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 |
|---|---|---|
| 15820 | HCPCS | Covered |
| 15821 | HCPCS | Covered |
| 15822 | HCPCS | Covered |
| 15823 | HCPCS | Covered |
| 67900 | HCPCS | Covered |
| 67901 | HCPCS | Covered |
| 67902 | HCPCS | Covered |
| 67903 | HCPCS | Covered |
| 67904 | HCPCS | Covered |
| 67906 | HCPCS | Covered |
| 67908 | HCPCS | Covered |
| 67909 | HCPCS | Covered |
| 67911 | HCPCS | Covered |
| 67914 | HCPCS | Covered |
| 67915 | HCPCS | Covered |
| 67916 | HCPCS | Covered |
| 67917 | HCPCS | Covered |
| 67921 | HCPCS | Covered |
| 67922 | HCPCS | Covered |
| 67923 | HCPCS | Covered |
| 67924 | HCPCS | Covered |
| C44.1021 | ICD10CM | Covered |
| C44.1022 | ICD10CM | Covered |
| C44.1091 | ICD10CM | Covered |
| C44.1092 | ICD10CM | Covered |
| C44.1121 | ICD10CM | Covered |
| C44.1122 | ICD10CM | Covered |
| C44.1191 | ICD10CM | Covered |
| C44.1192 | ICD10CM | Covered |
| C44.1221 | ICD10CM | Covered |
| C44.1222 | ICD10CM | Covered |
| C44.1291 | ICD10CM | Covered |
| C44.1292 | ICD10CM | Covered |
| C44.131 | ICD10CM | Covered |
| C44.1321 | ICD10CM | Covered |
| C44.1322 | ICD10CM | Covered |
| C44.1391 | ICD10CM | Covered |
| C44.1392 | ICD10CM | Covered |
| C44.1921 | ICD10CM | Covered |
| C44.1922 | ICD10CM | Covered |
| C44.1991 | ICD10CM | Covered |
| C44.1992 | ICD10CM | Covered |
| C44.301 | ICD10CM | Covered |
| C44.309 | ICD10CM | Covered |
| C44.311 | ICD10CM | Covered |
| C44.319 | ICD10CM | Covered |
| C44.321 | ICD10CM | Covered |
| C44.329 | ICD10CM | Covered |
| C44.391 | ICD10CM | Covered |
| C44.399 | ICD10CM | Covered |
| C44.90 | ICD10CM | Covered |
| C44.91 | ICD10CM | Covered |
| C44.92 | ICD10CM | Covered |
| C44.99 | ICD10CM | Covered |
| C47.0 | ICD10CM | Covered |
| C49.0 | ICD10CM | Covered |
| D04.111 | ICD10CM | Covered |
| D04.112 | ICD10CM | Covered |
| D04.121 | ICD10CM | Covered |
| D04.122 | ICD10CM | Covered |
| D22.111 | ICD10CM | Covered |
| D22.112 | ICD10CM | Covered |
| D22.121 | ICD10CM | Covered |
| D22.122 | ICD10CM | Covered |
| D22.30 | ICD10CM | Covered |
| D22.39 | ICD10CM | Covered |
| D23.111 | ICD10CM | Covered |
| D23.112 | ICD10CM | Covered |
| D23.121 | ICD10CM | Covered |
| D23.122 | ICD10CM | Covered |
| D23.30 | ICD10CM | Covered |
| D23.39 | ICD10CM | Covered |
| G24.5 | ICD10CM | Covered |
| G51.0 | ICD10CM | Covered |
| G51.2 | ICD10CM | Covered |
| G51.31 | ICD10CM | Covered |
| G51.32 | ICD10CM | Covered |
| G51.33 | ICD10CM | Covered |
| G51.4 | ICD10CM | Covered |
| G51.8 | ICD10CM | Covered |
| G51.9 | ICD10CM | Covered |
| G70.00 | ICD10CM | Covered |
