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 |
|---|---|---|
| 67228 | HCPCS | Covered |
| E08.3211 | ICD10CM | Covered |
| E08.3212 | ICD10CM | Covered |
| E08.3213 | ICD10CM | Covered |
| E08.3291 | ICD10CM | Covered |
| E08.3292 | ICD10CM | Covered |
| E08.3293 | ICD10CM | Covered |
| E08.3311 | ICD10CM | Covered |
| E08.3312 | ICD10CM | Covered |
| E08.3313 | ICD10CM | Covered |
| E08.3391 | ICD10CM | Covered |
| E08.3392 | ICD10CM | Covered |
| E08.3393 | ICD10CM | Covered |
| E08.3411 | ICD10CM | Covered |
| E08.3412 | ICD10CM | Covered |
| E08.3413 | ICD10CM | Covered |
| E08.3491 | ICD10CM | Covered |
| E08.3492 | ICD10CM | Covered |
| E08.3493 | ICD10CM | Covered |
| E08.3511 | ICD10CM | Covered |
| E08.3512 | ICD10CM | Covered |
| E08.3513 | ICD10CM | Covered |
| E08.3521 | ICD10CM | Covered |
| E08.3522 | ICD10CM | Covered |
| E08.3523 | ICD10CM | Covered |
| E08.3531 | ICD10CM | Covered |
| E08.3532 | ICD10CM | Covered |
| E08.3533 | ICD10CM | Covered |
| E08.3541 | ICD10CM | Covered |
| E08.3542 | ICD10CM | Covered |
| E08.3543 | ICD10CM | Covered |
| E08.3551 | ICD10CM | Covered |
| E08.3552 | ICD10CM | Covered |
| E08.3553 | ICD10CM | Covered |
| E08.3591 | ICD10CM | Covered |
| E08.3592 | ICD10CM | Covered |
| E08.3593 | ICD10CM | Covered |
| E09.311 | ICD10CM | Covered |
| E09.3211 | ICD10CM | Covered |
| E09.3212 | ICD10CM | Covered |
| E09.3213 | ICD10CM | Covered |
| E09.3291 | ICD10CM | Covered |
| E09.3292 | ICD10CM | Covered |
| E09.3293 | ICD10CM | Covered |
| E09.3311 | ICD10CM | Covered |
| E09.3312 | ICD10CM | Covered |
| E09.3313 | ICD10CM | Covered |
| E09.3391 | ICD10CM | Covered |
| E09.3392 | ICD10CM | Covered |
| E09.3393 | ICD10CM | Covered |
| E09.3411 | ICD10CM | Covered |
| E09.3412 | ICD10CM | Covered |
| E09.3413 | ICD10CM | Covered |
| E09.3491 | ICD10CM | Covered |
| E09.3492 | ICD10CM | Covered |
| E09.3493 | ICD10CM | Covered |
| E09.3511 | ICD10CM | Covered |
| E09.3512 | ICD10CM | Covered |
| E09.3513 | ICD10CM | Covered |
| E09.3521 | ICD10CM | Covered |
| E09.3522 | ICD10CM | Covered |
| E09.3523 | ICD10CM | Covered |
| E09.3531 | ICD10CM | Covered |
| E09.3532 | ICD10CM | Covered |
| E09.3533 | ICD10CM | Covered |
| E09.3541 | ICD10CM | Covered |
| E09.3542 | ICD10CM | Covered |
| E09.3543 | ICD10CM | Covered |
| E09.3551 | ICD10CM | Covered |
| E09.3552 | ICD10CM | Covered |
| E09.3553 | ICD10CM | Covered |
| E09.3591 | ICD10CM | Covered |
| E09.3592 | ICD10CM | Covered |
| E09.3593 | ICD10CM | Covered |
| E10.311 | ICD10CM | Covered |
| E10.3211 | ICD10CM | Covered |
| E10.3212 | ICD10CM | Covered |
