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 |
|---|---|---|
| 86790 | HCPCS | Covered |
| 86794 | HCPCS | Covered |
| 87662 | HCPCS | Covered |
| 87798 | HCPCS | Covered |
| 87801 | HCPCS | Covered |
| A92.5 | ICD10CM | Covered |
| B30.9 | ICD10CM | Covered |
| M25.50 | ICD10CM | Covered |
| M25.511 | ICD10CM | Covered |
| M25.512 | ICD10CM | Covered |
| M25.519 | ICD10CM | Covered |
| M25.521 | ICD10CM | Covered |
| M25.522 | ICD10CM | Covered |
| M25.529 | ICD10CM | Covered |
| M25.531 | ICD10CM | Covered |
| M25.532 | ICD10CM | Covered |
| M25.539 | ICD10CM | Covered |
| M25.551 | ICD10CM | Covered |
| M25.552 | ICD10CM | Covered |
| M25.559 | ICD10CM | Covered |
| M25.561 | ICD10CM | Covered |
| M25.562 | ICD10CM | Covered |
| M25.569 | ICD10CM | Covered |
| M25.571 | ICD10CM | Covered |
| M25.572 | ICD10CM | Covered |
| M25.579 | ICD10CM | Covered |
| O09.00 | ICD10CM | Covered |
| O09.01 | ICD10CM | Covered |
| O09.02 | ICD10CM | Covered |
| O09.03 | ICD10CM | Covered |
| O09.10 | ICD10CM | Covered |
| O09.11 | ICD10CM | Covered |
| O09.12 | ICD10CM | Covered |
| O09.13 | ICD10CM | Covered |
| O09.211 | ICD10CM | Covered |
| O09.212 | ICD10CM | Covered |
| O09.213 | ICD10CM | Covered |
| O09.219 | ICD10CM | Covered |
| O09.291 | ICD10CM | Covered |
| O09.292 | ICD10CM | Covered |
| O09.293 | ICD10CM | Covered |
| O09.299 | ICD10CM | Covered |
| O09.30 | ICD10CM | Covered |
| O09.31 | ICD10CM | Covered |
| O09.32 | ICD10CM | Covered |
| O09.33 | ICD10CM | Covered |
| O09.40 | ICD10CM | Covered |
| O09.41 | ICD10CM | Covered |
| O09.42 | ICD10CM | Covered |
| O09.43 | ICD10CM | Covered |
| O09.511 | ICD10CM | Covered |
| O09.512 | ICD10CM | Covered |
| O09.513 | ICD10CM | Covered |
| O09.519 | ICD10CM | Covered |
| O09.521 | ICD10CM | Covered |
| O09.522 | ICD10CM | Covered |
| O09.523 | ICD10CM | Covered |
| O09.529 | ICD10CM | Covered |
| O09.611 | ICD10CM | Covered |
| O09.612 | ICD10CM | Covered |
| O09.613 | ICD10CM | Covered |
| O09.619 | ICD10CM | Covered |
| O09.621 | ICD10CM | Covered |
| O09.622 | ICD10CM | Covered |
| O09.623 | ICD10CM | Covered |
| O09.629 | ICD10CM | Covered |
| O09.70 | ICD10CM | Covered |
| O09.71 | ICD10CM | Covered |
| O09.72 | ICD10CM | Covered |
| O09.73 | ICD10CM | Covered |
| O09.811 | ICD10CM | Covered |
| O09.812 | ICD10CM | Covered |
| O09.813 | ICD10CM | Covered |
| O09.819 | ICD10CM | Covered |
| O09.821 | ICD10CM | Covered |
| O09.822 | ICD10CM | Covered |
| O09.823 | ICD10CM | Covered |
| O09.829 | ICD10CM | Covered |
| O09.891 | ICD10CM | Covered |
| O09.892 | ICD10CM | Covered |
| O09.893 | ICD10CM | Covered |
| O09.899 | ICD10CM | Covered |
| O09.90 | ICD10CM | Covered |
| O09.91 | ICD10CM | Covered |
| O09.92 | ICD10CM | Covered |
| O09.93 | ICD10CM | Covered |
| O28.3 | ICD10CM | Covered |
| O28.4 | ICD10CM | Covered |
| O35.00X1 | ICD10CM | Covered |
| O35.00X2 | ICD10CM | Covered |
| O35.00X3 | ICD10CM | Covered |
| O35.00X4 | ICD10CM | Covered |
| O35.00X5 | ICD10CM | Covered |
| O35.00X9 | ICD10CM | Covered |
| O35.07X1 | ICD10CM | Covered |
| O35.07X2 | ICD10CM | Covered |
| O35.07X3 | ICD10CM | Covered |
| O35.07X4 | ICD10CM | Covered |
| O35.07X5 | ICD10CM | Covered |
| O35.07X9 | ICD10CM | Covered |
| O35.09X1 | ICD10CM | Covered |
| O35.09X2 | ICD10CM | Covered |
| O35.09X3 | ICD10CM | Covered |
| O35.09X4 | ICD10CM | Covered |
| O35.09X5 | ICD10CM | Covered |
| O35.09X9 | ICD10CM | Covered |
| O35.3XX0 | ICD10CM | Covered |
| O35.3XX1 | ICD10CM | Covered |
| O35.3XX2 | ICD10CM | Covered |
| O35.3XX3 | ICD10CM | Covered |
| O35.3XX4 | ICD10CM | Covered |
| O35.3XX5 | ICD10CM | Covered |
| O35.3XX9 | ICD10CM | Covered |
| R21 | ICD10CM | Covered |
| R50.9 | ICD10CM | Covered |
| Z03.73 | ICD10CM | Covered |
| Z03.79 | ICD10CM | Covered |
| Z03.89 | ICD10CM | Covered |
| Z20.821 | ICD10CM | Covered |
| Z33.1 | ICD10CM | Covered |
| Z34.00 | ICD10CM | Covered |
| Z34.01 | ICD10CM | Covered |
| Z34.02 | ICD10CM | Covered |
| Z34.03 | ICD10CM | Covered |
| Z34.80 | ICD10CM | Covered |
| Z34.81 | ICD10CM | Covered |
| Z34.82 | ICD10CM | Covered |
| Z34.83 | ICD10CM | Covered |
| Z34.90 | ICD10CM | Covered |
| Z34.91 | ICD10CM | Covered |
| Z34.92 | ICD10CM | Covered |
| Z34.93 | ICD10CM | Covered |
| Z36.89 | ICD10CM | Covered |