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 |
|---|---|---|
| 93880 | HCPCS | Covered |
| 93882 | HCPCS | Covered |
| 93886 | HCPCS | Covered |
| 93888 | HCPCS | Covered |
| 93892 | HCPCS | Covered |
| 93893 | HCPCS | Covered |
| 93896 | HCPCS | Covered |
| 93897 | HCPCS | Covered |
| 93898 | HCPCS | Covered |
| D44.6 | ICD10CM | Covered |
| D44.7 | ICD10CM | Covered |
| G45.0 | ICD10CM | Covered |
| G45.1 | ICD10CM | Covered |
| G45.2 | ICD10CM | Covered |
| G45.3 | ICD10CM | Covered |
| G45.4 | ICD10CM | Covered |
| G45.8 | ICD10CM | Covered |
| G45.9 | ICD10CM | Covered |
| G46.0 | ICD10CM | Covered |
| G46.1 | ICD10CM | Covered |
| G46.2 | ICD10CM | Covered |
| G46.3 | ICD10CM | Covered |
| G46.4 | ICD10CM | Covered |
| G46.5 | ICD10CM | Covered |
| G46.6 | ICD10CM | Covered |
| G46.7 | ICD10CM | Covered |
| G46.8 | ICD10CM | Covered |
| G81.01 | ICD10CM | Covered |
| G81.02 | ICD10CM | Covered |
| G81.03 | ICD10CM | Covered |
| G81.04 | ICD10CM | Covered |
| G81.11 | ICD10CM | Covered |
| G81.12 | ICD10CM | Covered |
| G81.13 | ICD10CM | Covered |
| G81.14 | ICD10CM | Covered |
| G81.91 | ICD10CM | Covered |
| G81.92 | ICD10CM | Covered |
| G81.93 | ICD10CM | Covered |
| G81.94 | ICD10CM | Covered |
| G83.0 | ICD10CM | Covered |
| G83.11 | ICD10CM | Covered |
| G83.12 | ICD10CM | Covered |
| G83.13 | ICD10CM | Covered |
| G83.14 | ICD10CM | Covered |
| G83.21 | ICD10CM | Covered |
| G83.22 | ICD10CM | Covered |
| G83.23 | ICD10CM | Covered |
| G83.24 | ICD10CM | Covered |
| G83.31 | ICD10CM | Covered |
| G83.32 | ICD10CM | Covered |
| G83.33 | ICD10CM | Covered |
| G83.34 | ICD10CM | Covered |
| G93.82 | ICD10CM | Covered |
| G93.89 | ICD10CM | Covered |
| G97.31 | ICD10CM | Covered |
| G97.32 | ICD10CM | Covered |
| G97.48 | ICD10CM | Covered |
| G97.49 | ICD10CM | Covered |
| G97.51 | ICD10CM | Covered |
| G97.52 | ICD10CM | Covered |
| H34.01 | ICD10CM | Covered |
| H34.02 | ICD10CM | Covered |
| H34.03 | ICD10CM | Covered |
| H34.11 | ICD10CM | Covered |
| H34.12 | ICD10CM | Covered |
| H34.13 | ICD10CM | Covered |
| H34.211 | ICD10CM | Covered |
| H34.212 | ICD10CM | Covered |
| H34.213 | ICD10CM | Covered |
| H34.231 | ICD10CM | Covered |
| H34.232 | ICD10CM | Covered |
| H34.233 | ICD10CM | Covered |
| H35.82 | ICD10CM | Covered |
| H53.11 | ICD10CM | Covered |
| H53.121 | ICD10CM | Covered |
| H53.122 | ICD10CM | Covered |
| H53.123 | ICD10CM | Covered |
| H53.131 | ICD10CM | Covered |
| H53.132 | ICD10CM | Covered |
| H53.133 | ICD10CM | Covered |
| I25.10 | ICD10CM | Covered |
| I25.110 | ICD10CM | Covered |
| I25.111 | ICD10CM | Covered |
| I25.118 | ICD10CM | Covered |
| I25.119 | ICD10CM | Covered |
| I34.0 | ICD10CM | Covered |
| I34.1 | ICD10CM | Covered |
| I34.2 | ICD10CM | Covered |
| I35.0 | ICD10CM | Covered |
| I35.1 | ICD10CM | Covered |
| I35.2 | ICD10CM | Covered |
| I60.11 | ICD10CM | Covered |
