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 |
|---|---|---|
| 92507 | HCPCS | Covered |
| 92517 | HCPCS | Covered |
| 92518 | HCPCS | Covered |
| 92519 | HCPCS | Covered |
| 92521 | HCPCS | Covered |
| 92522 | HCPCS | Covered |
| 92523 | HCPCS | Covered |
| 92524 | HCPCS | Covered |
| 92526 | HCPCS | Covered |
| 92597 | HCPCS | Covered |
| 92607 | HCPCS | Covered |
| 92608 | HCPCS | Covered |
| 92609 | HCPCS | Covered |
| 92610 | HCPCS | Covered |
| 92626 | HCPCS | Covered |
| 92627 | HCPCS | Covered |
| 92630 | HCPCS | Covered |
| 92633 | HCPCS | Covered |
| 92650 | HCPCS | Covered |
| 92651 | HCPCS | Covered |
| 92652 | HCPCS | Covered |
| 92653 | HCPCS | Covered |
| 96105 | HCPCS | Covered |
| 96112 | HCPCS | Covered |
| 96113 | HCPCS | Covered |
| 96116 | HCPCS | Covered |
| 96121 | HCPCS | Covered |
| 96125 | HCPCS | Covered |
| 97110 | HCPCS | Covered |
| 97129 | HCPCS | Covered |
| 97130 | HCPCS | Covered |
| 97530 | HCPCS | Covered |
| 97533 | HCPCS | Covered |
| 97535 | HCPCS | Covered |
| 97550 | HCPCS | Covered |
| 97551 | HCPCS | Covered |
| G0153 | HCPCS | Covered |
| G0161 | HCPCS | Covered |
| F01.518 | ICD10CM | Covered |
| F01.A18 | ICD10CM | Covered |
| F01.B18 | ICD10CM | Covered |
| F01.C18 | ICD10CM | Covered |
| F02.818 | ICD10CM | Covered |
| F02.A18 | ICD10CM | Covered |
| F02.B18 | ICD10CM | Covered |
| F02.C18 | ICD10CM | Covered |
| F80.1 | ICD10CM | Covered |
| F80.2 | ICD10CM | Covered |
| F80.4 | ICD10CM | Covered |
| F80.81 | ICD10CM | Covered |
| F80.82 | ICD10CM | Covered |
| F81.0 | ICD10CM | Covered |
| F81.81 | ICD10CM | Covered |
| F82 | ICD10CM | Covered |
| F88 | ICD10CM | Covered |
| F95.2 | ICD10CM | Covered |
| F98.29 | ICD10CM | Covered |
| F98.5 | ICD10CM | Covered |
| G30.0 | ICD10CM | Covered |
| G30.1 | ICD10CM | Covered |
| G30.8 | ICD10CM | Covered |
| G30.9 | ICD10CM | Covered |
| G31.80 | ICD10CM | Covered |
| G31.85 | ICD10CM | Covered |
| G31.86 | ICD10CM | Covered |
| G31.87 | ICD10CM | Covered |
| G36.0 | ICD10CM | Covered |
| G36.1 | ICD10CM | Covered |
| G36.8 | ICD10CM | Covered |
| G36.9 | ICD10CM | Covered |
| G37.0 | ICD10CM | Covered |
| G37.1 | ICD10CM | Covered |
| G37.2 | ICD10CM | Covered |
| G37.4 | ICD10CM | Covered |
| G37.5 | ICD10CM | Covered |
| G37.9 | ICD10CM | Covered |
| G70.81 | ICD10CM | Covered |
| G71.11 | ICD10CM | Covered |
| G71.12 | ICD10CM | Covered |
| G71.13 | ICD10CM | Covered |
| G71.14 | ICD10CM | Covered |
| G71.19 | ICD10CM | Covered |
| G71.20 | ICD10CM | Covered |
| G71.21 | ICD10CM | Covered |
| G71.220 | ICD10CM | Covered |
| G71.228 | ICD10CM | Covered |
| G71.29 | ICD10CM | Covered |
