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 |
|---|---|---|
| 0742T | HCPCS | Covered |
| 75559 | HCPCS | Covered |
| 75563 | HCPCS | Covered |
| 78429 | HCPCS | Covered |
| 78430 | HCPCS | Covered |
| 78431 | HCPCS | Covered |
| 78432 | HCPCS | Covered |
| 78433 | HCPCS | Covered |
| 78434 | HCPCS | Covered |
| 78451 | HCPCS | Covered |
| 78452 | HCPCS | Covered |
| 78453 | HCPCS | Covered |
| 78454 | HCPCS | Covered |
| 78459 | HCPCS | Covered |
| 78491 | HCPCS | Covered |
| 78492 | HCPCS | Covered |
| 93015 | HCPCS | Covered |
| 93016 | HCPCS | Covered |
| 93017 | HCPCS | Covered |
| 93018 | HCPCS | Covered |
| 93350 | HCPCS | Covered |
| 93351 | HCPCS | Covered |
| 93352 | HCPCS | Covered |
| D86.0 | ICD10CM | Covered |
| D86.1 | ICD10CM | Covered |
| D86.2 | ICD10CM | Covered |
| D86.3 | ICD10CM | Covered |
| D86.81 | ICD10CM | Covered |
| D86.82 | ICD10CM | Covered |
| D86.83 | ICD10CM | Covered |
| D86.84 | ICD10CM | Covered |
| D86.85 | ICD10CM | Covered |
| D86.86 | ICD10CM | Covered |
| D86.87 | ICD10CM | Covered |
| D86.89 | ICD10CM | Covered |
| I05.0 | ICD10CM | Covered |
| I05.1 | ICD10CM | Covered |
| I05.2 | ICD10CM | Covered |
| I05.8 | ICD10CM | Covered |
| I06.0 | ICD10CM | Covered |
| I06.1 | ICD10CM | Covered |
| I06.2 | ICD10CM | Covered |
| I06.8 | ICD10CM | Covered |
| I07.0 | ICD10CM | Covered |
| I07.1 | ICD10CM | Covered |
| I07.2 | ICD10CM | Covered |
| I07.8 | ICD10CM | Covered |
| I08.0 | ICD10CM | Covered |
| I08.1 | ICD10CM | Covered |
| I08.2 | ICD10CM | Covered |
| I08.3 | ICD10CM | Covered |
| I08.8 | ICD10CM | Covered |
| I09.81 | ICD10CM | Covered |
| I09.89 | ICD10CM | Covered |
| I11.0 | ICD10CM | Covered |
| I11.9 | ICD10CM | Covered |
| I12.0 | ICD10CM | Covered |
| I12.9 | ICD10CM | Covered |
| I13.0 | ICD10CM | Covered |
| I13.10 | ICD10CM | Covered |
| I13.11 | ICD10CM | Covered |
| I13.2 | ICD10CM | Covered |
| I20.0 | ICD10CM | Covered |
| I20.1 | ICD10CM | Covered |
| I20.2 | ICD10CM | Covered |
| I20.81 | ICD10CM | Covered |
| I20.89 | ICD10CM | Covered |
| I20.9 | ICD10CM | Covered |
| I21.01 | ICD10CM | Covered |
| I21.02 | ICD10CM | Covered |
| I21.09 | ICD10CM | Covered |
| I21.11 | ICD10CM | Covered |
| I21.19 | ICD10CM | Covered |
| I21.21 | ICD10CM | Covered |
| I21.29 | ICD10CM | Covered |
| I21.3 | ICD10CM | Covered |
| I21.4 | ICD10CM | Covered |
| I21.A1 | ICD10CM | Covered |
| I21.A9 | ICD10CM | Covered |
| I21.B | ICD10CM | Covered |
| I22.0 | ICD10CM | Covered |
| I22.1 | ICD10CM | Covered |
| I22.2 | ICD10CM | Covered |
| I22.8 | ICD10CM | Covered |
| I23.7 | ICD10CM | Covered |
| I24.0 | ICD10CM | Covered |
| I24.81 | ICD10CM | Covered |
| I24.89 | ICD10CM | Covered |
| I25.10 | ICD10CM | Covered |
| I25.110 | ICD10CM | Covered |
| I25.111 | ICD10CM | Covered |
| I25.112 | ICD10CM | Covered |
| I25.118 | ICD10CM | Covered |
| I25.119 | ICD10CM | Covered |
| I25.5 | ICD10CM | Covered |
| I25.710 | ICD10CM | Covered |
| I25.711 | ICD10CM | Covered |
| I25.712 | ICD10CM | Covered |
| I25.718 | ICD10CM | Covered |
| I25.720 | ICD10CM | Covered |
| I25.721 | ICD10CM | Covered |
