["evidence"]])
for r in cov.get("results", []):
    print(r["document"]["id"], r["coverage"]["answer"], r["basis"])
print(cov["disclaimer"])

Ask an agentCopy Anchor Link

Does Medicare support HCPCS/CPT code 11720 for diagnosis B35.1 in Texas? Tell me the answer, how it was reached (derivation and confidence), and link the CMS document section to read. Remind me this isn't a coverage determination.

The agent uses check_medicare_coverage (and lookup_code for the diagnosis).

Read the answerCopy Anchor Link

coverage.answer is one of three:

• supported: a document lists the diagnosis among the codes that support medical necessity for this code.
• not_supported: a document lists it among the codes that don't, or says unlisted diagnoses don't support the code and this one isn't listed.
• unclear: the documents don't settle it (narrative criteria only, extra conditions, lists not tied to this code), or they disagree. No document listing the code at all is also unclear, with empty results: there is no local policy for it.

Every answer says how it was reached:

• derivation: source_stated means the CMS document states it in its published code lists and we only read the list (every supported and not_supported). derived means we concluded it from what the document says, without the document stating it outright (every unclear). reviewed means a person checked it.
• confidence: from 0 to 1. 1 when the document states the answer, 0 for unclear. Don't act on an answer below your own threshold without reading the evidence.
• evidence: the document's page in the Medicare Coverage Database and the section (anchor) to read. We serve facts and links, never the policy text.
• as_of: when CMS published the export the answer was read from.

What it is notCopy Anchor Link

Reference data, not a coverage determination. A listed diagnosis doesn't guarantee payment: the service must still be reasonable and necessary, meet the LCD's criteria, and be supported by the medical record. It is not prior authorization, a Medicare Advantage plan's criteria (see MA internal criteria) or a payment amount. CPT codes are served as numbers only, never with their descriptions.

Next: get pushed when a coverage document changes, in Keep your data fresh.