| G72.0 | ICD10CM | Covered |
| G72.1 | ICD10CM | Covered |
| G72.2 | ICD10CM | Covered |
| G72.3 | ICD10CM | Covered |
| G73.1 | ICD10CM | Covered |
| G80.0 | ICD10CM | Covered |
| G80.1 | ICD10CM | Covered |
| G80.2 | ICD10CM | Covered |
| G80.3 | ICD10CM | Covered |
| G80.4 | ICD10CM | Covered |
| G80.8 | ICD10CM | Covered |
| G80.9 | ICD10CM | Covered |
| H90.0 | ICD10CM | Covered |
| H90.11 | ICD10CM | Covered |
| H90.12 | ICD10CM | Covered |
| H90.3 | ICD10CM | Covered |
| H90.41 | ICD10CM | Covered |
| H90.42 | ICD10CM | Covered |
| H90.6 | ICD10CM | Covered |
| H90.71 | ICD10CM | Covered |
| H90.72 | ICD10CM | Covered |
| H90.A11 | ICD10CM | Covered |
| H90.A12 | ICD10CM | Covered |
| H90.A21 | ICD10CM | Covered |
| H90.A22 | ICD10CM | Covered |
| H90.A31 | ICD10CM | Covered |
| H90.A32 | ICD10CM | Covered |
| H91.3 | ICD10CM | Covered |
| H93.221 | ICD10CM | Covered |
| H93.222 | ICD10CM | Covered |
| H93.223 | ICD10CM | Covered |
| H93.241 | ICD10CM | Covered |
| H93.242 | ICD10CM | Covered |
| H93.243 | ICD10CM | Covered |
| H93.25 | ICD10CM | Covered |
| H93.291 | ICD10CM | Covered |
| H93.292 | ICD10CM | Covered |
| H93.293 | ICD10CM | Covered |
| I69.010 | ICD10CM | Covered |
| I69.012 | ICD10CM | Covered |
| I69.013 | ICD10CM | Covered |
| I69.014 | ICD10CM | Covered |
| I69.015 | ICD10CM | Covered |
| I69.018 | ICD10CM | Covered |
| I69.019 | ICD10CM | Covered |
| I69.020 | ICD10CM | Covered |
| I69.021 | ICD10CM | Covered |
| I69.022 | ICD10CM | Covered |
| I69.023 | ICD10CM | Covered |
| I69.028 | ICD10CM | Covered |
| I69.090 | ICD10CM | Covered |
| I69.091 | ICD10CM | Covered |
| I69.092 | ICD10CM | Covered |
| I69.110 | ICD10CM | Covered |
| I69.112 | ICD10CM | Covered |
| I69.114 | ICD10CM | Covered |
| I69.115 | ICD10CM | Covered |
| I69.118 | ICD10CM | Covered |
| I69.120 | ICD10CM | Covered |
| I69.121 | ICD10CM | Covered |
| I69.122 | ICD10CM | Covered |
| I69.123 | ICD10CM | Covered |
| I69.128 | ICD10CM | Covered |
| I69.190 | ICD10CM | Covered |
| I69.191 | ICD10CM | Covered |
| I69.192 | ICD10CM | Covered |
| I69.210 | ICD10CM | Covered |
| I69.212 | ICD10CM | Covered |
| I69.214 | ICD10CM | Covered |
| I69.215 | ICD10CM | Covered |
| I69.220 | ICD10CM | Covered |
| I69.221 | ICD10CM | Covered |
| I69.222 | ICD10CM | Covered |
| I69.223 | ICD10CM | Covered |
| I69.228 | ICD10CM | Covered |
| I69.290 | ICD10CM | Covered |
| I69.291 | ICD10CM | Covered |
| I69.292 | ICD10CM | Covered |
| I69.310 | ICD10CM | Covered |
| I69.312 | ICD10CM | Covered |
| I69.313 | ICD10CM | Covered |
| I69.314 | ICD10CM | Covered |
| I69.315 | ICD10CM | Covered |
| I69.320 | ICD10CM | Covered |
