# Check Medicare coverage for a code and diagnosis URL: https://docs.healthcare.dev/recipes/medicare-coverage | | | | ---------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | Plan | **Pro**, or a preview on Free and Builder (below). `as_of`, the answer on a past date, is **Team** | | Datasets | [Medicare coverage support](/datasets/medicare-coverage) (CMS Medicare Coverage Database), [ICD-10-CM](/datasets/icd10cm) (every plan) | | Calls per answer | 1, plus 1 if you check the diagnosis code first | | Limits | Each account can look up a limited number of different code and diagnosis pairs a day (5,000 on Pro, 20,000 on Team; previews have [their own](/rate-limits#daily-lookup-limits-on-derived-data)); repeats don't count | Free and Builder keys can call it as a preview: 50 preview calls a month on Free, 200 on Builder, per feature. A preview answer is the real answer, with `meta.preview` (calls `remaining` this month and the plan that `unlocks` it) and `links.upgrade`. Preview calls count toward your included calls. Once they're used up, the `403` `plan-upgrade-required` adds `upgrade_url` and a sample answer for a fixed demo subject. See [Plans](/plans#previews). ## 1. Check the diagnosis code (any plan) 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: ```sh 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 support ```sh curl "https://api.healthcare.dev/v1/coverage/medicare?code=11720&dx=B35.1&state=TX&view=compact" \ -H "Authorization: Bearer $HDEV_API_KEY" ``` ```json { "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** ```ts 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** ```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 agent > 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 answer `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 not **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](/recipes/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](/recipes/keep-data-fresh).