| I25.722 | ICD10CM | Covered |
| I25.728 | ICD10CM | Covered |
| I25.730 | ICD10CM | Covered |
| I25.731 | ICD10CM | Covered |
| I25.732 | ICD10CM | Covered |
| I25.738 | ICD10CM | Covered |
| I25.750 | ICD10CM | Covered |
| I25.751 | ICD10CM | Covered |
| I25.752 | ICD10CM | Covered |
| I25.758 | ICD10CM | Covered |
| I25.760 | ICD10CM | Covered |
| I25.761 | ICD10CM | Covered |
| I25.762 | ICD10CM | Covered |
| I25.768 | ICD10CM | Covered |
| I25.790 | ICD10CM | Covered |
| I25.791 | ICD10CM | Covered |
| I25.792 | ICD10CM | Covered |
| I25.798 | ICD10CM | Covered |
| I25.810 | ICD10CM | Covered |
| I25.811 | ICD10CM | Covered |
| I25.812 | ICD10CM | Covered |
| I27.0 | ICD10CM | Covered |
| I27.21 | ICD10CM | Covered |
| I27.22 | ICD10CM | Covered |
| I27.23 | ICD10CM | Covered |
| I27.24 | ICD10CM | Covered |
| I27.29 | ICD10CM | Covered |
| I27.81 | ICD10CM | Covered |
| I27.82 | ICD10CM | Covered |
| I27.83 | ICD10CM | Covered |
| I27.89 | ICD10CM | Covered |
| I34.0 | ICD10CM | Covered |
| I34.1 | ICD10CM | Covered |
| I34.2 | ICD10CM | Covered |
| I34.81 | ICD10CM | Covered |
| I34.89 | ICD10CM | Covered |
| I35.0 | ICD10CM | Covered |
| I35.1 | ICD10CM | Covered |
| I35.2 | ICD10CM | Covered |
| I35.8 | ICD10CM | Covered |
| I36.0 | ICD10CM | Covered |
| I36.1 | ICD10CM | Covered |
| I36.2 | ICD10CM | Covered |
| I36.8 | ICD10CM | Covered |
| I37.0 | ICD10CM | Covered |
| I37.1 | ICD10CM | Covered |
| I37.2 | ICD10CM | Covered |
| I37.8 | ICD10CM | Covered |
| I42.1 | ICD10CM | Covered |
| I42.2 | ICD10CM | Covered |
| I43 | ICD10CM | Covered |
| I44.7 | ICD10CM | Covered |
| I45.6 | ICD10CM | Covered |
| I47.0 | ICD10CM | Covered |
| I47.21 | ICD10CM | Covered |
| I47.29 | ICD10CM | Covered |
| I47.9 | ICD10CM | Covered |
| I48.0 | ICD10CM | Covered |
| I48.19 | ICD10CM | Covered |
| I49.01 | ICD10CM | Covered |
| I49.02 | ICD10CM | Covered |
| I49.8 | ICD10CM | Covered |
| I50.1 | ICD10CM | Covered |
| I50.21 | ICD10CM | Covered |
| I50.22 | ICD10CM | Covered |
| I50.23 | ICD10CM | Covered |
| I50.31 | ICD10CM | Covered |
| I50.32 | ICD10CM | Covered |
| I50.33 | ICD10CM | Covered |
| I50.41 | ICD10CM | Covered |
| I50.42 | ICD10CM | Covered |
| I50.43 | ICD10CM | Covered |
| I50.811 | ICD10CM | Covered |
| I50.812 | ICD10CM | Covered |
| I50.813 | ICD10CM | Covered |
| I50.814 | ICD10CM | Covered |
| I50.82 | ICD10CM | Covered |
| I50.83 | ICD10CM | Covered |
| I50.84 | ICD10CM | Covered |
| I50.89 | ICD10CM | Covered |
| I51.81 | ICD10CM | Covered |
| I65.01 | ICD10CM | Covered |
| I65.02 | ICD10CM | Covered |
| I65.03 | ICD10CM | Covered |
| I65.1 | ICD10CM | Covered |
| I65.21 | ICD10CM | Covered |
| I65.22 | ICD10CM | Covered |
| I65.23 | ICD10CM | Covered |
| I65.8 | ICD10CM | Covered |
| I66.01 | ICD10CM | Covered |
| I66.02 | ICD10CM | Covered |
| I66.03 | ICD10CM | Covered |
| I66.11 | ICD10CM | Covered |
| I66.12 | ICD10CM | Covered |
| I66.13 | ICD10CM | Covered |
| I66.21 | ICD10CM | Covered |
| I66.22 | ICD10CM | Covered |
| I66.23 | ICD10CM | Covered |
| I66.3 | ICD10CM | Covered |
| I66.8 | ICD10CM | Covered |
| I67.2 | ICD10CM | Covered |