| I69.321 | ICD10CM | Covered |
| I69.322 | ICD10CM | Covered |
| I69.323 | ICD10CM | Covered |
| I69.328 | ICD10CM | Covered |
| I69.390 | ICD10CM | Covered |
| I69.391 | ICD10CM | Covered |
| I69.392 | ICD10CM | Covered |
| I69.810 | ICD10CM | Covered |
| I69.812 | ICD10CM | Covered |
| I69.813 | ICD10CM | Covered |
| I69.814 | ICD10CM | Covered |
| I69.815 | ICD10CM | Covered |
| I69.820 | ICD10CM | Covered |
| I69.821 | ICD10CM | Covered |
| I69.822 | ICD10CM | Covered |
| I69.823 | ICD10CM | Covered |
| I69.828 | ICD10CM | Covered |
| I69.890 | ICD10CM | Covered |
| I69.891 | ICD10CM | Covered |
| I69.892 | ICD10CM | Covered |
| I69.910 | ICD10CM | Covered |
| I69.912 | ICD10CM | Covered |
| I69.913 | ICD10CM | Covered |
| I69.914 | ICD10CM | Covered |
| I69.915 | ICD10CM | Covered |
| I69.920 | ICD10CM | Covered |
| I69.921 | ICD10CM | Covered |
| I69.922 | ICD10CM | Covered |
| I69.923 | ICD10CM | Covered |
| I69.928 | ICD10CM | Covered |
| I69.990 | ICD10CM | Covered |
| I69.991 | ICD10CM | Covered |
| I69.992 | ICD10CM | Covered |
| J38.01 | ICD10CM | Covered |
| J38.02 | ICD10CM | Covered |
| J38.2 | ICD10CM | Covered |
| J38.3 | ICD10CM | Covered |
| K14.8 | ICD10CM | Covered |
| M26.211 | ICD10CM | Covered |
| M26.212 | ICD10CM | Covered |
| M26.213 | ICD10CM | Covered |
| M26.220 | ICD10CM | Covered |
| M26.221 | ICD10CM | Covered |
| M26.23 | ICD10CM | Covered |
| M26.24 | ICD10CM | Covered |
| M26.25 | ICD10CM | Covered |
| M26.29 | ICD10CM | Covered |
| Q38.1 | ICD10CM | Covered |
| Q38.2 | ICD10CM | Covered |
| Q38.3 | ICD10CM | Covered |
| R05.8 | ICD10CM | Covered |
| R06.1 | ICD10CM | Covered |
| R06.89 | ICD10CM | Covered |
| R13.0 | ICD10CM | Covered |
| R13.10 | ICD10CM | Covered |
| R13.11 | ICD10CM | Covered |
| R13.12 | ICD10CM | Covered |
| R13.13 | ICD10CM | Covered |
| R13.14 | ICD10CM | Covered |
| R13.19 | ICD10CM | Covered |
| R41.4 | ICD10CM | Covered |
| R41.841 | ICD10CM | Covered |
| R41.85 | ICD10CM | Covered |
| R47.01 | ICD10CM | Covered |
| R47.02 | ICD10CM | Covered |
| R47.1 | ICD10CM | Covered |
| R47.81 | ICD10CM | Covered |
| R47.82 | ICD10CM | Covered |
| R47.89 | ICD10CM | Covered |
| R48.0 | ICD10CM | Covered |
| R48.1 | ICD10CM | Covered |
| R48.2 | ICD10CM | Covered |
| R48.8 | ICD10CM | Covered |
| R49.0 | ICD10CM | Covered |
| R49.1 | ICD10CM | Covered |
| R49.21 | ICD10CM | Covered |
| R49.22 | ICD10CM | Covered |
| R49.8 | ICD10CM | Covered |
| R62.0 | ICD10CM | Covered |
| R63.39 | ICD10CM | Covered |
| R68.89 | ICD10CM | Covered |
| Z43.0 | ICD10CM | Covered |
| Z44.8 | ICD10CM | Covered |
| Z96.3 | ICD10CM | Covered |