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 |
|---|---|---|
| 0018U | HCPCS | Covered |
| 0026U | HCPCS | Covered |
| 0245U | HCPCS | Covered |
| 81120 | HCPCS | Covered |
| 81121 | HCPCS | Covered |
| 81170 | HCPCS | Covered |
| 81175 | HCPCS | Covered |
| 81176 | HCPCS | Covered |
| 81206 | HCPCS | Covered |
| 81207 | HCPCS | Covered |
| 81208 | HCPCS | Covered |
| 81210 | HCPCS | Covered |
| 81218 | HCPCS | Covered |
| 81219 | HCPCS | Covered |
| 81233 | HCPCS | Covered |
| 81235 | HCPCS | Covered |
| 81236 | HCPCS | Covered |
| 81237 | HCPCS | Covered |
| 81245 | HCPCS | Covered |
| 81246 | HCPCS | Covered |
| 81261 | HCPCS | Covered |
| 81262 | HCPCS | Covered |
| 81263 | HCPCS | Covered |
| 81270 | HCPCS | Covered |
| 81272 | HCPCS | Covered |
| 81273 | HCPCS | Covered |
| 81275 | HCPCS | Covered |
| 81276 | HCPCS | Covered |
| 81287 | HCPCS | Covered |
| 81292 | HCPCS | Covered |
| 81293 | HCPCS | Covered |
| 81294 | HCPCS | Covered |
| 81301 | HCPCS | Covered |
| 81305 | HCPCS | Covered |
| 81310 | HCPCS | Covered |
| 81311 | HCPCS | Covered |
| 81313 | HCPCS | Covered |
| 81314 | HCPCS | Covered |
| 81315 | HCPCS | Covered |
| 81316 | HCPCS | Covered |
| 81320 | HCPCS | Covered |
| 81321 | HCPCS | Covered |
| 81322 | HCPCS | Covered |
| 81323 | HCPCS | Covered |
| 81327 | HCPCS | Covered |
| 81334 | HCPCS | Covered |
| 81340 | HCPCS | Covered |
| 81342 | HCPCS | Covered |
| 81345 | HCPCS | Covered |
| 81347 | HCPCS | Covered |
| 81348 | HCPCS | Covered |
| 81351 | HCPCS | Covered |
| 81352 | HCPCS | Covered |
| 81353 | HCPCS | Covered |
| 81357 | HCPCS | Covered |
| 81360 | HCPCS | Covered |
| 81435 | HCPCS | Covered |
| 81437 | HCPCS | Covered |
| 81445 | HCPCS | Covered |
| 81450 | HCPCS | Covered |
| 81479 | HCPCS | Covered |
| 81503 | HCPCS | Covered |
| 81520 | HCPCS | Covered |
| 81525 | HCPCS | Covered |
| 81538 | HCPCS | Covered |
| 81540 | HCPCS | Covered |
| 81546 | 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 |
| C21.0 | ICD10CM | Covered |
| C21.1 | ICD10CM | Covered |
| C21.2 | ICD10CM | Covered |
| C21.8 | ICD10CM | Covered |
| C22.0 | ICD10CM | Covered |
| C22.2 | ICD10CM | Covered |
| C22.3 | ICD10CM | Covered |
| C22.4 | ICD10CM | Covered |
| C22.7 | ICD10CM | Covered |
| C22.8 | ICD10CM | Covered |
| C22.9 | ICD10CM | Covered |
| C25.2 | ICD10CM | Covered |
| C25.7 | ICD10CM | Covered |
| C25.8 | ICD10CM | Covered |
| C25.9 | 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 |
| C43.0 | ICD10CM | Covered |
| C43.10 | ICD10CM | Covered |
| C43.111 | ICD10CM | Covered |
| C43.112 | ICD10CM | Covered |
| C43.121 | ICD10CM | Covered |
| C43.122 | ICD10CM | Covered |
