Policy source
The recorded policy does not contain a public text excerpt. Read the official source for details.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| 67028 | HCPCS | Covered |
| C9257 | HCPCS | Covered |
| J3590 | HCPCS | Covered |
| J9035 | HCPCS | Covered |
| Q5107 | HCPCS | Covered |
| Q5118 | HCPCS | Covered |
| Q5126 | HCPCS | Covered |
| Q5129 | HCPCS | Covered |
| Q5160 | HCPCS | Covered |
| C17.0 | ICD10CM | Covered |
| C17.1 | ICD10CM | Covered |
| C17.2 | ICD10CM | Covered |
| C17.3 | ICD10CM | Covered |
| C17.8 | ICD10CM | Covered |
| C17.9 | ICD10CM | Covered |
| C18.0 | ICD10CM | Covered |
| C18.1 | ICD10CM | Covered |
| C18.2 | ICD10CM | Covered |
| C18.3 | ICD10CM | Covered |
| C18.4 | ICD10CM | Covered |
| C18.5 | ICD10CM | Covered |
| C18.6 | ICD10CM | Covered |
| C18.7 | ICD10CM | Covered |
| C18.8 | ICD10CM | Covered |
| C18.9 | ICD10CM | Covered |
| C19 | ICD10CM | Covered |
| C20 | ICD10CM | Covered |
| C21.2 | ICD10CM | Covered |
| C21.8 | ICD10CM | Covered |
| C22.0 | ICD10CM | Covered |
| C22.3 | ICD10CM | Covered |
| C22.8 | ICD10CM | Covered |
| C22.9 | ICD10CM | Covered |
| C24.1 | ICD10CM | Covered |
| C33 | ICD10CM | Covered |
| C34.00 | ICD10CM | Covered |
| C34.01 | ICD10CM | Covered |
| C34.02 | ICD10CM | Covered |
| C34.10 | ICD10CM | Covered |
| C34.11 | ICD10CM | Covered |
| C34.12 | ICD10CM | Covered |
| C34.2 | ICD10CM | Covered |
| C34.30 | ICD10CM | Covered |
| C34.31 | ICD10CM | Covered |
| C34.32 | ICD10CM | Covered |
| C34.80 | ICD10CM | Covered |
| C34.81 | ICD10CM | Covered |
| C34.82 | ICD10CM | Covered |
| C34.90 | ICD10CM | Covered |
| C34.91 | ICD10CM | Covered |
| C34.92 | ICD10CM | Covered |
| C38.4 | ICD10CM | Covered |
| C45.0 | ICD10CM | Covered |
| C45.1 | ICD10CM | Covered |
| C45.2 | ICD10CM | Covered |
| C45.7 | ICD10CM | Covered |
| C46.0 | ICD10CM | Covered |
| C46.1 | ICD10CM | Covered |
| C46.2 | ICD10CM | Covered |
| C46.3 | ICD10CM | Covered |
| C46.4 | ICD10CM | Covered |
| C46.51 | ICD10CM | Covered |
| C46.52 | ICD10CM | Covered |
| C46.7 | ICD10CM | Covered |
| C48.0 | ICD10CM | Covered |
| C48.1 | ICD10CM | Covered |
| C48.2 | ICD10CM | Covered |
| C48.8 | ICD10CM | Covered |
| C49.0 | ICD10CM | Covered |
| C49.10 | ICD10CM | Covered |
| C49.11 | ICD10CM | Covered |
| C49.12 | ICD10CM | Covered |
| C49.20 | ICD10CM | Covered |
| C49.21 | ICD10CM | Covered |
| C49.22 | ICD10CM | Covered |
| C49.3 | ICD10CM | Covered |
| C49.4 | ICD10CM | Covered |
| C49.5 | ICD10CM | Covered |
| C49.6 | ICD10CM | Covered |
| C49.8 | ICD10CM | Covered |
| C49.9 | ICD10CM | Covered |
| C50.011 | ICD10CM | Covered |
| C50.012 | ICD10CM | Covered |
| C50.019 | ICD10CM | Covered |
| C50.021 | ICD10CM | Covered |
| C50.022 | ICD10CM | Covered |
| C50.029 | ICD10CM | Covered |
| C50.111 | ICD10CM | Covered |
| C50.112 | ICD10CM | Covered |
| C50.119 | ICD10CM | Covered |
| C50.121 | ICD10CM | Covered |
| C50.122 | ICD10CM | Covered |
| C50.129 | ICD10CM | Covered |
