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 |
|---|---|---|
| 81540 | HCPCS | Covered |
| C02.1 | ICD10CM | Covered |
| C08.9 | ICD10CM | Covered |
| C09.9 | ICD10CM | Covered |
| C11.8 | ICD10CM | Covered |
| C15.3 | ICD10CM | Covered |
| C15.4 | ICD10CM | Covered |
| C15.5 | ICD10CM | Covered |
| C15.9 | ICD10CM | Covered |
| C16.0 | ICD10CM | Covered |
| C16.2 | ICD10CM | Covered |
| C16.8 | ICD10CM | Covered |
| C16.9 | ICD10CM | Covered |
| C17.9 | ICD10CM | Covered |
| C18.0 | ICD10CM | Covered |
| C18.2 | ICD10CM | Covered |
| C18.4 | ICD10CM | Covered |
| C18.7 | ICD10CM | Covered |
| C18.8 | ICD10CM | Covered |
| C18.9 | ICD10CM | Covered |
| C22.0 | ICD10CM | Covered |
| C22.1 | ICD10CM | Covered |
| C22.7 | ICD10CM | Covered |
| C22.8 | ICD10CM | Covered |
| C22.9 | ICD10CM | Covered |
| C23 | ICD10CM | Covered |
| C24.8 | ICD10CM | Covered |
| C24.9 | ICD10CM | Covered |
| C25.0 | ICD10CM | Covered |
| C25.1 | ICD10CM | Covered |
| C25.2 | ICD10CM | Covered |
| C25.7 | ICD10CM | Covered |
| C25.8 | ICD10CM | Covered |
| C25.9 | ICD10CM | Covered |
| C26.9 | ICD10CM | Covered |
| C31.9 | ICD10CM | Covered |
| C32.0 | ICD10CM | Covered |
| C32.8 | 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 |
| C37 | ICD10CM | Covered |
| C38.3 | ICD10CM | Covered |
| C38.4 | ICD10CM | Covered |
| C40.01 | ICD10CM | Covered |
| C40.02 | ICD10CM | Covered |
| C41.2 | ICD10CM | Covered |
| C41.3 | ICD10CM | Covered |
| C41.9 | 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 |
| C43.9 | ICD10CM | Covered |
| C44.222 | ICD10CM | Covered |
| C44.229 | ICD10CM | Covered |
| C44.329 | ICD10CM | Covered |
| C44.399 | ICD10CM | Covered |
| C44.42 | ICD10CM | Covered |
| C44.49 | ICD10CM | Covered |
| C44.501 | ICD10CM | Covered |
| C44.509 | ICD10CM | Covered |
| C44.521 | ICD10CM | Covered |
| C44.529 | ICD10CM | Covered |
| C44.599 | ICD10CM | Covered |
| C44.622 | ICD10CM | Covered |
| C44.629 | ICD10CM | Covered |
| C44.709 | ICD10CM | Covered |
| C44.90 | ICD10CM | Covered |
| C44.92 | ICD10CM | Covered |
| C45.7 | 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 |
| C49.12 | ICD10CM | Covered |
| C49.5 | ICD10CM | Covered |
| C49.9 | ICD10CM | Covered |
| C4A.71 | ICD10CM | Covered |
| C4A.9 | 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 |
| C50.421 | ICD10CM | Covered |
| C50.422 | 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 |
| C50.819 | ICD10CM | Covered |
| C50.911 | ICD10CM | Covered |
| C50.912 | ICD10CM | Covered |
| C50.919 | ICD10CM | Covered |
| C50.921 | ICD10CM | Covered |
| C50.922 | ICD10CM | Covered |
| C50.929 | ICD10CM | Covered |
| C53.0 | ICD10CM | Covered |
| C53.8 | ICD10CM | Covered |
| C53.9 | ICD10CM | Covered |
| C54.1 | ICD10CM | Covered |
| C54.3 | 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 |
| C57.8 | ICD10CM | Covered |
| C57.9 | ICD10CM | Covered |