| C43.20 | ICD10CM | Covered |
| C43.21 | ICD10CM | Covered |
| C43.22 | ICD10CM | Covered |
| C43.30 | ICD10CM | Covered |
| C43.31 | ICD10CM | Covered |
| C43.39 | ICD10CM | Covered |
| C43.4 | ICD10CM | Covered |
| C43.51 | ICD10CM | Covered |
| C43.52 | ICD10CM | Covered |
| C43.59 | ICD10CM | Covered |
| C43.60 | ICD10CM | Covered |
| C43.61 | ICD10CM | Covered |
| C43.62 | ICD10CM | Covered |
| C43.70 | ICD10CM | Covered |
| C43.71 | ICD10CM | Covered |
| C43.72 | ICD10CM | Covered |
| C43.8 | ICD10CM | Covered |
| C43.9 | ICD10CM | Covered |
| C45.0 | ICD10CM | Covered |
| C45.1 | ICD10CM | Covered |
| C45.9 | ICD10CM | Covered |
| C47.0 | ICD10CM | Covered |
| C47.9 | ICD10CM | Covered |
| C48.0 | ICD10CM | Covered |
| C48.1 | ICD10CM | Covered |
| C48.2 | ICD10CM | Covered |
| C48.8 | ICD10CM | Covered |
| C49.0 | ICD10CM | Covered |
| C49.9 | ICD10CM | Covered |
| C49.A0 | ICD10CM | Covered |
| C49.A1 | ICD10CM | Covered |
| C49.A2 | ICD10CM | Covered |
| C49.A3 | ICD10CM | Covered |
| C49.A4 | ICD10CM | Covered |
| C49.A5 | ICD10CM | Covered |
| C49.A9 | ICD10CM | Covered |
| C50.011 | ICD10CM | Covered |
| C50.012 | ICD10CM | Covered |
| C50.111 | ICD10CM | Covered |
| C50.112 | ICD10CM | Covered |
| C50.211 | ICD10CM | Covered |
| C50.212 | ICD10CM | Covered |
| C50.311 | ICD10CM | Covered |
| C50.312 | ICD10CM | Covered |
| C50.411 | ICD10CM | Covered |
| C50.412 | ICD10CM | Covered |
| C50.511 | ICD10CM | Covered |
| C50.512 | ICD10CM | Covered |
| C50.611 | ICD10CM | Covered |
| C50.612 | ICD10CM | Covered |
| C50.811 | ICD10CM | Covered |
| C50.812 | ICD10CM | Covered |
| C50.911 | ICD10CM | Covered |
| C50.912 | 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 |
| C55 | 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 |
| C61 | ICD10CM | Covered |
| C64.1 | ICD10CM | Covered |
| C64.2 | ICD10CM | Covered |
| C65.1 | ICD10CM | Covered |
| C65.2 | ICD10CM | Covered |
| C65.9 | ICD10CM | Covered |
| C66.1 | ICD10CM | Covered |
| C66.2 | ICD10CM | Covered |
| C66.9 | ICD10CM | Covered |
| C67.0 | ICD10CM | Covered |
| C67.1 | ICD10CM | Covered |
| C67.2 | ICD10CM | Covered |
| C67.3 | ICD10CM | Covered |
| C67.4 | ICD10CM | Covered |
| C67.5 | ICD10CM | Covered |
| C67.6 | ICD10CM | Covered |
| C67.7 | ICD10CM | Covered |
| C67.8 | ICD10CM | Covered |
| C67.9 | ICD10CM | Covered |
| C68.0 | ICD10CM | Covered |
| C68.1 | ICD10CM | Covered |
| C68.8 | ICD10CM | Covered |
| C68.9 | ICD10CM | Covered |
| C69.01 | ICD10CM | Covered |
| C69.02 | ICD10CM | Covered |
| C69.11 | ICD10CM | Covered |
| C69.12 | ICD10CM | Covered |
| C69.21 | ICD10CM | Covered |