| I70.0 | ICD10CM | Covered |
| I70.1 | ICD10CM | Covered |
| I70.211 | ICD10CM | Covered |
| I70.212 | ICD10CM | Covered |
| I70.213 | ICD10CM | Covered |
| I70.218 | ICD10CM | Covered |
| I70.221 | ICD10CM | Covered |
| I70.222 | ICD10CM | Covered |
| I70.223 | ICD10CM | Covered |
| I70.228 | ICD10CM | Covered |
| I70.231 | ICD10CM | Covered |
| I70.232 | ICD10CM | Covered |
| I70.233 | ICD10CM | Covered |
| I70.234 | ICD10CM | Covered |
| I70.235 | ICD10CM | Covered |
| I70.238 | ICD10CM | Covered |
| I70.241 | ICD10CM | Covered |
| I70.242 | ICD10CM | Covered |
| I70.243 | ICD10CM | Covered |
| I70.244 | ICD10CM | Covered |
| I70.245 | ICD10CM | Covered |
| I70.248 | ICD10CM | Covered |
| I70.25 | ICD10CM | Covered |
| I70.261 | ICD10CM | Covered |
| I70.262 | ICD10CM | Covered |
| I70.263 | ICD10CM | Covered |
| I70.268 | ICD10CM | Covered |
| I70.291 | ICD10CM | Covered |
| I70.292 | ICD10CM | Covered |
| I70.293 | ICD10CM | Covered |
| I70.298 | ICD10CM | Covered |
| I70.411 | ICD10CM | Covered |
| I70.412 | ICD10CM | Covered |
| I70.413 | ICD10CM | Covered |
| I70.418 | ICD10CM | Covered |
| I70.421 | ICD10CM | Covered |
| I70.422 | ICD10CM | Covered |
| I70.423 | ICD10CM | Covered |
| I70.428 | ICD10CM | Covered |
| I70.431 | ICD10CM | Covered |
| I70.432 | ICD10CM | Covered |
| I70.433 | ICD10CM | Covered |
| I70.434 | ICD10CM | Covered |
| I70.435 | ICD10CM | Covered |
| I70.438 | ICD10CM | Covered |
| I70.441 | ICD10CM | Covered |
| I70.442 | ICD10CM | Covered |
| I70.443 | ICD10CM | Covered |
| I70.444 | ICD10CM | Covered |
| I70.445 | ICD10CM | Covered |
| I70.448 | ICD10CM | Covered |
| I70.45 | ICD10CM | Covered |
| I70.461 | ICD10CM | Covered |
| I70.462 | ICD10CM | Covered |
| I70.463 | ICD10CM | Covered |
| I70.468 | ICD10CM | Covered |
| I70.491 | ICD10CM | Covered |
| I70.492 | ICD10CM | Covered |
| I70.493 | ICD10CM | Covered |
| I70.498 | ICD10CM | Covered |
| I70.511 | ICD10CM | Covered |
| I70.512 | ICD10CM | Covered |
| I70.513 | ICD10CM | Covered |
| I70.518 | ICD10CM | Covered |
| I70.521 | ICD10CM | Covered |
| I70.522 | ICD10CM | Covered |
| I70.523 | ICD10CM | Covered |
| I70.528 | ICD10CM | Covered |
| I70.531 | ICD10CM | Covered |
| I70.532 | ICD10CM | Covered |
| I70.533 | ICD10CM | Covered |
| I70.534 | ICD10CM | Covered |
| I70.535 | ICD10CM | Covered |
| I70.538 | ICD10CM | Covered |
| I70.541 | ICD10CM | Covered |
| I70.542 | ICD10CM | Covered |
| I70.543 | ICD10CM | Covered |
| I70.544 | ICD10CM | Covered |
| I70.545 | ICD10CM | Covered |
| I70.548 | ICD10CM | Covered |
| I70.55 | ICD10CM | Covered |
| I70.561 | ICD10CM | Covered |
| I70.562 | ICD10CM | Covered |
| I70.563 | ICD10CM | Covered |
| I70.568 | ICD10CM | Covered |
| I70.591 | ICD10CM | Covered |
| I70.592 | ICD10CM | Covered |
| I70.593 | ICD10CM | Covered |
| I70.598 | ICD10CM | Covered |
| I70.611 | ICD10CM | Covered |
| I70.612 | ICD10CM | Covered |
| I70.613 | ICD10CM | Covered |
| I70.618 | ICD10CM | Covered |
| I70.621 | ICD10CM | Covered |
| I70.622 | ICD10CM | Covered |
| I70.623 | ICD10CM | Covered |
| I70.628 | ICD10CM | Covered |
