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 |
|---|---|---|
| 0571T | HCPCS | Covered |
| 0572T | HCPCS | Covered |
| 0573T | HCPCS | Covered |
| 0574T | HCPCS | Covered |
| 0575T | HCPCS | Covered |
| 0576T | HCPCS | Covered |
| 0577T | HCPCS | Covered |
| 0578T | HCPCS | Covered |
| 0579T | HCPCS | Covered |
| 0580T | HCPCS | Covered |
| 0614T | HCPCS | Covered |
| 33202 | HCPCS | Covered |
| 33203 | HCPCS | Covered |
| 33215 | HCPCS | Covered |
| 33216 | HCPCS | Covered |
| 33217 | HCPCS | Covered |
| 33218 | HCPCS | Covered |
| 33220 | HCPCS | Covered |
| 33223 | HCPCS | Covered |
| 33224 | HCPCS | Covered |
| 33225 | HCPCS | Covered |
| 33230 | HCPCS | Covered |
| 33231 | HCPCS | Covered |
| 33240 | HCPCS | Covered |
| 33241 | HCPCS | Covered |
| 33243 | HCPCS | Covered |
| 33244 | HCPCS | Covered |
| 33249 | HCPCS | Covered |
| 33262 | HCPCS | Covered |
| 33263 | HCPCS | Covered |
| 33264 | HCPCS | Covered |
| 33270 | HCPCS | Covered |
| 33271 | HCPCS | Covered |
| 33272 | HCPCS | Covered |
| 33273 | HCPCS | Covered |
| C7537 | HCPCS | Covered |
| C7538 | HCPCS | Covered |
| C7539 | HCPCS | Covered |
| C7540 | HCPCS | Covered |
| G0448 | HCPCS | Covered |
| G90.01 | ICD10CM | Covered |
| I25.2 | ICD10CM | Covered |
| I25.5 | ICD10CM | Covered |
| I42.00 | ICD10CM | Covered |
| I42.01 | ICD10CM | Covered |
| I42.09 | ICD10CM | Covered |
| I42.1 | ICD10CM | Covered |
| I42.2 | ICD10CM | Covered |
| I42.6 | ICD10CM | Covered |
| I42.7 | ICD10CM | Covered |
| I42.81 | ICD10CM | Covered |
| I42.89 | ICD10CM | Covered |
| I44.0 | ICD10CM | Covered |
| I44.1 | ICD10CM | Covered |
| I44.2 | ICD10CM | Covered |
| I44.30 | ICD10CM | Covered |
| I44.7 | ICD10CM | Covered |
| I45.10 | ICD10CM | Covered |
| I45.19 | ICD10CM | Covered |
| I45.2 | ICD10CM | Covered |
| I45.3 | ICD10CM | Covered |
| I45.6 | ICD10CM | Covered |
| I45.81 | ICD10CM | Covered |
| I45.89 | ICD10CM | Covered |
| I46.2 | ICD10CM | Covered |
| I46.9 | ICD10CM | Covered |
| I47.10 | ICD10CM | Covered |
| I47.11 | ICD10CM | Covered |
| I47.19 | ICD10CM | Covered |
| I47.20 | ICD10CM | Covered |
| I47.21 | ICD10CM | Covered |
| I47.22 | ICD10CM | Covered |
| I47.29 | ICD10CM | Covered |
| I47.9 | ICD10CM | Covered |
| I48.11 | ICD10CM | Covered |
| I48.19 | ICD10CM | Covered |
| I48.3 | ICD10CM | Covered |
| I48.4 | ICD10CM | Covered |
| I48.91 | ICD10CM | Covered |
| I48.92 | ICD10CM | Covered |
| I49.01 | ICD10CM | Covered |
| I49.02 | ICD10CM | Covered |
| I49.3 | ICD10CM | Covered |
| I49.5 | ICD10CM | Covered |
| I49.9 | ICD10CM | Covered |
| I50.21 | ICD10CM | Covered |
| I50.22 | ICD10CM | Covered |
| I50.23 | ICD10CM | Covered |
| I50.41 | ICD10CM | Covered |
| I50.42 | ICD10CM | Covered |
| I50.43 | ICD10CM | Covered |
| I50.84 | ICD10CM | Covered |
| I5A | ICD10CM | Covered |
| Q24.6 | ICD10CM | Covered |
| T82.110A | ICD10CM | Covered |
| T82.111A | ICD10CM | Covered |
| T82.118A | ICD10CM | Covered |
| T82.119A | ICD10CM | Covered |
| T82.120A | ICD10CM | Covered |
| T82.121A | ICD10CM | Covered |
| T82.128A | ICD10CM | Covered |
| T82.129A | ICD10CM | Covered |
| T82.190A | ICD10CM | Covered |
| T82.191A | ICD10CM | Covered |
| T82.198A | ICD10CM | Covered |
| T82.199A | ICD10CM | Covered |
| T82.7XXA | ICD10CM | Covered |
| Z00.6 | ICD10CM | Covered |
| Z45.02 | ICD10CM | Covered |
| Z76.82 | ICD10CM | Covered |
| Z86.74 | ICD10CM | Covered |