| C50.211 | ICD10CM | Covered |
| C50.212 | ICD10CM | Covered |
| C50.219 | ICD10CM | Covered |
| C50.221 | ICD10CM | Covered |
| C50.222 | ICD10CM | Covered |
| C50.229 | ICD10CM | Covered |
| C50.311 | ICD10CM | Covered |
| C50.312 | ICD10CM | Covered |
| C50.319 | ICD10CM | Covered |
| C50.321 | ICD10CM | Covered |
| C50.322 | ICD10CM | Covered |
| C50.329 | ICD10CM | Covered |
| C50.411 | ICD10CM | Covered |
| C50.412 | ICD10CM | Covered |
| C50.419 | ICD10CM | Covered |
| C50.421 | ICD10CM | Covered |
| C50.422 | ICD10CM | Covered |
| C50.429 | ICD10CM | Covered |
| C50.511 | ICD10CM | Covered |
| C50.512 | ICD10CM | Covered |
| C50.519 | ICD10CM | Covered |
| C50.521 | ICD10CM | Covered |
| C50.522 | ICD10CM | Covered |
| C50.529 | ICD10CM | Covered |
| C50.611 | ICD10CM | Covered |
| C50.612 | ICD10CM | Covered |
| C50.619 | ICD10CM | Covered |
| C50.621 | ICD10CM | Covered |
| C50.622 | ICD10CM | Covered |
| C50.629 | ICD10CM | Covered |
| C50.811 | ICD10CM | Covered |
| C50.812 | ICD10CM | Covered |
| C50.819 | ICD10CM | Covered |
| C50.821 | ICD10CM | Covered |
| C50.822 | ICD10CM | Covered |
| C50.829 | ICD10CM | Covered |
| C50.911 | ICD10CM | Covered |
| C50.912 | ICD10CM | Covered |
| C50.919 | ICD10CM | Covered |
| C50.921 | ICD10CM | Covered |
| C50.922 | ICD10CM | Covered |
| C50.929 | ICD10CM | Covered |
| C50.A1 | ICD10CM | Covered |
| C50.A2 | ICD10CM | Covered |
| C51.0 | ICD10CM | Covered |
| C51.1 | ICD10CM | Covered |
| C51.2 | ICD10CM | Covered |
| C51.8 | ICD10CM | Covered |
| C52 | ICD10CM | Covered |
| C53.0 | ICD10CM | Covered |
| C53.1 | ICD10CM | Covered |
| C53.8 | ICD10CM | Covered |
| C53.9 | ICD10CM | Covered |
| C54.0 | ICD10CM | Covered |
| C54.1 | ICD10CM | Covered |
| C54.2 | ICD10CM | Covered |
| C54.3 | ICD10CM | Covered |
| C54.8 | ICD10CM | Covered |
| C54.9 | ICD10CM | Covered |
| C56.1 | ICD10CM | Covered |
| C56.2 | ICD10CM | Covered |
| C56.3 | ICD10CM | Covered |
| C56.9 | ICD10CM | Covered |
| C57.00 | ICD10CM | Covered |
| C57.01 | ICD10CM | Covered |
| C57.02 | ICD10CM | Covered |
| C57.10 | ICD10CM | Covered |
| C57.11 | ICD10CM | Covered |
| C57.12 | ICD10CM | Covered |
| C57.20 | ICD10CM | Covered |
| C57.21 | ICD10CM | Covered |
| C57.22 | ICD10CM | Covered |
| C57.3 | ICD10CM | Covered |
| C57.4 | ICD10CM | Covered |
| C57.7 | ICD10CM | Covered |
| C57.8 | ICD10CM | Covered |
| C57.9 | ICD10CM | Covered |
| C61 | ICD10CM | Covered |
| C64.1 | ICD10CM | Covered |
| C64.2 | ICD10CM | Covered |
| C64.9 | ICD10CM | Covered |
| C65.1 | ICD10CM | Covered |
| C65.2 | ICD10CM | Covered |
| C65.9 | ICD10CM | Covered |
| C70.0 | ICD10CM | Covered |
| C70.1 | ICD10CM | Covered |
| C71.0 | ICD10CM | Covered |
| C71.1 | ICD10CM | Covered |
| C71.2 | ICD10CM | Covered |
| C71.3 | ICD10CM | Covered |
| C71.4 | ICD10CM | Covered |
| C71.5 | ICD10CM | Covered |
| C71.6 | ICD10CM | Covered |
| C71.7 | ICD10CM | Covered |
| C71.8 | ICD10CM | Covered |
| C71.9 | ICD10CM | Covered |
| C72.0 | ICD10CM | Covered |