| I60.12 | ICD10CM | Covered |
| I60.2 | ICD10CM | Covered |
| I60.31 | ICD10CM | Covered |
| I60.32 | ICD10CM | Covered |
| I60.4 | ICD10CM | Covered |
| I60.51 | ICD10CM | Covered |
| I60.52 | ICD10CM | Covered |
| I60.6 | ICD10CM | Covered |
| I60.8 | ICD10CM | Covered |
| I61.0 | ICD10CM | Covered |
| I61.1 | ICD10CM | Covered |
| I61.2 | ICD10CM | Covered |
| I61.3 | ICD10CM | Covered |
| I61.4 | ICD10CM | Covered |
| I61.5 | ICD10CM | Covered |
| I61.6 | ICD10CM | Covered |
| I61.8 | ICD10CM | Covered |
| I61.9 | ICD10CM | Covered |
| I63.00 | ICD10CM | Covered |
| I63.011 | ICD10CM | Covered |
| I63.012 | ICD10CM | Covered |
| I63.013 | ICD10CM | Covered |
| I63.02 | ICD10CM | Covered |
| I63.031 | ICD10CM | Covered |
| I63.032 | ICD10CM | Covered |
| I63.033 | ICD10CM | Covered |
| I63.09 | ICD10CM | Covered |
| I63.10 | ICD10CM | Covered |
| I63.111 | ICD10CM | Covered |
| I63.112 | ICD10CM | Covered |
| I63.113 | ICD10CM | Covered |
| I63.12 | ICD10CM | Covered |
| I63.131 | ICD10CM | Covered |
| I63.132 | ICD10CM | Covered |
| I63.133 | ICD10CM | Covered |
| I63.19 | ICD10CM | Covered |
| I63.20 | ICD10CM | Covered |
| I63.211 | ICD10CM | Covered |
| I63.212 | ICD10CM | Covered |
| I63.213 | ICD10CM | Covered |
| I63.219 | ICD10CM | Covered |
| I63.22 | ICD10CM | Covered |
| I63.231 | ICD10CM | Covered |
| I63.232 | ICD10CM | Covered |
| I63.233 | ICD10CM | Covered |
| I63.29 | ICD10CM | Covered |
| I63.311 | ICD10CM | Covered |
| I63.312 | ICD10CM | Covered |
| I63.313 | ICD10CM | Covered |
| I63.321 | ICD10CM | Covered |
| I63.322 | ICD10CM | Covered |
| I63.323 | ICD10CM | Covered |
| I63.331 | ICD10CM | Covered |
| I63.332 | ICD10CM | Covered |
| I63.333 | ICD10CM | Covered |
| I63.341 | ICD10CM | Covered |
| I63.342 | ICD10CM | Covered |
| I63.343 | ICD10CM | Covered |
| I63.39 | ICD10CM | Covered |
| I63.411 | ICD10CM | Covered |
| I63.412 | ICD10CM | Covered |
| I63.413 | ICD10CM | Covered |
| I63.421 | ICD10CM | Covered |
| I63.422 | ICD10CM | Covered |
| I63.423 | ICD10CM | Covered |
| I63.431 | ICD10CM | Covered |
| I63.432 | ICD10CM | Covered |
| I63.433 | ICD10CM | Covered |
| I63.441 | ICD10CM | Covered |
| I63.442 | ICD10CM | Covered |
| I63.443 | ICD10CM | Covered |
| I63.49 | ICD10CM | Covered |
| I63.511 | ICD10CM | Covered |
| I63.512 | ICD10CM | Covered |
| I63.513 | ICD10CM | Covered |
| I63.521 | ICD10CM | Covered |
| I63.522 | ICD10CM | Covered |
| I63.523 | ICD10CM | Covered |
| I63.531 | ICD10CM | Covered |
| I63.532 | ICD10CM | Covered |
| I63.533 | ICD10CM | Covered |
| I63.541 | ICD10CM | Covered |
| I63.542 | ICD10CM | Covered |
| I63.543 | ICD10CM | Covered |
| I63.59 | ICD10CM | Covered |
| I63.6 | ICD10CM | Covered |
| I63.81 | ICD10CM | Covered |
| I63.89 | ICD10CM | Covered |
| I63.9 | ICD10CM | Covered |
| I65.01 | ICD10CM | Covered |
| I65.02 | ICD10CM | Covered |
| I65.03 | ICD10CM | Covered |
| I65.1 | ICD10CM | Covered |
