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 |
|---|---|---|
| 93970 | HCPCS | Covered |
| 93971 | HCPCS | Covered |
| I26.01 | ICD10CM | Covered |
| I26.02 | ICD10CM | Covered |
| I26.03 | ICD10CM | Covered |
| I26.04 | ICD10CM | Covered |
| I26.09 | ICD10CM | Covered |
| I26.90 | ICD10CM | Covered |
| I26.92 | ICD10CM | Covered |
| I26.93 | ICD10CM | Covered |
| I26.94 | ICD10CM | Covered |
| I26.95 | ICD10CM | Covered |
| I26.96 | ICD10CM | Covered |
| I26.99 | ICD10CM | Covered |
| I80.01 | ICD10CM | Covered |
| I80.02 | ICD10CM | Covered |
| I80.03 | ICD10CM | Covered |
| I80.11 | ICD10CM | Covered |
| I80.12 | ICD10CM | Covered |
| I80.13 | ICD10CM | Covered |
| I80.211 | ICD10CM | Covered |
| I80.212 | ICD10CM | Covered |
| I80.213 | ICD10CM | Covered |
| I80.221 | ICD10CM | Covered |
| I80.222 | ICD10CM | Covered |
| I80.223 | ICD10CM | Covered |
| I80.231 | ICD10CM | Covered |
| I80.232 | ICD10CM | Covered |
| I80.233 | ICD10CM | Covered |
| I80.241 | ICD10CM | Covered |
| I80.242 | ICD10CM | Covered |
| I80.243 | ICD10CM | Covered |
| I80.251 | ICD10CM | Covered |
| I80.252 | ICD10CM | Covered |
| I80.253 | ICD10CM | Covered |
| I80.291 | ICD10CM | Covered |
| I80.292 | ICD10CM | Covered |
| I80.293 | ICD10CM | Covered |
| I80.8 | ICD10CM | Covered |
| I82.1 | ICD10CM | Covered |
| I82.220 | ICD10CM | Covered |
| I82.411 | ICD10CM | Covered |
| I82.412 | ICD10CM | Covered |
| I82.413 | ICD10CM | Covered |
| I82.421 | ICD10CM | Covered |
| I82.422 | ICD10CM | Covered |
| I82.423 | ICD10CM | Covered |
| I82.431 | ICD10CM | Covered |
| I82.432 | ICD10CM | Covered |
| I82.433 | ICD10CM | Covered |
| I82.441 | ICD10CM | Covered |
| I82.442 | ICD10CM | Covered |
| I82.443 | ICD10CM | Covered |
| I82.451 | ICD10CM | Covered |
| I82.452 | ICD10CM | Covered |
| I82.453 | ICD10CM | Covered |
| I82.461 | ICD10CM | Covered |
| I82.462 | ICD10CM | Covered |
| I82.463 | ICD10CM | Covered |
| I82.491 | ICD10CM | Covered |
| I82.492 | ICD10CM | Covered |
| I82.493 | ICD10CM | Covered |
| I82.511 | ICD10CM | Covered |
| I82.512 | ICD10CM | Covered |
| I82.513 | ICD10CM | Covered |
| I82.521 | ICD10CM | Covered |
| I82.522 | ICD10CM | Covered |
| I82.523 | ICD10CM | Covered |
| I82.531 | ICD10CM | Covered |
| I82.532 | ICD10CM | Covered |
| I82.533 | ICD10CM | Covered |
| I82.541 | ICD10CM | Covered |
| I82.542 | ICD10CM | Covered |
| I82.543 | ICD10CM | Covered |
| I82.551 | ICD10CM | Covered |
| I82.552 | ICD10CM | Covered |
| I82.553 | ICD10CM | Covered |
| I82.561 | ICD10CM | Covered |
| I82.562 | ICD10CM | Covered |
| I82.563 | ICD10CM | Covered |
| I82.591 | ICD10CM | Covered |
| I82.592 | ICD10CM | Covered |
| I82.593 | ICD10CM | Covered |
| I82.611 | ICD10CM | Covered |
| I82.612 | ICD10CM | Covered |
| I82.613 | ICD10CM | Covered |
| I82.621 | ICD10CM | Covered |
| I82.622 | ICD10CM | Covered |
| I82.623 | ICD10CM | Covered |
| I82.711 | ICD10CM | Covered |
| I82.712 | ICD10CM | Covered |
| I82.713 | ICD10CM | Covered |
| I82.721 | ICD10CM | Covered |
| I82.722 | ICD10CM | Covered |
| I82.723 | ICD10CM | Covered |
| I82.811 | ICD10CM | Covered |
| I82.812 | ICD10CM | Covered |
| I82.813 | ICD10CM | Covered |
| I82.890 | ICD10CM | Covered |
| I82.891 | ICD10CM | Covered |