| C72.1 | ICD10CM | Covered |
| C72.9 | ICD10CM | Covered |
| C73 | ICD10CM | Covered |
| C78.01 | ICD10CM | Covered |
| C78.02 | ICD10CM | Covered |
| C78.6 | ICD10CM | Covered |
| C78.7 | ICD10CM | Covered |
| C79.31 | ICD10CM | Covered |
| C79.51 | ICD10CM | Covered |
| C83.30 | ICD10CM | Covered |
| C83.31 | ICD10CM | Covered |
| C83.390 | ICD10CM | Covered |
| C83.398 | ICD10CM | Covered |
| C83.3A | ICD10CM | Covered |
| C83.59 | ICD10CM | Covered |
| C83.79 | ICD10CM | Covered |
| C83.80 | ICD10CM | Covered |
| C83.81 | ICD10CM | Covered |
| C83.89 | ICD10CM | Covered |
| C84.49 | ICD10CM | Covered |
| C85.89 | ICD10CM | Covered |
| C90.00 | ICD10CM | Covered |
| C90.01 | ICD10CM | Covered |
| C90.02 | ICD10CM | Covered |
| C90.20 | ICD10CM | Covered |
| C90.21 | ICD10CM | Covered |
| C90.22 | ICD10CM | Covered |
| C90.30 | ICD10CM | Covered |
| C90.31 | ICD10CM | Covered |
| C90.32 | ICD10CM | Covered |
| C94.30 | ICD10CM | Covered |
| C94.31 | ICD10CM | Covered |
| C94.32 | ICD10CM | Covered |
| C96.20 | ICD10CM | Covered |
| C96.21 | ICD10CM | Covered |
| C96.22 | ICD10CM | Covered |
| C96.29 | ICD10CM | Covered |
| D05.11 | ICD10CM | Covered |
| D05.12 | ICD10CM | Covered |
| D05.81 | ICD10CM | Covered |
| D05.82 | ICD10CM | Covered |
| D19.1 | ICD10CM | Covered |
| D32.0 | ICD10CM | Covered |
| D32.1 | ICD10CM | Covered |
| D37.3 | ICD10CM | Covered |
| D42.0 | ICD10CM | Covered |
| D42.1 | ICD10CM | Covered |
| D43.0 | ICD10CM | Covered |
| D43.1 | ICD10CM | Covered |
| D43.2 | ICD10CM | Covered |
| D43.4 | ICD10CM | Covered |
| D47.02 | ICD10CM | Covered |
| D48.0 | ICD10CM | Covered |
| D49.2 | ICD10CM | Covered |
| E08.311 | ICD10CM | Covered |
| E08.3211 | ICD10CM | Covered |
| E08.3212 | ICD10CM | Covered |
| E08.3213 | ICD10CM | Covered |
| E08.3311 | ICD10CM | Covered |
| E08.3312 | ICD10CM | Covered |
| E08.3313 | ICD10CM | Covered |
| E08.3411 | ICD10CM | Covered |
| E08.3412 | ICD10CM | Covered |
| E08.3413 | ICD10CM | Covered |
| E08.3511 | ICD10CM | Covered |
| E08.3512 | ICD10CM | Covered |
| E08.3513 | ICD10CM | Covered |
| E08.3521 | ICD10CM | Covered |
| E08.3522 | ICD10CM | Covered |
| E08.3523 | ICD10CM | Covered |
| E08.3531 | ICD10CM | Covered |
| E08.3532 | ICD10CM | Covered |
| E08.3533 | ICD10CM | Covered |
| E08.3541 | ICD10CM | Covered |
| E08.3542 | ICD10CM | Covered |
| E08.3543 | ICD10CM | Covered |
| E08.3551 | ICD10CM | Covered |
| E08.3552 | ICD10CM | Covered |
| E08.3553 | ICD10CM | Covered |
| E08.3591 | ICD10CM | Covered |
| E08.3592 | ICD10CM | Covered |
| E08.3593 | ICD10CM | Covered |
| E09.311 | ICD10CM | Covered |
| E09.3211 | ICD10CM | Covered |
| E09.3212 | ICD10CM | Covered |
| E09.3213 | ICD10CM | Covered |
| E09.3311 | ICD10CM | Covered |
| E09.3312 | ICD10CM | Covered |
| E09.3313 | ICD10CM | Covered |
| E09.3411 | ICD10CM | Covered |
| E09.3412 | ICD10CM | Covered |
| E09.3413 | ICD10CM | Covered |
| E09.3511 | ICD10CM | Covered |
| E09.3512 | ICD10CM | Covered |