| C69.22 | ICD10CM | Covered |
| C69.31 | ICD10CM | Covered |
| C69.32 | ICD10CM | Covered |
| C69.41 | ICD10CM | Covered |
| C69.42 | ICD10CM | Covered |
| C69.51 | ICD10CM | Covered |
| C69.52 | ICD10CM | Covered |
| C69.61 | ICD10CM | Covered |
| C69.62 | ICD10CM | Covered |
| C69.81 | ICD10CM | Covered |
| C69.82 | 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 |
| C73 | ICD10CM | Covered |
| C76.0 | ICD10CM | Covered |
| C77.0 | ICD10CM | Covered |
| C77.1 | ICD10CM | Covered |
| C77.2 | ICD10CM | Covered |
| C77.3 | ICD10CM | Covered |
| C77.4 | ICD10CM | Covered |
| C77.5 | ICD10CM | Covered |
| C77.8 | ICD10CM | Covered |
| C77.9 | ICD10CM | Covered |
| C78.01 | ICD10CM | Covered |
| C78.02 | ICD10CM | Covered |
| C78.5 | ICD10CM | Covered |
| C78.6 | ICD10CM | Covered |
| C78.7 | ICD10CM | Covered |
| C79.01 | ICD10CM | Covered |
| C79.02 | ICD10CM | Covered |
| C79.2 | ICD10CM | Covered |
| C79.31 | ICD10CM | Covered |
| C79.49 | ICD10CM | Covered |
| C79.51 | ICD10CM | Covered |
| C79.52 | ICD10CM | Covered |
| C79.61 | ICD10CM | Covered |
| C79.62 | ICD10CM | Covered |
| C79.63 | ICD10CM | Covered |
| C79.89 | ICD10CM | Covered |
| C7A.010 | ICD10CM | Covered |
| C7A.011 | ICD10CM | Covered |
| C7A.012 | ICD10CM | Covered |
| C7A.019 | ICD10CM | Covered |
| C7A.020 | ICD10CM | Covered |
| C7A.021 | ICD10CM | Covered |
| C7A.022 | ICD10CM | Covered |
| C7A.023 | ICD10CM | Covered |
| C7A.024 | ICD10CM | Covered |
| C7A.025 | ICD10CM | Covered |
| C7A.026 | ICD10CM | Covered |
| C7A.029 | ICD10CM | Covered |
| C7A.090 | ICD10CM | Covered |
| C7A.091 | ICD10CM | Covered |
| C7A.092 | ICD10CM | Covered |
| C7A.093 | ICD10CM | Covered |
| C7A.094 | ICD10CM | Covered |
| C7A.095 | ICD10CM | Covered |
| C7A.096 | ICD10CM | Covered |
| C7A.098 | ICD10CM | Covered |
| C7A.1 | ICD10CM | Covered |
| C7A.8 | ICD10CM | Covered |
| C7B.01 | ICD10CM | Covered |
| C7B.02 | ICD10CM | Covered |
| C7B.03 | ICD10CM | Covered |
| C7B.04 | ICD10CM | Covered |
| C7B.09 | ICD10CM | Covered |
| C7B.1 | ICD10CM | Covered |
| C7B.8 | ICD10CM | Covered |
| C80.0 | ICD10CM | Covered |
| C80.1 | ICD10CM | Covered |
| C82.57 | ICD10CM | Covered |
| C83.70 | ICD10CM | Covered |
| C83.71 | ICD10CM | Covered |
| C83.72 | ICD10CM | Covered |
| C83.73 | ICD10CM | Covered |
| C83.74 | ICD10CM | Covered |
| C83.75 | ICD10CM | Covered |
| C83.76 | ICD10CM | Covered |
| C83.77 | ICD10CM | Covered |
| C83.78 | ICD10CM | Covered |
| C83.79 | ICD10CM | Covered |
| C83.7A | ICD10CM | Covered |
| C84.97 | ICD10CM | Covered |
| C84.A7 | ICD10CM | Covered |
| C84.Z7 | ICD10CM | Covered |
| C85.17 | ICD10CM | Covered |
| C85.27 | ICD10CM | Covered |
