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 |
|---|---|---|
| 76519 | HCPCS | Covered |
| 92136 | HCPCS | Covered |
| E10.36 | ICD10CM | Covered |
| E11.36 | ICD10CM | Covered |
| E13.36 | ICD10CM | Covered |
| H25.011 | ICD10CM | Covered |
| H25.012 | ICD10CM | Covered |
| H25.013 | ICD10CM | Covered |
| H25.031 | ICD10CM | Covered |
| H25.032 | ICD10CM | Covered |
| H25.033 | ICD10CM | Covered |
| H25.041 | ICD10CM | Covered |
| H25.042 | ICD10CM | Covered |
| H25.043 | ICD10CM | Covered |
| H25.11 | ICD10CM | Covered |
| H25.12 | ICD10CM | Covered |
| H25.13 | ICD10CM | Covered |
| H25.21 | ICD10CM | Covered |
| H25.22 | ICD10CM | Covered |
| H25.23 | ICD10CM | Covered |
| H25.811 | ICD10CM | Covered |
| H25.812 | ICD10CM | Covered |
| H25.813 | ICD10CM | Covered |
| H25.89 | ICD10CM | Covered |
| H25.9 | ICD10CM | Covered |
| H26.001 | ICD10CM | Covered |
| H26.002 | ICD10CM | Covered |
| H26.003 | ICD10CM | Covered |
| H26.011 | ICD10CM | Covered |
| H26.012 | ICD10CM | Covered |
| H26.013 | ICD10CM | Covered |
| H26.031 | ICD10CM | Covered |
| H26.032 | ICD10CM | Covered |
| H26.033 | ICD10CM | Covered |
| H26.041 | ICD10CM | Covered |
| H26.042 | ICD10CM | Covered |
| H26.043 | ICD10CM | Covered |
| H26.051 | ICD10CM | Covered |
| H26.052 | ICD10CM | Covered |
| H26.053 | ICD10CM | Covered |
| H26.061 | ICD10CM | Covered |
| H26.062 | ICD10CM | Covered |
| H26.063 | ICD10CM | Covered |
| H26.09 | ICD10CM | Covered |
| H26.101 | ICD10CM | Covered |
| H26.102 | ICD10CM | Covered |
| H26.103 | ICD10CM | Covered |
| H26.111 | ICD10CM | Covered |
| H26.112 | ICD10CM | Covered |
| H26.113 | ICD10CM | Covered |
| H26.121 | ICD10CM | Covered |
| H26.122 | ICD10CM | Covered |
| H26.123 | ICD10CM | Covered |
| H26.131 | ICD10CM | Covered |
| H26.132 | ICD10CM | Covered |
| H26.133 | ICD10CM | Covered |
| H26.20 | ICD10CM | Covered |
| H26.211 | ICD10CM | Covered |
| H26.212 | ICD10CM | Covered |
| H26.213 | ICD10CM | Covered |
| H26.221 | ICD10CM | Covered |
| H26.222 | ICD10CM | Covered |
| H26.223 | ICD10CM | Covered |
| H26.231 | ICD10CM | Covered |
| H26.232 | ICD10CM | Covered |
| H26.233 | ICD10CM | Covered |
| H26.31 | ICD10CM | Covered |
| H26.32 | ICD10CM | Covered |
| H26.33 | ICD10CM | Covered |
| H26.8 | ICD10CM | Covered |
| H26.9 | ICD10CM | Covered |
| H27.01 | ICD10CM | Covered |
| H27.02 | ICD10CM | Covered |
| H27.03 | ICD10CM | Covered |
| H27.111 | ICD10CM | Covered |
| H27.112 | ICD10CM | Covered |
| H27.113 | ICD10CM | Covered |
| H27.121 | ICD10CM | Covered |
| H27.122 | ICD10CM | Covered |
| H27.123 | ICD10CM | Covered |
| H27.131 | ICD10CM | Covered |
| H27.132 | ICD10CM | Covered |
| H27.133 | ICD10CM | Covered |
| H28 | ICD10CM | Covered |
| Q12.0 | ICD10CM | Covered |
| Q12.1 | ICD10CM | Covered |
| Q12.2 | ICD10CM | Covered |
| Q12.3 | ICD10CM | Covered |
| Q12.4 | ICD10CM | Covered |
| Q12.8 | ICD10CM | Covered |
| T85.21XA | ICD10CM | Covered |
| T85.21XD | ICD10CM | Covered |
| T85.21XS | ICD10CM | Covered |
| T85.22XA | ICD10CM | Covered |
| T85.22XD | ICD10CM | Covered |
| T85.22XS | ICD10CM | Covered |
| T85.29XA | ICD10CM | Covered |
| T85.29XD | ICD10CM | Covered |
| T85.29XS | ICD10CM | Covered |