| E09.3513 | ICD10CM | Covered |
| E09.3521 | ICD10CM | Covered |
| E09.3522 | ICD10CM | Covered |
| E09.3523 | ICD10CM | Covered |
| E09.3531 | ICD10CM | Covered |
| E09.3532 | ICD10CM | Covered |
| E09.3533 | ICD10CM | Covered |
| E09.3541 | ICD10CM | Covered |
| E09.3542 | ICD10CM | Covered |
| E09.3543 | ICD10CM | Covered |
| E09.3551 | ICD10CM | Covered |
| E09.3552 | ICD10CM | Covered |
| E09.3553 | ICD10CM | Covered |
| E09.3591 | ICD10CM | Covered |
| E09.3592 | ICD10CM | Covered |
| E09.3593 | ICD10CM | Covered |
| E10.311 | ICD10CM | Covered |
| E10.3211 | ICD10CM | Covered |
| E10.3212 | ICD10CM | Covered |
| E10.3213 | ICD10CM | Covered |
| E10.3311 | ICD10CM | Covered |
| E10.3312 | ICD10CM | Covered |
| E10.3313 | ICD10CM | Covered |
| E10.3411 | ICD10CM | Covered |
| E10.3412 | ICD10CM | Covered |
| E10.3413 | ICD10CM | Covered |
| E10.3511 | ICD10CM | Covered |
| E10.3512 | ICD10CM | Covered |
| E10.3513 | ICD10CM | Covered |
| E10.3521 | ICD10CM | Covered |
| E10.3522 | ICD10CM | Covered |
| E10.3523 | ICD10CM | Covered |
| E10.3531 | ICD10CM | Covered |
| E10.3532 | ICD10CM | Covered |
| E10.3533 | ICD10CM | Covered |
| E10.3541 | ICD10CM | Covered |
| E10.3542 | ICD10CM | Covered |
| E10.3543 | ICD10CM | Covered |
| E10.3551 | ICD10CM | Covered |
| E10.3552 | ICD10CM | Covered |
| E10.3553 | ICD10CM | Covered |
| E10.3591 | ICD10CM | Covered |
| E10.3592 | ICD10CM | Covered |
| E10.3593 | ICD10CM | Covered |
| E11.311 | ICD10CM | Covered |
| E11.3211 | ICD10CM | Covered |
| E11.3212 | ICD10CM | Covered |
| E11.3213 | ICD10CM | Covered |
| E11.3311 | ICD10CM | Covered |
| E11.3312 | ICD10CM | Covered |
| E11.3313 | ICD10CM | Covered |
| E11.3411 | ICD10CM | Covered |
| E11.3412 | ICD10CM | Covered |
| E11.3413 | ICD10CM | Covered |
| E11.3511 | ICD10CM | Covered |
| E11.3512 | ICD10CM | Covered |
| E11.3513 | ICD10CM | Covered |
| E11.3521 | ICD10CM | Covered |
| E11.3522 | ICD10CM | Covered |
| E11.3523 | ICD10CM | Covered |
| E11.3531 | ICD10CM | Covered |
| E11.3532 | ICD10CM | Covered |
| E11.3533 | ICD10CM | Covered |
| E11.3541 | ICD10CM | Covered |
| E11.3542 | ICD10CM | Covered |
| E11.3543 | ICD10CM | Covered |
| E11.3551 | ICD10CM | Covered |
| E11.3552 | ICD10CM | Covered |
| E11.3553 | ICD10CM | Covered |
| E11.3591 | ICD10CM | Covered |
| E11.3592 | ICD10CM | Covered |
| E11.3593 | ICD10CM | Covered |
| E11.A | ICD10CM | Covered |
| E13.311 | ICD10CM | Covered |
| E13.3211 | ICD10CM | Covered |
| E13.3212 | ICD10CM | Covered |
| E13.3213 | ICD10CM | Covered |
| E13.3311 | ICD10CM | Covered |
| E13.3312 | ICD10CM | Covered |
| E13.3313 | ICD10CM | Covered |
| E13.3411 | ICD10CM | Covered |
| E13.3412 | ICD10CM | Covered |
| E13.3413 | ICD10CM | Covered |
| E13.3511 | ICD10CM | Covered |
| E13.3512 | ICD10CM | Covered |
| E13.3513 | ICD10CM | Covered |
| E13.3521 | ICD10CM | Covered |
| E13.3522 | ICD10CM | Covered |
| E13.3523 | ICD10CM | Covered |
| E13.3531 | ICD10CM | Covered |