| C85.87 | ICD10CM | Covered |
| C85.97 | ICD10CM | Covered |
| C86.10 | ICD10CM | Covered |
| C88.00 | ICD10CM | Covered |
| C90.00 | ICD10CM | Covered |
| C90.02 | ICD10CM | Covered |
| C91.00 | ICD10CM | Covered |
| C91.01 | ICD10CM | Covered |
| C91.02 | ICD10CM | Covered |
| C91.10 | ICD10CM | Covered |
| C91.11 | ICD10CM | Covered |
| C91.12 | ICD10CM | Covered |
| C91.40 | ICD10CM | Covered |
| C91.41 | ICD10CM | Covered |
| C91.42 | ICD10CM | Covered |
| C91.60 | ICD10CM | Covered |
| C91.61 | ICD10CM | Covered |
| C91.62 | ICD10CM | Covered |
| C91.Z0 | ICD10CM | Covered |
| C91.Z1 | ICD10CM | Covered |
| C91.Z2 | ICD10CM | Covered |
| C92.00 | ICD10CM | Covered |
| C92.01 | ICD10CM | Covered |
| C92.02 | ICD10CM | Covered |
| C92.10 | ICD10CM | Covered |
| C92.11 | ICD10CM | Covered |
| C92.12 | ICD10CM | Covered |
| C92.40 | ICD10CM | Covered |
| C92.41 | ICD10CM | Covered |
| C92.42 | ICD10CM | Covered |
| C92.50 | ICD10CM | Covered |
| C92.51 | ICD10CM | Covered |
| C92.52 | ICD10CM | Covered |
| C92.60 | ICD10CM | Covered |
| C92.61 | ICD10CM | Covered |
| C92.62 | ICD10CM | Covered |
| C92.A0 | ICD10CM | Covered |
| C92.A1 | ICD10CM | Covered |
| C92.A2 | ICD10CM | Covered |
| C93.10 | ICD10CM | Covered |
| C93.11 | ICD10CM | Covered |
| C93.12 | ICD10CM | Covered |
| C95.90 | ICD10CM | Covered |
| C95.91 | ICD10CM | Covered |
| C95.92 | ICD10CM | Covered |
| C96.20 | ICD10CM | Covered |
| C96.22 | ICD10CM | Covered |
| C96.29 | ICD10CM | Covered |
| D01.5 | ICD10CM | Covered |
| D01.7 | ICD10CM | Covered |
| D01.9 | ICD10CM | Covered |
| D02.21 | ICD10CM | Covered |
| D02.22 | ICD10CM | Covered |
| D03.0 | ICD10CM | Covered |
| D03.10 | ICD10CM | Covered |
| D03.111 | ICD10CM | Covered |
| D03.112 | ICD10CM | Covered |
| D03.121 | ICD10CM | Covered |
| D03.122 | ICD10CM | Covered |
| D03.20 | ICD10CM | Covered |
| D03.21 | ICD10CM | Covered |
| D03.22 | ICD10CM | Covered |
| D03.30 | ICD10CM | Covered |
| D03.39 | ICD10CM | Covered |
| D03.4 | ICD10CM | Covered |
| D03.51 | ICD10CM | Covered |
| D03.52 | ICD10CM | Covered |
| D03.59 | ICD10CM | Covered |
| D03.60 | ICD10CM | Covered |
| D03.61 | ICD10CM | Covered |
| D03.62 | ICD10CM | Covered |
| D03.70 | ICD10CM | Covered |
| D03.71 | ICD10CM | Covered |
| D03.72 | ICD10CM | Covered |
| D03.8 | ICD10CM | Covered |
| D03.9 | ICD10CM | Covered |
| D29.1 | ICD10CM | Covered |
| D34 | ICD10CM | Covered |
| D3A.010 | ICD10CM | Covered |
| D3A.011 | ICD10CM | Covered |
| D3A.012 | ICD10CM | Covered |
| D3A.019 | ICD10CM | Covered |
| D3A.020 | ICD10CM | Covered |
| D3A.021 | ICD10CM | Covered |
| D3A.022 | ICD10CM | Covered |