| I82.A11 | ICD10CM | Covered |
| I82.A12 | ICD10CM | Covered |
| I82.A13 | ICD10CM | Covered |
| I82.A21 | ICD10CM | Covered |
| I82.A22 | ICD10CM | Covered |
| I82.A23 | ICD10CM | Covered |
| I82.B11 | ICD10CM | Covered |
| I82.B12 | ICD10CM | Covered |
| I82.B13 | ICD10CM | Covered |
| I82.B21 | ICD10CM | Covered |
| I82.B22 | ICD10CM | Covered |
| I82.B23 | ICD10CM | Covered |
| I82.C11 | ICD10CM | Covered |
| I82.C12 | ICD10CM | Covered |
| I82.C13 | ICD10CM | Covered |
| I82.C21 | ICD10CM | Covered |
| I82.C22 | ICD10CM | Covered |
| I82.C23 | ICD10CM | Covered |
| I83.011 | ICD10CM | Covered |
| I83.012 | ICD10CM | Covered |
| I83.013 | ICD10CM | Covered |
| I83.014 | ICD10CM | Covered |
| I83.015 | ICD10CM | Covered |
| I83.018 | ICD10CM | Covered |
| I83.021 | ICD10CM | Covered |
| I83.022 | ICD10CM | Covered |
| I83.023 | ICD10CM | Covered |
| I83.024 | ICD10CM | Covered |
| I83.025 | ICD10CM | Covered |
| I83.028 | ICD10CM | Covered |
| I83.11 | ICD10CM | Covered |
| I83.12 | ICD10CM | Covered |
| I83.211 | ICD10CM | Covered |
| I83.212 | ICD10CM | Covered |
| I83.213 | ICD10CM | Covered |
| I83.214 | ICD10CM | Covered |
| I83.215 | ICD10CM | Covered |
| I83.218 | ICD10CM | Covered |
| I83.221 | ICD10CM | Covered |
| I83.222 | ICD10CM | Covered |
| I83.223 | ICD10CM | Covered |
| I83.224 | ICD10CM | Covered |
| I83.225 | ICD10CM | Covered |
| I83.228 | ICD10CM | Covered |
| I83.811 | ICD10CM | Covered |
| I83.812 | ICD10CM | Covered |
| I83.813 | ICD10CM | Covered |
| I83.891 | ICD10CM | Covered |
| I83.892 | ICD10CM | Covered |
| I83.893 | ICD10CM | Covered |
| I87.011 | ICD10CM | Covered |
| I87.012 | ICD10CM | Covered |
| I87.013 | ICD10CM | Covered |
| I87.021 | ICD10CM | Covered |
| I87.022 | ICD10CM | Covered |
| I87.023 | ICD10CM | Covered |
| I87.031 | ICD10CM | Covered |
| I87.032 | ICD10CM | Covered |
| I87.033 | ICD10CM | Covered |
| I87.091 | ICD10CM | Covered |
| I87.092 | ICD10CM | Covered |
| I87.093 | ICD10CM | Covered |
| I87.1 | ICD10CM | Covered |
| I87.2 | ICD10CM | Covered |
| I87.311 | ICD10CM | Covered |
| I87.312 | ICD10CM | Covered |
| I87.313 | ICD10CM | Covered |
| I87.321 | ICD10CM | Covered |
| I87.322 | ICD10CM | Covered |
| I87.323 | ICD10CM | Covered |
| I87.331 | ICD10CM | Covered |
| I87.332 | ICD10CM | Covered |
| I87.333 | ICD10CM | Covered |
| I87.391 | ICD10CM | Covered |
| I87.392 | ICD10CM | Covered |
| I87.393 | ICD10CM | Covered |
| I89.0 | ICD10CM | Covered |
| L97.111 | ICD10CM | Covered |
| L97.112 | ICD10CM | Covered |
| L97.113 | ICD10CM | Covered |
| L97.114 | ICD10CM | Covered |
| L97.115 | ICD10CM | Covered |
| L97.116 | ICD10CM | Covered |
| L97.118 | ICD10CM | Covered |
| L97.119 | ICD10CM | Covered |
| L97.121 | ICD10CM | Covered |
| L97.122 | ICD10CM | Covered |
| L97.123 | ICD10CM | Covered |
| L97.124 | ICD10CM | Covered |
| L97.125 | ICD10CM | Covered |
| L97.126 | ICD10CM | Covered |
| L97.128 | ICD10CM | Covered |
| L97.129 | ICD10CM | Covered |
| L97.211 | ICD10CM | Covered |
| L97.212 | ICD10CM | Covered |
| L97.213 | ICD10CM | Covered |
| L97.214 | ICD10CM | Covered |
| L97.215 | ICD10CM | Covered |
| L97.216 | ICD10CM | Covered |
| L97.218 | ICD10CM | Covered |
| L97.219 | ICD10CM | Covered |
