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 |
|---|---|---|
| 20550 | HCPCS | Covered |
| 20551 | HCPCS | Covered |
| 20560 | HCPCS | Covered |
| 20561 | HCPCS | Covered |
| 20612 | HCPCS | Covered |
| M20.11 | ICD10CM | Covered |
| M20.12 | ICD10CM | Covered |
| M25.711 | ICD10CM | Covered |
| M25.712 | ICD10CM | Covered |
| M25.721 | ICD10CM | Covered |
| M25.722 | ICD10CM | Covered |
| M25.731 | ICD10CM | Covered |
| M25.732 | ICD10CM | Covered |
| M25.741 | ICD10CM | Covered |
| M25.742 | ICD10CM | Covered |
| M25.751 | ICD10CM | Covered |
| M25.752 | ICD10CM | Covered |
| M25.761 | ICD10CM | Covered |
| M25.762 | ICD10CM | Covered |
| M25.771 | ICD10CM | Covered |
| M25.772 | ICD10CM | Covered |
| M25.774 | ICD10CM | Covered |
| M25.775 | ICD10CM | Covered |
| M65.111 | ICD10CM | Covered |
| M65.112 | ICD10CM | Covered |
| M65.121 | ICD10CM | Covered |
| M65.122 | ICD10CM | Covered |
| M65.131 | ICD10CM | Covered |
| M65.132 | ICD10CM | Covered |
| M65.141 | ICD10CM | Covered |
| M65.142 | ICD10CM | Covered |
| M65.151 | ICD10CM | Covered |
| M65.152 | ICD10CM | Covered |
| M65.161 | ICD10CM | Covered |
| M65.162 | ICD10CM | Covered |
| M65.171 | ICD10CM | Covered |
| M65.172 | ICD10CM | Covered |
| M65.18 | ICD10CM | Covered |
| M65.19 | ICD10CM | Covered |
| M65.311 | ICD10CM | Covered |
| M65.312 | ICD10CM | Covered |
| M65.321 | ICD10CM | Covered |
| M65.322 | ICD10CM | Covered |
| M65.331 | ICD10CM | Covered |
| M65.332 | ICD10CM | Covered |
| M65.341 | ICD10CM | Covered |
| M65.342 | ICD10CM | Covered |
| M65.351 | ICD10CM | Covered |
| M65.352 | ICD10CM | Covered |
| M65.4 | ICD10CM | Covered |
| M65.80 | ICD10CM | Covered |
| M65.811 | ICD10CM | Covered |
| M65.812 | ICD10CM | Covered |
| M65.821 | ICD10CM | Covered |
| M65.822 | ICD10CM | Covered |
| M65.831 | ICD10CM | Covered |
| M65.832 | ICD10CM | Covered |
| M65.841 | ICD10CM | Covered |
| M65.842 | ICD10CM | Covered |
| M65.851 | ICD10CM | Covered |
| M65.852 | ICD10CM | Covered |
| M65.861 | ICD10CM | Covered |
| M65.862 | ICD10CM | Covered |
| M65.871 | ICD10CM | Covered |
| M65.872 | ICD10CM | Covered |
| M65.88 | ICD10CM | Covered |
| M65.89 | ICD10CM | Covered |
| M65.90 | ICD10CM | Covered |
| M65.911 | ICD10CM | Covered |
| M65.912 | ICD10CM | Covered |
| M65.919 | ICD10CM | Covered |
| M65.921 | ICD10CM | Covered |
| M65.922 | ICD10CM | Covered |
| M65.929 | ICD10CM | Covered |
| M65.931 | ICD10CM | Covered |
| M65.932 | ICD10CM | Covered |
| M65.939 | ICD10CM | Covered |
| M65.941 | ICD10CM | Covered |
| M65.942 | ICD10CM | Covered |
| M65.949 | ICD10CM | Covered |
| M65.951 | ICD10CM | Covered |
| M65.952 | ICD10CM | Covered |
| M65.959 | ICD10CM | Covered |
| M65.961 | ICD10CM | Covered |
| M65.962 | ICD10CM | Covered |
| M65.969 | ICD10CM | Covered |
| M65.971 | ICD10CM | Covered |
| M65.972 | ICD10CM | Covered |
| M65.979 | ICD10CM | Covered |
| M65.98 | ICD10CM | Covered |
| M65.99 | ICD10CM | Covered |
| M66.211 | ICD10CM | Covered |
| M66.212 | ICD10CM | Covered |
| M66.811 | ICD10CM | Covered |
| M66.812 | ICD10CM | Covered |
| M67.311 | ICD10CM | Covered |
| M67.312 | ICD10CM | Covered |
| M67.321 | ICD10CM | Covered |
| M67.322 | ICD10CM | Covered |
| M67.331 | ICD10CM | Covered |
| M67.332 | ICD10CM | Covered |
| M67.341 | ICD10CM | Covered |
| M67.342 | ICD10CM | Covered |
| M67.351 | ICD10CM | Covered |
| M67.352 | ICD10CM | Covered |
| M67.361 | ICD10CM | Covered |
| M67.362 | ICD10CM | Covered |
| M67.371 | ICD10CM | Covered |
| M67.372 | ICD10CM | Covered |
| M67.38 | ICD10CM | Covered |
| M67.39 | ICD10CM | Covered |
| M67.40 | ICD10CM | Covered |
| M67.411 | ICD10CM | Covered |
| M67.412 | ICD10CM | Covered |
| M67.421 | ICD10CM | Covered |
| M67.422 | ICD10CM | Covered |
| M67.431 | ICD10CM | Covered |