| C61 | ICD10CM | Covered |
| C64.1 | ICD10CM | Covered |
| C64.2 | ICD10CM | Covered |
| C64.9 | ICD10CM | Covered |
| C65.1 | ICD10CM | Covered |
| C65.2 | ICD10CM | Covered |
| C66.1 | ICD10CM | Covered |
| C66.2 | ICD10CM | Covered |
| C67.1 | ICD10CM | Covered |
| C67.2 | ICD10CM | Covered |
| C67.4 | ICD10CM | Covered |
| C67.5 | ICD10CM | Covered |
| C67.8 | ICD10CM | Covered |
| C67.9 | ICD10CM | Covered |
| C68.9 | ICD10CM | Covered |
| C71.1 | ICD10CM | Covered |
| C71.9 | ICD10CM | Covered |
| C73 | ICD10CM | Covered |
| C74.90 | ICD10CM | Covered |
| C74.92 | ICD10CM | Covered |
| C75.1 | ICD10CM | Covered |
| C76.0 | ICD10CM | Covered |
| C76.2 | ICD10CM | Covered |
| C76.3 | ICD10CM | Covered |
| C76.51 | ICD10CM | Covered |
| C76.52 | ICD10CM | Covered |
| C76.8 | 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 |
| C78.00 | ICD10CM | Covered |
| C78.01 | ICD10CM | Covered |
| C78.02 | ICD10CM | Covered |
| C78.1 | ICD10CM | Covered |
| C78.2 | ICD10CM | Covered |
| C78.4 | ICD10CM | Covered |
| C78.5 | ICD10CM | Covered |
| C78.6 | ICD10CM | Covered |
| C78.7 | ICD10CM | Covered |
| C78.80 | ICD10CM | Covered |
| C78.89 | 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 |
| C79.60 | ICD10CM | Covered |
| C79.61 | ICD10CM | Covered |
| C79.62 | ICD10CM | Covered |
| C79.63 | ICD10CM | Covered |
| C79.70 | ICD10CM | Covered |
| C79.71 | ICD10CM | Covered |
| C79.72 | ICD10CM | Covered |
| C79.81 | ICD10CM | Covered |
| C79.82 | ICD10CM | Covered |
| C79.89 | ICD10CM | Covered |
| C79.9 | ICD10CM | Covered |
| C7A.00 | ICD10CM | Covered |
| C7A.019 | ICD10CM | Covered |
| C7A.090 | ICD10CM | Covered |
| C7A.1 | ICD10CM | Covered |
| C7A.8 | ICD10CM | Covered |
| C7B.02 | ICD10CM | Covered |
| C7B.03 | ICD10CM | Covered |
| C7B.8 | ICD10CM | Covered |
| C80.0 | ICD10CM | Covered |
| C80.1 | ICD10CM | Covered |
| C81.90 | ICD10CM | Covered |
| C82.00 | ICD10CM | Covered |
| C82.57 | ICD10CM | Covered |
| C83.09 | ICD10CM | Covered |
| C83.10 | ICD10CM | Covered |
| C83.31 | ICD10CM | Covered |
| C83.390 | ICD10CM | Covered |
| C83.398 | ICD10CM | Covered |
| C84.97 | ICD10CM | Covered |
| C84.A7 | ICD10CM | Covered |
| C84.Z7 | ICD10CM | Covered |
| C85.14 | ICD10CM | Covered |
| C85.17 | ICD10CM | Covered |
| C85.27 | ICD10CM | Covered |
| C85.80 | ICD10CM | Covered |
| C85.87 | ICD10CM | Covered |
| C85.88 | ICD10CM | Covered |
| C85.97 | ICD10CM | Covered |
| D37.6 | ICD10CM | Covered |
| D37.8 | ICD10CM | Covered |
| D37.9 | ICD10CM | Covered |
| D38.1 | ICD10CM | Covered |
| D38.3 | ICD10CM | Covered |
| D41.01 | ICD10CM | Covered |
| D48.0 | ICD10CM | Covered |
| D48.3 | ICD10CM | Covered |
| D48.4 | ICD10CM | Covered |
| D48.5 | ICD10CM | Covered |
| D48.61 | ICD10CM | Covered |
| D48.62 | 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 |
| J91.0 | ICD10CM | Covered |