| I65.21 | ICD10CM | Covered |
| I65.22 | ICD10CM | Covered |
| I65.23 | ICD10CM | Covered |
| I65.8 | ICD10CM | Covered |
| I66.01 | ICD10CM | Covered |
| I66.02 | ICD10CM | Covered |
| I66.03 | ICD10CM | Covered |
| I66.11 | ICD10CM | Covered |
| I66.12 | ICD10CM | Covered |
| I66.13 | ICD10CM | Covered |
| I66.21 | ICD10CM | Covered |
| I66.22 | ICD10CM | Covered |
| I66.23 | ICD10CM | Covered |
| I66.3 | ICD10CM | Covered |
| I66.8 | ICD10CM | Covered |
| I67.1 | ICD10CM | Covered |
| I67.2 | ICD10CM | Covered |
| I67.6 | ICD10CM | Covered |
| I67.7 | ICD10CM | Covered |
| I67.81 | ICD10CM | Covered |
| I67.82 | ICD10CM | Covered |
| I67.841 | ICD10CM | Covered |
| I67.848 | ICD10CM | Covered |
| I67.89 | ICD10CM | Covered |
| I67.9 | ICD10CM | Covered |
| I68.0 | ICD10CM | Covered |
| I69.031 | ICD10CM | Covered |
| I69.032 | ICD10CM | Covered |
| I69.033 | ICD10CM | Covered |
| I69.034 | ICD10CM | Covered |
| I69.041 | ICD10CM | Covered |
| I69.042 | ICD10CM | Covered |
| I69.043 | ICD10CM | Covered |
| I69.044 | ICD10CM | Covered |
| I69.051 | ICD10CM | Covered |
| I69.052 | ICD10CM | Covered |
| I69.053 | ICD10CM | Covered |
| I69.054 | ICD10CM | Covered |
| I69.131 | ICD10CM | Covered |
| I69.132 | ICD10CM | Covered |
| I69.133 | ICD10CM | Covered |
| I69.134 | ICD10CM | Covered |
| I69.141 | ICD10CM | Covered |
| I69.142 | ICD10CM | Covered |
| I69.143 | ICD10CM | Covered |
| I69.144 | ICD10CM | Covered |
| I69.151 | ICD10CM | Covered |
| I69.152 | ICD10CM | Covered |
| I69.153 | ICD10CM | Covered |
| I69.154 | ICD10CM | Covered |
| I69.231 | ICD10CM | Covered |
| I69.232 | ICD10CM | Covered |
| I69.233 | ICD10CM | Covered |
| I69.234 | ICD10CM | Covered |
| I69.241 | ICD10CM | Covered |
| I69.242 | ICD10CM | Covered |
| I69.243 | ICD10CM | Covered |
| I69.244 | ICD10CM | Covered |
| I69.251 | ICD10CM | Covered |
| I69.252 | ICD10CM | Covered |
| I69.253 | ICD10CM | Covered |
| I69.254 | ICD10CM | Covered |
| I69.331 | ICD10CM | Covered |
| I69.332 | ICD10CM | Covered |
| I69.333 | ICD10CM | Covered |
| I69.334 | ICD10CM | Covered |
| I69.341 | ICD10CM | Covered |
| I69.342 | ICD10CM | Covered |
| I69.343 | ICD10CM | Covered |
| I69.344 | ICD10CM | Covered |
| I69.351 | ICD10CM | Covered |
| I69.352 | ICD10CM | Covered |
| I69.353 | ICD10CM | Covered |
| I69.354 | ICD10CM | Covered |
| I69.831 | ICD10CM | Covered |
| I69.832 | ICD10CM | Covered |
| I69.833 | ICD10CM | Covered |
| I69.834 | ICD10CM | Covered |
| I69.841 | ICD10CM | Covered |
| I69.842 | ICD10CM | Covered |
| I69.843 | ICD10CM | Covered |
| I69.844 | ICD10CM | Covered |
| I69.851 | ICD10CM | Covered |
| I69.852 | ICD10CM | Covered |
| I69.853 | ICD10CM | Covered |
| I69.854 | ICD10CM | Covered |
| I69.931 | ICD10CM | Covered |
| I69.932 | ICD10CM | Covered |
| I69.933 | ICD10CM | Covered |
| I69.934 | ICD10CM | Covered |
| I69.941 | ICD10CM | Covered |
| I69.942 | ICD10CM | Covered |