| I70.631 | ICD10CM | Covered |
| I70.632 | ICD10CM | Covered |
| I70.633 | ICD10CM | Covered |
| I70.634 | ICD10CM | Covered |
| I70.635 | ICD10CM | Covered |
| I70.638 | ICD10CM | Covered |
| I70.641 | ICD10CM | Covered |
| I70.642 | ICD10CM | Covered |
| I70.643 | ICD10CM | Covered |
| I70.644 | ICD10CM | Covered |
| I70.645 | ICD10CM | Covered |
| I70.648 | ICD10CM | Covered |
| I70.65 | ICD10CM | Covered |
| I70.661 | ICD10CM | Covered |
| I70.662 | ICD10CM | Covered |
| I70.663 | ICD10CM | Covered |
| I70.668 | ICD10CM | Covered |
| I70.691 | ICD10CM | Covered |
| I70.692 | ICD10CM | Covered |
| I70.693 | ICD10CM | Covered |
| I70.698 | ICD10CM | Covered |
| I70.711 | ICD10CM | Covered |
| I70.712 | ICD10CM | Covered |
| I70.713 | ICD10CM | Covered |
| I70.718 | ICD10CM | Covered |
| I70.721 | ICD10CM | Covered |
| I70.722 | ICD10CM | Covered |
| I70.723 | ICD10CM | Covered |
| I70.728 | ICD10CM | Covered |
| I70.731 | ICD10CM | Covered |
| I70.732 | ICD10CM | Covered |
| I70.733 | ICD10CM | Covered |
| I70.734 | ICD10CM | Covered |
| I70.735 | ICD10CM | Covered |
| I70.738 | ICD10CM | Covered |
| I70.741 | ICD10CM | Covered |
| I70.742 | ICD10CM | Covered |
| I70.743 | ICD10CM | Covered |
| I70.744 | ICD10CM | Covered |
| I70.745 | ICD10CM | Covered |
| I70.748 | ICD10CM | Covered |
| I70.75 | ICD10CM | Covered |
| I70.761 | ICD10CM | Covered |
| I70.762 | ICD10CM | Covered |
| I70.763 | ICD10CM | Covered |
| I70.768 | ICD10CM | Covered |
| I70.791 | ICD10CM | Covered |
| I70.792 | ICD10CM | Covered |
| I70.793 | ICD10CM | Covered |
| I70.798 | ICD10CM | Covered |
| I70.8 | ICD10CM | Covered |
| I70.92 | ICD10CM | Covered |
| N18.1 | ICD10CM | Covered |
| N18.2 | ICD10CM | Covered |
| N18.31 | ICD10CM | Covered |
| N18.32 | ICD10CM | Covered |
| N18.4 | ICD10CM | Covered |
| N18.5 | ICD10CM | Covered |
| N18.6 | ICD10CM | Covered |
| R06.01 | ICD10CM | Covered |
| R06.02 | ICD10CM | Covered |
| R06.09 | ICD10CM | Covered |
| R07.2 | ICD10CM | Covered |
| R07.81 | ICD10CM | Covered |
| R07.82 | ICD10CM | Covered |
| R07.89 | ICD10CM | Covered |
| R07.9 | ICD10CM | Covered |
| R55 | ICD10CM | Covered |
| R77.8 | ICD10CM | Covered |
| R79.89 | ICD10CM | Covered |
| R93.1 | ICD10CM | Covered |
| R94.31 | ICD10CM | Covered |
| R94.39 | ICD10CM | Covered |
| T82.855A | ICD10CM | Covered |
| T82.855D | ICD10CM | Covered |
| T82.855S | ICD10CM | Covered |
| T82.857A | ICD10CM | Covered |
| T82.857D | ICD10CM | Covered |
| T82.857S | ICD10CM | Covered |
| T82.867A | ICD10CM | Covered |
| T82.867D | ICD10CM | Covered |
| T82.867S | ICD10CM | Covered |
| T86.19 | ICD10CM | Covered |
| T86.290 | ICD10CM | Covered |
| T86.298 | ICD10CM | Covered |
| T86.39 | ICD10CM | Covered |
| Z01.810 | ICD10CM | Covered |
| Z48.21 | ICD10CM | Covered |
| Z48.22 | ICD10CM | Covered |
| Z48.280 | ICD10CM | Covered |
| Z76.82 | ICD10CM | Covered |
| Z79.899 | ICD10CM | Covered |
| Z94.0 | ICD10CM | Covered |
| Z94.1 | ICD10CM | Covered |
| Z94.3 | ICD10CM | Covered |
| Z95.0 | ICD10CM | Covered |
| Z95.1 | ICD10CM | Covered |
| Z95.5 | ICD10CM | Covered |
| Z98.61 | ICD10CM | Covered |