| H01.001 | ICD10CM | Covered |
| H01.002 | ICD10CM | Covered |
| H01.004 | ICD10CM | Covered |
| H01.005 | ICD10CM | Covered |
| H01.00A | ICD10CM | Covered |
| H01.00B | ICD10CM | Covered |
| H01.01A | ICD10CM | Covered |
| H01.01B | ICD10CM | Covered |
| H01.02A | ICD10CM | Covered |
| H01.02B | ICD10CM | Covered |
| H02.001 | ICD10CM | Covered |
| H02.002 | ICD10CM | Covered |
| H02.004 | ICD10CM | Covered |
| H02.005 | ICD10CM | Covered |
| H02.011 | ICD10CM | Covered |
| H02.012 | ICD10CM | Covered |
| H02.014 | ICD10CM | Covered |
| H02.015 | ICD10CM | Covered |
| H02.021 | ICD10CM | Covered |
| H02.022 | ICD10CM | Covered |
| H02.024 | ICD10CM | Covered |
| H02.025 | ICD10CM | Covered |
| H02.031 | ICD10CM | Covered |
| H02.032 | ICD10CM | Covered |
| H02.034 | ICD10CM | Covered |
| H02.035 | ICD10CM | Covered |
| H02.041 | ICD10CM | Covered |
| H02.042 | ICD10CM | Covered |
| H02.044 | ICD10CM | Covered |
| H02.045 | ICD10CM | Covered |
| H02.051 | ICD10CM | Covered |
| H02.052 | ICD10CM | Covered |
| H02.054 | ICD10CM | Covered |
| H02.055 | ICD10CM | Covered |
| H02.101 | ICD10CM | Covered |
| H02.102 | ICD10CM | Covered |
| H02.104 | ICD10CM | Covered |
| H02.105 | ICD10CM | Covered |
| H02.111 | ICD10CM | Covered |
| H02.112 | ICD10CM | Covered |
| H02.114 | ICD10CM | Covered |
| H02.115 | ICD10CM | Covered |
| H02.121 | ICD10CM | Covered |
| H02.122 | ICD10CM | Covered |
| H02.124 | ICD10CM | Covered |
| H02.125 | ICD10CM | Covered |
| H02.131 | ICD10CM | Covered |
| H02.132 | ICD10CM | Covered |
| H02.134 | ICD10CM | Covered |
| H02.135 | ICD10CM | Covered |
| H02.141 | ICD10CM | Covered |
| H02.142 | ICD10CM | Covered |
| H02.144 | ICD10CM | Covered |
| H02.145 | ICD10CM | Covered |
| H02.151 | ICD10CM | Covered |
| H02.152 | ICD10CM | Covered |
| H02.154 | ICD10CM | Covered |
| H02.155 | ICD10CM | Covered |
| H02.156 | ICD10CM | Covered |
| H02.159 | ICD10CM | Covered |
| H02.201 | ICD10CM | Covered |
| H02.202 | ICD10CM | Covered |
| H02.204 | ICD10CM | Covered |
| H02.205 | ICD10CM | Covered |
| H02.20A | ICD10CM | Covered |
| H02.20B | ICD10CM | Covered |
| H02.20C | ICD10CM | Covered |
| H02.211 | ICD10CM | Covered |
| H02.212 | ICD10CM | Covered |
| H02.214 | ICD10CM | Covered |
| H02.215 | ICD10CM | Covered |
| H02.21A | ICD10CM | Covered |
| H02.21B | ICD10CM | Covered |
| H02.21C | ICD10CM | Covered |
| H02.221 | ICD10CM | Covered |
| H02.222 | ICD10CM | Covered |
| H02.224 | ICD10CM | Covered |
| H02.225 | ICD10CM | Covered |
| H02.22A | ICD10CM | Covered |
| H02.22B | ICD10CM | Covered |
