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 |
|---|---|---|
| 67027 | HCPCS | Covered |
| 67028 | HCPCS | Covered |
| C9399 | HCPCS | Covered |
| J0177 | HCPCS | Covered |
| J0178 | HCPCS | Covered |
| J0179 | HCPCS | Covered |
| J2777 | HCPCS | Covered |
| J2778 | HCPCS | Covered |
| J2779 | HCPCS | Covered |
| J3490 | HCPCS | Covered |
| J3590 | HCPCS | Covered |
| Q5124 | HCPCS | Covered |
| Q5128 | HCPCS | Covered |
| Q5147 | HCPCS | Covered |
| Q5149 | HCPCS | Covered |
| Q5150 | HCPCS | Covered |
| Q5153 | HCPCS | Covered |
| Q5155 | HCPCS | Covered |
| Q5168 | HCPCS | Covered |
| Q5170 | HCPCS | Covered |
| E08.311 | ICD10CM | Covered |
| E08.319 | ICD10CM | Covered |
| E08.3211 | ICD10CM | Covered |
| E08.3212 | ICD10CM | Covered |
| E08.3213 | ICD10CM | Covered |
| E08.3291 | ICD10CM | Covered |
| E08.3292 | ICD10CM | Covered |
| E08.3293 | ICD10CM | Covered |
| E08.3311 | ICD10CM | Covered |
| E08.3312 | ICD10CM | Covered |
| E08.3313 | ICD10CM | Covered |
| E08.3391 | ICD10CM | Covered |
| E08.3392 | ICD10CM | Covered |
| E08.3393 | ICD10CM | Covered |
| E08.3411 | ICD10CM | Covered |
| E08.3412 | ICD10CM | Covered |
| E08.3413 | ICD10CM | Covered |
| E08.3491 | ICD10CM | Covered |
| E08.3492 | ICD10CM | Covered |
| E08.3493 | 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 |
| E09.319 | ICD10CM | Covered |
| E09.3211 | ICD10CM | Covered |
| E09.3212 | ICD10CM | Covered |
| E09.3213 | ICD10CM | Covered |
| E09.3291 | ICD10CM | Covered |
| E09.3292 | ICD10CM | Covered |
| E09.3293 | ICD10CM | Covered |
| E09.3311 | ICD10CM | Covered |
| E09.3312 | ICD10CM | Covered |
| E09.3313 | ICD10CM | Covered |
| E09.3391 | ICD10CM | Covered |
| E09.3392 | ICD10CM | Covered |
| E09.3393 | ICD10CM | Covered |
| E09.3411 | ICD10CM | Covered |
| E09.3412 | ICD10CM | Covered |
| E09.3413 | ICD10CM | Covered |
| E09.3491 | ICD10CM | Covered |
| E09.3492 | ICD10CM | Covered |
| E09.3493 | 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 |
| E10.319 | ICD10CM | Covered |
| E10.3211 | ICD10CM | Covered |
| E10.3212 | ICD10CM | Covered |
| E10.3213 | ICD10CM | Covered |
| E10.3291 | ICD10CM | Covered |
| E10.3292 | ICD10CM | Covered |
| E10.3293 | ICD10CM | Covered |
| E10.3311 | ICD10CM | Covered |
| E10.3312 | ICD10CM | Covered |
| E10.3313 | ICD10CM | Covered |
| E10.3391 | ICD10CM | Covered |
| E10.3392 | ICD10CM | Covered |
| E10.3393 | ICD10CM | Covered |
| E10.3411 | ICD10CM | Covered |
| E10.3412 | ICD10CM | Covered |
| E10.3413 | ICD10CM | Covered |
| E10.3491 | ICD10CM | Covered |
| E10.3492 | ICD10CM | Covered |
| E10.3493 | 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 |
| E11.319 | ICD10CM | Covered |
| E11.3211 | ICD10CM | Covered |
| E11.3212 | ICD10CM | Covered |
| E11.3213 | ICD10CM | Covered |
| E11.3291 | ICD10CM | Covered |
| E11.3292 | ICD10CM | Covered |
| E11.3293 | ICD10CM | Covered |
| E11.3311 | ICD10CM | Covered |
| E11.3312 | ICD10CM | Covered |
| E11.3313 | ICD10CM | Covered |
| E11.3391 | ICD10CM | Covered |
| E11.3392 | ICD10CM | Covered |
| E11.3393 | ICD10CM | Covered |
| E11.3411 | ICD10CM | Covered |
| E11.3412 | ICD10CM | Covered |
| E11.3413 | ICD10CM | Covered |
| E11.3491 | ICD10CM | Covered |
| E11.3492 | ICD10CM | Covered |
| E11.3493 | 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 |
| E13.311 | ICD10CM | Covered |
| E13.319 | ICD10CM | Covered |
| E13.3211 | ICD10CM | Covered |
| E13.3212 | ICD10CM | Covered |
| E13.3213 | ICD10CM | Covered |
| E13.3291 | ICD10CM | Covered |
| E13.3292 | ICD10CM | Covered |
| E13.3293 | ICD10CM | Covered |
| E13.3311 | ICD10CM | Covered |
| E13.3312 | ICD10CM | Covered |
| E13.3313 | ICD10CM | Covered |
| E13.3391 | ICD10CM | Covered |
| E13.3392 | ICD10CM | Covered |
| E13.3393 | ICD10CM | Covered |
| E13.3411 | ICD10CM | Covered |
| E13.3412 | ICD10CM | Covered |
| E13.3413 | ICD10CM | Covered |
| E13.3491 | ICD10CM | Covered |
| E13.3492 | ICD10CM | Covered |
| E13.3493 | 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 |
| 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 |
| H35.3210 | 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 |
| H35.81 | ICD10CM | Covered |
| H44.2A1 | ICD10CM | Covered |
| H44.2A2 | ICD10CM | Covered |
| H44.2A3 | ICD10CM | Covered |