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 |
|---|---|---|
| 19030 | HCPCS | Covered |
| 76641 | HCPCS | Covered |
| 76642 | HCPCS | Covered |
| 77046 | HCPCS | Covered |
| 77047 | HCPCS | Covered |
| 77048 | HCPCS | Covered |
| 77049 | HCPCS | Covered |
| 77053 | HCPCS | Covered |
| 77054 | HCPCS | Covered |
| C8903 | HCPCS | Covered |
| C8905 | HCPCS | Covered |
| C8906 | HCPCS | Covered |
| C8908 | HCPCS | Covered |
| C50.011 | ICD10CM | Covered |
| C50.012 | ICD10CM | Covered |
| C50.021 | ICD10CM | Covered |
| C50.022 | ICD10CM | Covered |
| C50.111 | ICD10CM | Covered |
| C50.112 | ICD10CM | Covered |
| C50.121 | ICD10CM | Covered |
| C50.122 | ICD10CM | Covered |
| C50.211 | ICD10CM | Covered |
| C50.212 | ICD10CM | Covered |
| C50.221 | ICD10CM | Covered |
| C50.222 | ICD10CM | Covered |
| C50.311 | ICD10CM | Covered |
| C50.312 | ICD10CM | Covered |
| C50.321 | ICD10CM | Covered |
| C50.322 | ICD10CM | Covered |
| C50.411 | ICD10CM | Covered |
| C50.412 | ICD10CM | Covered |
| C50.421 | ICD10CM | Covered |
| C50.422 | ICD10CM | Covered |
| C50.511 | ICD10CM | Covered |
| C50.512 | ICD10CM | Covered |
| C50.521 | ICD10CM | Covered |
| C50.522 | ICD10CM | Covered |
| C50.611 | ICD10CM | Covered |
| C50.612 | ICD10CM | Covered |
| C50.621 | ICD10CM | Covered |
| C50.622 | ICD10CM | Covered |
| C50.811 | ICD10CM | Covered |
| C50.812 | ICD10CM | Covered |
| C50.821 | ICD10CM | Covered |
| C50.822 | ICD10CM | Covered |
| C50.911 | ICD10CM | Covered |
| C50.912 | ICD10CM | Covered |
| C79.2 | ICD10CM | Covered |
| C79.81 | ICD10CM | Covered |
| D05.01 | ICD10CM | Covered |
| D05.02 | ICD10CM | Covered |
| D05.11 | ICD10CM | Covered |
| D05.12 | ICD10CM | Covered |
| D05.81 | ICD10CM | Covered |
| D05.82 | ICD10CM | Covered |
| D24.1 | ICD10CM | Covered |
| D24.2 | ICD10CM | Covered |
| D48.61 | ICD10CM | Covered |
| D48.62 | ICD10CM | Covered |
| N60.01 | ICD10CM | Covered |
| N60.02 | ICD10CM | Covered |
| N60.11 | ICD10CM | Covered |
| N60.12 | ICD10CM | Covered |
| N60.21 | ICD10CM | Covered |
| N60.22 | ICD10CM | Covered |
| N60.31 | ICD10CM | Covered |
| N60.32 | ICD10CM | Covered |
| N60.41 | ICD10CM | Covered |
| N60.42 | ICD10CM | Covered |
| N60.81 | ICD10CM | Covered |
| N60.82 | ICD10CM | Covered |
| N61.0 | ICD10CM | Covered |
| N61.1 | ICD10CM | Covered |
| N62 | ICD10CM | Covered |
| N63.11 | ICD10CM | Covered |
| N63.12 | ICD10CM | Covered |
| N63.13 | ICD10CM | Covered |
| N63.14 | ICD10CM | Covered |
| N63.15 | ICD10CM | Covered |
| N63.21 | ICD10CM | Covered |
| N63.22 | ICD10CM | Covered |
| N63.23 | ICD10CM | Covered |
| N63.24 | ICD10CM | Covered |
| N63.25 | ICD10CM | Covered |
| N63.31 | ICD10CM | Covered |
| N63.32 | ICD10CM | Covered |
| N63.41 | ICD10CM | Covered |
| N63.42 | ICD10CM | Covered |
| N64.0 | ICD10CM | Covered |
| N64.1 | ICD10CM | Covered |
| N64.2 | ICD10CM | Covered |
| N64.3 | ICD10CM | Covered |
| N64.4 | ICD10CM | Covered |
| N64.51 | ICD10CM | Covered |
| N64.52 | ICD10CM | Covered |
| N64.53 | ICD10CM | Covered |
| N64.59 | ICD10CM | Covered |
| N64.89 | ICD10CM | Covered |
| N65.0 | ICD10CM | Covered |
| N65.1 | ICD10CM | Covered |
| R92.0 | ICD10CM | Covered |
| R92.1 | ICD10CM | Covered |
| R92.2 | ICD10CM | Covered |
| R92.8 | ICD10CM | Covered |
| T85.41XA | ICD10CM | Covered |
| T85.41XD | ICD10CM | Covered |
| T85.41XS | ICD10CM | Covered |
| T85.42XA | ICD10CM | Covered |
| T85.42XD | ICD10CM | Covered |
| T85.42XS | ICD10CM | Covered |
| T85.43XA | ICD10CM | Covered |
| T85.43XD | ICD10CM | Covered |
| T85.43XS | ICD10CM | Covered |
| T85.44XA | ICD10CM | Covered |
| T85.44XD | ICD10CM | Covered |
| T85.44XS | ICD10CM | Covered |
| T85.49XA | ICD10CM | Covered |
| T85.49XD | ICD10CM | Covered |
| T85.49XS | ICD10CM | Covered |
| T85.79XA | ICD10CM | Covered |
| T85.79XD | ICD10CM | Covered |
| T85.79XS | ICD10CM | Covered |
| Z85.3 | ICD10CM | Covered |
| Z86.000 | ICD10CM | Covered |
| Z86.018 | ICD10CM | Covered |
| Z86.03 | ICD10CM | Covered |
| Z87.42 | ICD10CM | Covered |