| L97.221 | ICD10CM | Covered |
| L97.222 | ICD10CM | Covered |
| L97.223 | ICD10CM | Covered |
| L97.224 | ICD10CM | Covered |
| L97.225 | ICD10CM | Covered |
| L97.226 | ICD10CM | Covered |
| L97.228 | ICD10CM | Covered |
| L97.229 | ICD10CM | Covered |
| L97.311 | ICD10CM | Covered |
| L97.312 | ICD10CM | Covered |
| L97.313 | ICD10CM | Covered |
| L97.314 | ICD10CM | Covered |
| L97.315 | ICD10CM | Covered |
| L97.316 | ICD10CM | Covered |
| L97.318 | ICD10CM | Covered |
| L97.319 | ICD10CM | Covered |
| L97.321 | ICD10CM | Covered |
| L97.322 | ICD10CM | Covered |
| L97.323 | ICD10CM | Covered |
| L97.324 | ICD10CM | Covered |
| L97.325 | ICD10CM | Covered |
| L97.326 | ICD10CM | Covered |
| L97.328 | ICD10CM | Covered |
| L97.329 | ICD10CM | Covered |
| L97.411 | ICD10CM | Covered |
| L97.412 | ICD10CM | Covered |
| L97.413 | ICD10CM | Covered |
| L97.414 | ICD10CM | Covered |
| L97.415 | ICD10CM | Covered |
| L97.416 | ICD10CM | Covered |
| L97.418 | ICD10CM | Covered |
| L97.419 | ICD10CM | Covered |
| L97.421 | ICD10CM | Covered |
| L97.422 | ICD10CM | Covered |
| L97.423 | ICD10CM | Covered |
| L97.424 | ICD10CM | Covered |
| L97.425 | ICD10CM | Covered |
| L97.426 | ICD10CM | Covered |
| L97.428 | ICD10CM | Covered |
| L97.429 | ICD10CM | Covered |
| L97.511 | ICD10CM | Covered |
| L97.512 | ICD10CM | Covered |
| L97.513 | ICD10CM | Covered |
| L97.514 | ICD10CM | Covered |
| L97.515 | ICD10CM | Covered |
| L97.516 | ICD10CM | Covered |
| L97.518 | ICD10CM | Covered |
| L97.519 | ICD10CM | Covered |
| L97.521 | ICD10CM | Covered |
| L97.522 | ICD10CM | Covered |
| L97.523 | ICD10CM | Covered |
| L97.524 | ICD10CM | Covered |
| L97.525 | ICD10CM | Covered |
| L97.526 | ICD10CM | Covered |
| L97.528 | ICD10CM | Covered |
| L97.529 | ICD10CM | Covered |
| L97.811 | ICD10CM | Covered |
| L97.812 | ICD10CM | Covered |
| L97.813 | ICD10CM | Covered |
| L97.814 | ICD10CM | Covered |
| L97.815 | ICD10CM | Covered |
| L97.816 | ICD10CM | Covered |
| L97.818 | ICD10CM | Covered |
| L97.819 | ICD10CM | Covered |
| L97.821 | ICD10CM | Covered |
| L97.822 | ICD10CM | Covered |
| L97.823 | ICD10CM | Covered |
| L97.824 | ICD10CM | Covered |
| L97.825 | ICD10CM | Covered |
| L97.826 | ICD10CM | Covered |
| L97.828 | ICD10CM | Covered |
| L97.829 | ICD10CM | Covered |
| M79.601 | ICD10CM | Covered |
| M79.602 | ICD10CM | Covered |
| M79.604 | ICD10CM | Covered |
| M79.605 | ICD10CM | Covered |
| M79.621 | ICD10CM | Covered |
| M79.622 | ICD10CM | Covered |
| M79.631 | ICD10CM | Covered |
| M79.632 | ICD10CM | Covered |
| M79.651 | ICD10CM | Covered |
| M79.652 | ICD10CM | Covered |
| M79.661 | ICD10CM | Covered |
| M79.662 | ICD10CM | Covered |
| Q27.31 | ICD10CM | Covered |
| Q27.32 | ICD10CM | Covered |
| Q27.8 | ICD10CM | Covered |
| Q82.0 | ICD10CM | Covered |
| R22.31 | ICD10CM | Covered |
| R22.32 | ICD10CM | Covered |
| R22.33 | ICD10CM | Covered |
| R22.41 | ICD10CM | Covered |
| R22.42 | ICD10CM | Covered |
| R22.43 | ICD10CM | Covered |
| R60.0 | ICD10CM | Covered |
| R60.1 | ICD10CM | Covered |
| R60.9 | ICD10CM | Covered |
| T81.72XA | ICD10CM | Covered |
| T81.72XD | ICD10CM | Covered |
| Z01.810 | ICD10CM | Covered |
| Z09 | ICD10CM | Covered |