Medicare coverage support for a code and diagnosis
GET /v1/coverage/medicare
GET https://api.healthcare.dev/v1/coverage/medicarePro plan and up (403 plan-upgrade-required below Pro). Whether Medicare's local coverage documents (LCDs and their billing and coding articles in the CMS Medicare Coverage Database) list an ICD-10-CM diagnosis as supporting medical necessity for a procedure code (HCPCS Level II or a CPT number), per document and overall: supported, not_supported or unclear. state limits it to the documents that apply there. Every answer says how it was reached: derivation: source_stated with confidence: 1 when the document lists the diagnosis for the code (or says unlisted diagnoses don't support it); unclear answers (narrative criteria, extra conditions, lists not tied to the code) have confidence: 0. evidence links the CMS Medicare Coverage Database page and section to check. No document listing the code means no local policy found: unclear with an empty results. Each account (all its keys together) can look up a limited number of different code and diagnosis pairs a day; repeats and failed lookups don't count (429 enumeration-limit past it, until 00:00 UTC). Reference data, not a coverage determination.
Requires an API key: Authorization: Bearer hdev_live_.... See Authentication.
Query parameters
| Name | Type | Required | Description | Example |
|---|---|---|---|---|
code | string | yes | HCPCS Level II code or CPT code number | 11720 |
dx | string | yes | ICD-10-CM code, with or without the dot | B35.1 |
state | string | no | Two-letter state or territory (USPS) | TX |
view | "compact" | "standard" | "full" | no | How much of each record to return (default full). compact: code, dx, state, disclaimer, coverage, basis (fewest tokens, for agents). standard: every field. full: every field. | compact |
fields | string | no | Comma-separated fields to return instead of a view. Valid fields: code, dx, state, disclaimer, coverage, basis, results. | code,dx,state |
Examples
curl
curl "https://api.healthcare.dev/v1/coverage/medicare?code=11720&dx=B35.1" \
-H "Authorization: Bearer $HDEV_API_KEY"TypeScript
const res = await fetch("https://api.healthcare.dev/v1/coverage/medicare?code=11720&dx=B35.1", {
headers: { Authorization: `Bearer ${process.env.HDEV_API_KEY}` },
});
const { data, meta } = await res.json();Python
import os
import requests
res = requests.get("https://api.healthcare.dev/v1/coverage/medicare?code=11720&dx=B35.1", headers={"Authorization": f"Bearer {os.environ['HDEV_API_KEY']}"})
body = res.json()Try it
Response
Coverage support per document and overall
{
"data": {
"code": "string",
"dx": "string",
"state": "string",
"disclaimer": "Reference data, not a coverage determination.",
"coverage": {
"answer": "supported",
"confidence": 0,
"derivation": "source_stated",
"evidence": [
{
"url": null,
"anchor": null
}
],
"as_of": "2026-10-24T12:00:00Z"
},
"basis": "dx_listed_as_supporting",
"results": [
{
"document": null,
"states": [
null
],
"state_regions": [
null
],
"coverage": null,
"basis": "dx_listed_as_supporting",
"context": true
}
]
},
"meta": {
"source": "cms-icd10",
"data_version": "2026.1",
"retrieved_at": "2026-10-24T12:00:00Z",
"license": "Public domain (CMS). Reference data, not medical advice."
},
"links": {
"self": "/v1/coverage/medicare?code=11720&dx=B35.1",
"next": null
}
}Fields
| Field | Type | Always present | Description |
|---|---|---|---|
code | string | yes | |
dx | string | yes | The diagnosis, as ICD-10-CM with the dot |
state | string | null | yes | |
disclaimer | "Reference data, not a coverage determination." | yes | |
coverage | object | yes | Across the documents below (not counting context ones): their answer when they agree, otherwise unclear |
basis | "dx_listed_as_supporting" | "dx_listed_as_not_supporting" | "dx_not_listed" | "conditional" | "conflicting_lists" | "pairing_not_stated" | "no_dx_list" | "documents_agree" | "documents_disagree" | "no_document_lists_code" | yes | What the answer rests on. Per document: dx_listed_as_supporting / dx_listed_as_not_supporting (the diagnosis is on that list for this code), dx_not_listed (not on the document's lists; not_supported only when the document says unlisted diagnoses don't support the code), conditional (listed, but with extra conditions such as another diagnosis on the claim), conflicting_lists, pairing_not_stated (listed, but the document doesn't tie that list to this code), no_dx_list (the criteria are narrative only). Overall: documents_agree, documents_disagree, no_document_lists_code. |
results | CoverageResult[] | yes | One per LCD or article that lists the code |
Errors
Errors are application/problem+json (RFC 9457). Branch on type, not on title. See Errors.
| Status | type | When |
|---|---|---|
| 400 | invalid-request | A parameter or the body failed validation; errors lists each field. |
| 401 | unauthorized | Missing, malformed or revoked API key. |
| 403 | plan-upgrade-required | The plan doesn't include this feature; required_plan names the plan that does. |
| 404 | not-found | No record with that id (retired records are still returned). |
| 429 | rate-limited / quota-exceeded | Too many requests per second (retry after Retry-After), or the monthly quota is used up. |
| 503 | dataset-unavailable / unavailable | The dataset has no published version yet, or the service is degraded. |