| D3A.023 | ICD10CM | Covered |
| D3A.024 | ICD10CM | Covered |
| D3A.025 | ICD10CM | Covered |
| D3A.026 | ICD10CM | Covered |
| D3A.029 | ICD10CM | Covered |
| D3A.090 | ICD10CM | Covered |
| D3A.091 | ICD10CM | Covered |
| D3A.092 | ICD10CM | Covered |
| D3A.093 | ICD10CM | Covered |
| D3A.094 | ICD10CM | Covered |
| D3A.095 | ICD10CM | Covered |
| D3A.096 | ICD10CM | Covered |
| D3A.098 | ICD10CM | Covered |
| D3A.8 | ICD10CM | Covered |
| D40.0 | ICD10CM | Covered |
| D44.0 | ICD10CM | Covered |
| D44.2 | ICD10CM | Covered |
| D44.9 | ICD10CM | Covered |
| D45 | ICD10CM | Covered |
| D46.0 | ICD10CM | Covered |
| D46.1 | ICD10CM | Covered |
| D46.20 | ICD10CM | Covered |
| D46.21 | ICD10CM | Covered |
| D46.22 | ICD10CM | Covered |
| D46.4 | ICD10CM | Covered |
| D46.9 | ICD10CM | Covered |
| D46.A | ICD10CM | Covered |
| D46.B | ICD10CM | Covered |
| D46.C | ICD10CM | Covered |
| D46.Z | ICD10CM | Covered |
| D47.1 | ICD10CM | Covered |
| D47.3 | ICD10CM | Covered |
| D48.19 | ICD10CM | Covered |
| D48.2 | ICD10CM | Covered |
| D49.0 | ICD10CM | Covered |
| D49.1 | ICD10CM | Covered |
| D49.2 | ICD10CM | Covered |
| D49.3 | ICD10CM | Covered |
| D49.4 | ICD10CM | Covered |
| D49.511 | ICD10CM | Covered |
| D49.512 | ICD10CM | Covered |
| D49.59 | ICD10CM | Covered |
| D49.6 | ICD10CM | Covered |
| D49.7 | ICD10CM | Covered |
| D49.89 | ICD10CM | Covered |
| D49.9 | ICD10CM | Covered |
| D60.0 | ICD10CM | Covered |
| D60.1 | ICD10CM | Covered |
| D60.8 | ICD10CM | Covered |
| D60.9 | ICD10CM | Covered |
| D61.01 | ICD10CM | Covered |
| D61.03 | ICD10CM | Covered |
| D61.09 | ICD10CM | Covered |
| D61.1 | ICD10CM | Covered |
| D61.2 | ICD10CM | Covered |
| D61.3 | ICD10CM | Covered |
| D61.89 | ICD10CM | Covered |
| D61.9 | ICD10CM | Covered |
| D72.110 | ICD10CM | Covered |
| D72.111 | ICD10CM | Covered |
| D72.118 | ICD10CM | Covered |
| D72.119 | ICD10CM | Covered |
| D75.81 | ICD10CM | Covered |
| E01.0 | ICD10CM | Covered |
| E01.1 | ICD10CM | Covered |
| E01.2 | ICD10CM | Covered |
| E04.0 | ICD10CM | Covered |
| E04.1 | ICD10CM | Covered |
| E04.2 | ICD10CM | Covered |
| E04.8 | ICD10CM | Covered |
| E04.9 | ICD10CM | Covered |
| J91.0 | ICD10CM | Covered |
| N40.0 | ICD10CM | Covered |
| N40.1 | ICD10CM | Covered |
| N40.2 | ICD10CM | Covered |
| N40.3 | ICD10CM | Covered |
| N42.31 | ICD10CM | Covered |
| N42.32 | ICD10CM | Covered |
| N42.39 | ICD10CM | Covered |
| N42.83 | ICD10CM | Covered |
| R31.1 | ICD10CM | Covered |
| R31.29 | ICD10CM | Covered |
| Z85.030 | ICD10CM | Covered |
| Z85.038 | ICD10CM | Covered |
| Z85.040 | ICD10CM | Covered |
| Z85.048 | ICD10CM | Covered |