| E13.3532 | ICD10CM | Covered |
| E13.3533 | ICD10CM | Covered |
| E13.3541 | ICD10CM | Covered |
| E13.3542 | ICD10CM | Covered |
| E13.3543 | ICD10CM | Covered |
| E13.3551 | ICD10CM | Covered |
| E13.3552 | ICD10CM | Covered |
| E13.3553 | ICD10CM | Covered |
| E13.3591 | ICD10CM | Covered |
| E13.3592 | ICD10CM | Covered |
| E13.3593 | ICD10CM | Covered |
| G93.6 | ICD10CM | Covered |
| G96.89 | ICD10CM | Covered |
| H21.1X1 | ICD10CM | Covered |
| H21.1X2 | ICD10CM | Covered |
| H21.1X3 | ICD10CM | Covered |
| H21.1X9 | ICD10CM | Covered |
| H34.8110 | ICD10CM | Covered |
| H34.8111 | ICD10CM | Covered |
| H34.8112 | ICD10CM | Covered |
| H34.8120 | ICD10CM | Covered |
| H34.8121 | ICD10CM | Covered |
| H34.8122 | ICD10CM | Covered |
| H34.8130 | ICD10CM | Covered |
| H34.8131 | ICD10CM | Covered |
| H34.8132 | ICD10CM | Covered |
| H34.8310 | ICD10CM | Covered |
| H34.8311 | ICD10CM | Covered |
| H34.8312 | ICD10CM | Covered |
| H34.8320 | ICD10CM | Covered |
| H34.8321 | ICD10CM | Covered |
| H34.8322 | ICD10CM | Covered |
| H34.8330 | ICD10CM | Covered |
| H34.8331 | ICD10CM | Covered |
| H34.8332 | ICD10CM | Covered |
| H35.051 | ICD10CM | Covered |
| H35.052 | ICD10CM | Covered |
| H35.053 | ICD10CM | Covered |
| H35.059 | ICD10CM | Covered |
| H35.3210 | ICD10CM | Covered |
| H35.3211 | ICD10CM | Covered |
| H35.3212 | ICD10CM | Covered |
| H35.3213 | ICD10CM | Covered |
| H35.3220 | ICD10CM | Covered |
| H35.3221 | ICD10CM | Covered |
| H35.3222 | ICD10CM | Covered |
| H35.3223 | ICD10CM | Covered |
| H35.3230 | ICD10CM | Covered |
| H35.3231 | ICD10CM | Covered |
| H35.3232 | ICD10CM | Covered |
| H35.3233 | ICD10CM | Covered |
| H35.351 | ICD10CM | Covered |
| H35.352 | ICD10CM | Covered |
| H35.353 | ICD10CM | Covered |
| H35.359 | ICD10CM | Covered |
| H35.81 | ICD10CM | Covered |
| H40.841 | ICD10CM | Covered |
| H40.842 | ICD10CM | Covered |
| H40.843 | ICD10CM | Covered |
| H40.89 | ICD10CM | Covered |
| H44.2A1 | ICD10CM | Covered |
| H44.2A2 | ICD10CM | Covered |
| H44.2A3 | ICD10CM | Covered |
| I67.89 | ICD10CM | Covered |
| I78.0 | ICD10CM | Covered |
| K31.811 | ICD10CM | Covered |
| Q27.33 | ICD10CM | Covered |
| Q85.02 | ICD10CM | Covered |
| Q85.03 | ICD10CM | Covered |
| Q85.83 | ICD10CM | Covered |
| T66.XXXA | ICD10CM | Covered |
| T66.XXXD | ICD10CM | Covered |
| T66.XXXS | ICD10CM | Covered |
| Y84.2 | ICD10CM | Covered |
| Z79.810 | ICD10CM | Covered |
| Z85.038 | ICD10CM | Covered |
| Z85.048 | ICD10CM | Covered |
| Z85.068 | ICD10CM | Covered |
| Z85.09 | ICD10CM | Covered |
| Z85.118 | ICD10CM | Covered |
| Z85.3 | ICD10CM | Covered |
| Z85.41 | ICD10CM | Covered |
| Z85.42 | ICD10CM | Covered |
| Z85.43 | ICD10CM | Covered |
| Z85.44 | ICD10CM | Covered |
| Z85.46 | ICD10CM | Covered |
| Z85.4A | ICD10CM | Covered |
| Z85.528 | ICD10CM | Covered |
| Z85.53 | ICD10CM | Covered |
| Z85.831 | ICD10CM | Covered |
| Z85.841 | ICD10CM | Covered |
| Z85.848 | ICD10CM | Covered |
| Z86.00A | ICD10CM | Covered |