| H02.22C | ICD10CM | Covered |
| H02.231 | ICD10CM | Covered |
| H02.232 | ICD10CM | Covered |
| H02.234 | ICD10CM | Covered |
| H02.235 | ICD10CM | Covered |
| H02.23A | ICD10CM | Covered |
| H02.23B | ICD10CM | Covered |
| H02.23C | ICD10CM | Covered |
| H02.31 | ICD10CM | Covered |
| H02.32 | ICD10CM | Covered |
| H02.34 | ICD10CM | Covered |
| H02.35 | ICD10CM | Covered |
| H02.401 | ICD10CM | Covered |
| H02.402 | ICD10CM | Covered |
| H02.403 | ICD10CM | Covered |
| H02.411 | ICD10CM | Covered |
| H02.412 | ICD10CM | Covered |
| H02.413 | ICD10CM | Covered |
| H02.421 | ICD10CM | Covered |
| H02.422 | ICD10CM | Covered |
| H02.423 | ICD10CM | Covered |
| H02.431 | ICD10CM | Covered |
| H02.432 | ICD10CM | Covered |
| H02.433 | ICD10CM | Covered |
| H02.521 | ICD10CM | Covered |
| H02.522 | ICD10CM | Covered |
| H02.524 | ICD10CM | Covered |
| H02.525 | ICD10CM | Covered |
| H02.531 | ICD10CM | Covered |
| H02.532 | ICD10CM | Covered |
| H02.534 | ICD10CM | Covered |
| H02.535 | ICD10CM | Covered |
| H02.70 | ICD10CM | Covered |
| H02.831 | ICD10CM | Covered |
| H02.832 | ICD10CM | Covered |
| H02.834 | ICD10CM | Covered |
| H02.835 | ICD10CM | Covered |
| H02.881 | ICD10CM | Covered |
| H02.882 | ICD10CM | Covered |
| H02.884 | ICD10CM | Covered |
| H02.885 | ICD10CM | Covered |
| H02.88A | ICD10CM | Covered |
| H02.88B | ICD10CM | Covered |
| H02.89 | ICD10CM | Covered |
| H02.9 | ICD10CM | Covered |
| H04.521 | ICD10CM | Covered |
| H04.522 | ICD10CM | Covered |
| H04.523 | ICD10CM | Covered |
| H50.89 | ICD10CM | Covered |
| H57.811 | ICD10CM | Covered |
| H57.812 | ICD10CM | Covered |
| H57.813 | ICD10CM | Covered |
| L11.8 | ICD10CM | Covered |
| L11.9 | ICD10CM | Covered |
| L57.2 | ICD10CM | Covered |
| L57.4 | ICD10CM | Covered |
| L66.4 | ICD10CM | Covered |
| L85.8 | ICD10CM | Covered |
| L87.1 | ICD10CM | Covered |
| L87.8 | ICD10CM | Covered |
| L90.3 | ICD10CM | Covered |
| L90.4 | ICD10CM | Covered |
| L90.8 | ICD10CM | Covered |
| L91.8 | ICD10CM | Covered |
| L92.2 | ICD10CM | Covered |
| L94.8 | ICD10CM | Covered |
| L98.5 | ICD10CM | Covered |
| L98.6 | ICD10CM | Covered |
| L99 | ICD10CM | Covered |
| Q10.0 | ICD10CM | Covered |
| Q10.1 | ICD10CM | Covered |
| Q10.2 | ICD10CM | Covered |
| Q10.3 | ICD10CM | Covered |
| Q11.1 | ICD10CM | Covered |
| S04.51XA | ICD10CM | Covered |
| S04.52XA | ICD10CM | Covered |
| T85.21XA | ICD10CM | Covered |
| T85.22XA | ICD10CM | Covered |
| T85.29XA | ICD10CM | Covered |
| Z41.1 | ICD10CM | Not covered |
| Z44.21 | ICD10CM | Covered |
| Z44.22 | ICD10CM | Covered |
| Z90.01 | ICD10CM | Covered |