# Medicare coverage support for a code and diagnosis

URL: https://docs.healthcare.dev/reference/coverage/medicare-coverage-support-for-a-code-and-diagnosis

```http
GET https://api.healthcare.dev/v1/coverage/medicare
```

Pro 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](/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**

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

**TypeScript**

```ts
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**

```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()
```

## Response

Coverage support per document and overall

```json
{
  "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](https://www.rfc-editor.org/rfc/rfc9457)). Branch on `type`, not on `title`. See [Errors](/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. |