| M67.432 | ICD10CM | Covered |
| M67.441 | ICD10CM | Covered |
| M67.442 | ICD10CM | Covered |
| M67.451 | ICD10CM | Covered |
| M67.452 | ICD10CM | Covered |
| M67.461 | ICD10CM | Covered |
| M67.462 | ICD10CM | Covered |
| M67.471 | ICD10CM | Covered |
| M67.472 | ICD10CM | Covered |
| M67.48 | ICD10CM | Covered |
| M67.49 | ICD10CM | Covered |
| M70.031 | ICD10CM | Covered |
| M70.032 | ICD10CM | Covered |
| M70.041 | ICD10CM | Covered |
| M70.042 | ICD10CM | Covered |
| M70.10 | ICD10CM | Covered |
| M70.11 | ICD10CM | Covered |
| M70.12 | ICD10CM | Covered |
| M70.21 | ICD10CM | Covered |
| M70.22 | ICD10CM | Covered |
| M70.31 | ICD10CM | Covered |
| M70.32 | ICD10CM | Covered |
| M70.41 | ICD10CM | Covered |
| M70.42 | ICD10CM | Covered |
| M70.51 | ICD10CM | Covered |
| M70.52 | ICD10CM | Covered |
| M70.61 | ICD10CM | Covered |
| M70.62 | ICD10CM | Covered |
| M70.71 | ICD10CM | Covered |
| M70.72 | ICD10CM | Covered |
| M71.111 | ICD10CM | Covered |
| M71.112 | ICD10CM | Covered |
| M71.121 | ICD10CM | Covered |
| M71.122 | ICD10CM | Covered |
| M71.131 | ICD10CM | Covered |
| M71.132 | ICD10CM | Covered |
| M71.141 | ICD10CM | Covered |
| M71.142 | ICD10CM | Covered |
| M71.151 | ICD10CM | Covered |
| M71.152 | ICD10CM | Covered |
| M71.161 | ICD10CM | Covered |
| M71.162 | ICD10CM | Covered |
| M71.171 | ICD10CM | Covered |
| M71.172 | ICD10CM | Covered |
| M71.18 | ICD10CM | Covered |
| M71.19 | ICD10CM | Covered |
| M71.30 | ICD10CM | Covered |
| M71.521 | ICD10CM | Covered |
| M71.522 | ICD10CM | Covered |
| M71.531 | ICD10CM | Covered |
| M71.532 | ICD10CM | Covered |
| M71.541 | ICD10CM | Covered |
| M71.542 | ICD10CM | Covered |
| M71.551 | ICD10CM | Covered |
| M71.552 | ICD10CM | Covered |
| M71.561 | ICD10CM | Covered |
| M71.562 | ICD10CM | Covered |
| M71.571 | ICD10CM | Covered |
| M71.572 | ICD10CM | Covered |
| M71.58 | ICD10CM | Covered |
| M72.0 | ICD10CM | Covered |
| M72.20 | ICD10CM | Covered |
| M72.21 | ICD10CM | Covered |
| M72.22 | ICD10CM | Covered |
| M72.9 | ICD10CM | Covered |
| M75.01 | ICD10CM | Covered |
| M75.02 | ICD10CM | Covered |
| M75.101 | ICD10CM | Covered |
| M75.102 | ICD10CM | Covered |
| M75.21 | ICD10CM | Covered |
| M75.22 | ICD10CM | Covered |
| M75.30 | ICD10CM | Covered |
| M75.31 | ICD10CM | Covered |
| M75.32 | ICD10CM | Covered |
| M75.41 | ICD10CM | Covered |
| M75.42 | ICD10CM | Covered |
| M75.51 | ICD10CM | Covered |
| M75.52 | ICD10CM | Covered |
| M75.81 | ICD10CM | Covered |
| M75.82 | ICD10CM | Covered |
| M75.91 | ICD10CM | Covered |
| M75.92 | ICD10CM | Covered |
| M76.01 | ICD10CM | Covered |
| M76.02 | ICD10CM | Covered |
| M76.11 | ICD10CM | Covered |
| M76.12 | ICD10CM | Covered |
| M76.21 | ICD10CM | Covered |
| M76.22 | ICD10CM | Covered |
| M76.31 | ICD10CM | Covered |
| M76.32 | ICD10CM | Covered |
| M76.41 | ICD10CM | Covered |
| M76.42 | ICD10CM | Covered |
| M76.51 | ICD10CM | Covered |
| M76.52 | ICD10CM | Covered |
| M76.61 | ICD10CM | Covered |
| M76.62 | ICD10CM | Covered |
| M76.71 | ICD10CM | Covered |
| M76.72 | ICD10CM | Covered |
| M76.811 | ICD10CM | Covered |
| M76.812 | ICD10CM | Covered |
| M76.821 | ICD10CM | Covered |
| M76.822 | ICD10CM | Covered |
| M76.891 | ICD10CM | Covered |
| M76.892 | ICD10CM | Covered |
| M76.899 | ICD10CM | Covered |
| M76.9 | ICD10CM | Covered |
| M77.01 | ICD10CM | Covered |
| M77.02 | ICD10CM | Covered |
| M77.11 | ICD10CM | Covered |
| M77.12 | ICD10CM | Covered |
| M77.21 | ICD10CM | Covered |
| M77.22 | ICD10CM | Covered |
| M77.30 | ICD10CM | Covered |
| M77.31 | ICD10CM | Covered |
| M77.32 | ICD10CM | Covered |
| M77.41 | ICD10CM | Covered |
| M77.42 | ICD10CM | Covered |
| M77.51 | ICD10CM | Covered |
| M77.52 | ICD10CM | Covered |
| M77.8 | ICD10CM | Covered |