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 |
|---|---|---|
| 91110 | HCPCS | Covered |
| 91111 | HCPCS | Covered |
| 91299 | HCPCS | Covered |
| C17.0 | ICD10CM | Covered |
| C17.1 | ICD10CM | Covered |
| C17.2 | ICD10CM | Covered |
| C17.3 | ICD10CM | Covered |
| C17.8 | ICD10CM | Covered |
| C17.9 | ICD10CM | Covered |
| C78.4 | ICD10CM | Covered |
| C7A.010 | ICD10CM | Covered |
| C7A.011 | ICD10CM | Covered |
| C7A.012 | ICD10CM | Covered |
| C7A.019 | ICD10CM | Covered |
| D01.40 | ICD10CM | Covered |
| D01.49 | ICD10CM | Covered |
| D12.0 | ICD10CM | Covered |
| D12.1 | ICD10CM | Covered |
| D12.2 | ICD10CM | Covered |
| D12.3 | ICD10CM | Covered |
| D12.4 | ICD10CM | Covered |
| D12.5 | ICD10CM | Covered |
| D13.2 | ICD10CM | Covered |
| D13.39 | ICD10CM | Covered |
| D37.1 | ICD10CM | Covered |
| D37.2 | ICD10CM | Covered |
| D37.3 | ICD10CM | Covered |
| D37.4 | ICD10CM | Covered |
| D37.5 | ICD10CM | Covered |
| D3A.010 | ICD10CM | Covered |
| D3A.011 | ICD10CM | Covered |
| D3A.012 | ICD10CM | Covered |
| D3A.019 | ICD10CM | Covered |
| D50.0 | ICD10CM | Covered |
| I85.00 | ICD10CM | Covered |
| I85.10 | ICD10CM | Covered |
| I89.0 | ICD10CM | Covered |
| K50.00 | ICD10CM | Covered |
| K50.011 | ICD10CM | Covered |
| K50.012 | ICD10CM | Covered |
| K50.013 | ICD10CM | Covered |
| K50.014 | ICD10CM | Covered |
| K50.018 | ICD10CM | Covered |
| K50.10 | ICD10CM | Covered |
| K50.111 | ICD10CM | Covered |
| K50.112 | ICD10CM | Covered |
| K50.113 | ICD10CM | Covered |
| K50.114 | ICD10CM | Covered |
| K50.118 | ICD10CM | Covered |
| K50.80 | ICD10CM | Covered |
| K50.811 | ICD10CM | Covered |
| K50.812 | ICD10CM | Covered |
| K50.813 | ICD10CM | Covered |
| K50.814 | ICD10CM | Covered |
| K50.818 | ICD10CM | Covered |
| K50.90 | ICD10CM | Covered |
| K50.911 | ICD10CM | Covered |
| K50.912 | ICD10CM | Covered |
| K50.913 | ICD10CM | Covered |
| K50.914 | ICD10CM | Covered |
| K50.918 | ICD10CM | Covered |
| K52.21 | ICD10CM | Covered |
| K52.22 | ICD10CM | Covered |
| K52.29 | ICD10CM | Covered |
| K52.3 | ICD10CM | Covered |
| K52.81 | ICD10CM | Covered |
| K52.82 | ICD10CM | Covered |
| K52.89 | ICD10CM | Covered |
| K52.9 | ICD10CM | Covered |
| K55.20 | ICD10CM | Covered |
| K55.21 | ICD10CM | Covered |
| K56.1 | ICD10CM | Covered |
| K56.600 | ICD10CM | Covered |
| K56.601 | ICD10CM | Covered |
| K56.609 | ICD10CM | Covered |
| K57.01 | ICD10CM | Covered |
| K57.11 | ICD10CM | Covered |
| K57.13 | ICD10CM | Covered |
| K57.41 | ICD10CM | Covered |
| K57.51 | ICD10CM | Covered |
| K57.53 | ICD10CM | Covered |
| K58.0 | ICD10CM | Covered |
| K58.9 | ICD10CM | Covered |
| K63.3 | ICD10CM | Covered |
| K63.5 | ICD10CM | Covered |
| K63.81 | ICD10CM | Covered |
| K70.2 | ICD10CM | Covered |
| K70.30 | ICD10CM | Covered |
| K70.31 | ICD10CM | Covered |
| K74.01 | ICD10CM | Covered |
| K74.02 | ICD10CM | Covered |
| K74.3 | ICD10CM | Covered |
| K74.4 | ICD10CM | Covered |
| K74.60 | ICD10CM | Covered |
| K74.69 | ICD10CM | Covered |
| K76.6 | ICD10CM | Covered |
| K90.41 | ICD10CM | Covered |
| K90.49 | ICD10CM | Covered |
| K90.89 | ICD10CM | Covered |
| K92.0 | ICD10CM | Covered |
| K92.1 | ICD10CM | Covered |
| K92.2 | ICD10CM | Covered |
| Q85.81 | ICD10CM | Covered |
| Q85.82 | ICD10CM | Covered |
| Q85.83 | ICD10CM | Covered |
| Q85.89 | ICD10CM | Covered |
| Q85.9 | ICD10CM | Covered |
| R10.11 | ICD10CM | Covered |
| R10.12 | ICD10CM | Covered |
| R10.13 | ICD10CM | Covered |
| R10.21 | ICD10CM | Covered |
| R10.22 | ICD10CM | Covered |
| R10.23 | ICD10CM | Covered |
| R10.31 | ICD10CM | Covered |
| R10.32 | ICD10CM | Covered |
| R10.33 | ICD10CM | Covered |
| R10.84 | ICD10CM | Covered |
| R19.5 | ICD10CM | Covered |
| R19.7 | ICD10CM | Covered |
| R93.3 | ICD10CM | Covered |
| Z98.890 | ICD10CM | Covered |
| Z98.891 | ICD10CM | Covered |