| I69.943 | ICD10CM | Covered |
| I69.944 | ICD10CM | Covered |
| I69.951 | ICD10CM | Covered |
| I69.952 | ICD10CM | Covered |
| I69.953 | ICD10CM | Covered |
| I69.954 | ICD10CM | Covered |
| I72.0 | ICD10CM | Covered |
| I72.6 | ICD10CM | Covered |
| I74.9 | ICD10CM | Covered |
| I76 | ICD10CM | Covered |
| I77.1 | ICD10CM | Covered |
| I77.2 | ICD10CM | Covered |
| I77.3 | ICD10CM | Covered |
| I77.6 | ICD10CM | Covered |
| I77.71 | ICD10CM | Covered |
| I77.89 | ICD10CM | Covered |
| Q28.2 | ICD10CM | Covered |
| Q28.3 | ICD10CM | Covered |
| R09.89 | ICD10CM | Covered |
| R22.1 | ICD10CM | Covered |
| R26.0 | ICD10CM | Covered |
| R26.1 | ICD10CM | Covered |
| R26.81 | ICD10CM | Covered |
| R26.89 | ICD10CM | Covered |
| R29.5 | ICD10CM | Covered |
| R29.810 | ICD10CM | Covered |
| R47.01 | ICD10CM | Covered |
| R47.02 | ICD10CM | Covered |
| R47.1 | ICD10CM | Covered |
| R47.81 | ICD10CM | Covered |
| R47.89 | ICD10CM | Covered |
| R55 | ICD10CM | Covered |
| S09.0XXA | ICD10CM | Covered |
| S09.0XXD | ICD10CM | Covered |
| S09.0XXS | ICD10CM | Covered |
| S15.011A | ICD10CM | Covered |
| S15.011D | ICD10CM | Covered |
| S15.011S | ICD10CM | Covered |
| S15.012A | ICD10CM | Covered |
| S15.012D | ICD10CM | Covered |
| S15.012S | ICD10CM | Covered |
| S15.021A | ICD10CM | Covered |
| S15.021D | ICD10CM | Covered |
| S15.021S | ICD10CM | Covered |
| S15.022A | ICD10CM | Covered |
| S15.022D | ICD10CM | Covered |
| S15.022S | ICD10CM | Covered |
| S15.091A | ICD10CM | Covered |
| S15.091D | ICD10CM | Covered |
| S15.091S | ICD10CM | Covered |
| S15.092A | ICD10CM | Covered |
| S15.092D | ICD10CM | Covered |
| S15.092S | ICD10CM | Covered |
| S15.111A | ICD10CM | Covered |
| S15.111D | ICD10CM | Covered |
| S15.111S | ICD10CM | Covered |
| S15.112A | ICD10CM | Covered |
| S15.112D | ICD10CM | Covered |
| S15.112S | ICD10CM | Covered |
| S15.121A | ICD10CM | Covered |
| S15.121D | ICD10CM | Covered |
| S15.121S | ICD10CM | Covered |
| S15.122A | ICD10CM | Covered |
| S15.122D | ICD10CM | Covered |
| S15.122S | ICD10CM | Covered |
| S15.191A | ICD10CM | Covered |
| S15.191D | ICD10CM | Covered |
| S15.191S | ICD10CM | Covered |
| S15.192A | ICD10CM | Covered |
| S15.192D | ICD10CM | Covered |
| S15.192S | ICD10CM | Covered |
| S25.111A | ICD10CM | Covered |
| S25.111D | ICD10CM | Covered |
| S25.111S | ICD10CM | Covered |
| S25.112A | ICD10CM | Covered |
| S25.112D | ICD10CM | Covered |
| S25.112S | ICD10CM | Covered |
| S25.121A | ICD10CM | Covered |
| S25.121D | ICD10CM | Covered |
| S25.121S | ICD10CM | Covered |
| S25.122A | ICD10CM | Covered |
| S25.122D | ICD10CM | Covered |
| S25.122S | ICD10CM | Covered |
| S25.191A | ICD10CM | Covered |
| S25.191D | ICD10CM | Covered |
| S25.191S | ICD10CM | Covered |
| S25.192A | ICD10CM | Covered |
| S25.192D | ICD10CM | Covered |
| S25.192S | ICD10CM | Covered |
| Z09 | ICD10CM | Covered |