| E10.3213 | ICD10CM | Covered |
| E10.3291 | ICD10CM | Covered |
| E10.3292 | ICD10CM | Covered |
| E10.3293 | ICD10CM | Covered |
| E10.3311 | ICD10CM | Covered |
| E10.3312 | ICD10CM | Covered |
| E10.3313 | ICD10CM | Covered |
| E10.3391 | ICD10CM | Covered |
| E10.3392 | ICD10CM | Covered |
| E10.3393 | ICD10CM | Covered |
| E10.3411 | ICD10CM | Covered |
| E10.3412 | ICD10CM | Covered |
| E10.3413 | ICD10CM | Covered |
| E10.3491 | ICD10CM | Covered |
| E10.3492 | ICD10CM | Covered |
| E10.3493 | ICD10CM | Covered |
| E10.3511 | ICD10CM | Covered |
| E10.3512 | ICD10CM | Covered |
| E10.3513 | ICD10CM | Covered |
| E10.3521 | ICD10CM | Covered |
| E10.3522 | ICD10CM | Covered |
| E10.3523 | ICD10CM | Covered |
| E10.3531 | ICD10CM | Covered |
| E10.3532 | ICD10CM | Covered |
| E10.3533 | ICD10CM | Covered |
| E10.3541 | ICD10CM | Covered |
| E10.3542 | ICD10CM | Covered |
| E10.3543 | ICD10CM | Covered |
| E10.3551 | ICD10CM | Covered |
| E10.3552 | ICD10CM | Covered |
| E10.3553 | ICD10CM | Covered |
| E10.3591 | ICD10CM | Covered |
| E10.3592 | ICD10CM | Covered |
| E10.3593 | ICD10CM | Covered |
| E11.311 | ICD10CM | Covered |
| E11.3211 | ICD10CM | Covered |
| E11.3212 | ICD10CM | Covered |
| E11.3213 | ICD10CM | Covered |
| E11.3291 | ICD10CM | Covered |
| E11.3292 | ICD10CM | Covered |
| E11.3293 | ICD10CM | Covered |
| E11.3311 | ICD10CM | Covered |
| E11.3312 | ICD10CM | Covered |
| E11.3313 | ICD10CM | Covered |
| E11.3391 | ICD10CM | Covered |
| E11.3392 | ICD10CM | Covered |
| E11.3393 | ICD10CM | Covered |
| E11.3411 | ICD10CM | Covered |
| E11.3412 | ICD10CM | Covered |
| E11.3413 | ICD10CM | Covered |
| E11.3491 | ICD10CM | Covered |
| E11.3492 | ICD10CM | Covered |
| E11.3493 | ICD10CM | Covered |
| E11.3511 | ICD10CM | Covered |
| E11.3512 | ICD10CM | Covered |
| E11.3513 | ICD10CM | Covered |
| E11.3521 | ICD10CM | Covered |
| E11.3522 | ICD10CM | Covered |
| E11.3523 | ICD10CM | Covered |
| E11.3531 | ICD10CM | Covered |
| E11.3532 | ICD10CM | Covered |
| E11.3533 | ICD10CM | Covered |
| E11.3541 | ICD10CM | Covered |
| E11.3542 | ICD10CM | Covered |
| E11.3543 | ICD10CM | Covered |
| E11.3551 | ICD10CM | Covered |
| E11.3552 | ICD10CM | Covered |
| E11.3553 | ICD10CM | Covered |
| E11.3591 | ICD10CM | Covered |
| E11.3592 | ICD10CM | Covered |
| E11.3593 | ICD10CM | Covered |
| E13.311 | ICD10CM | Covered |
| E13.3211 | ICD10CM | Covered |
| E13.3212 | ICD10CM | Covered |
| E13.3213 | ICD10CM | Covered |
| E13.3291 | ICD10CM | Covered |
| E13.3292 | ICD10CM | Covered |
| E13.3293 | ICD10CM | Covered |
| E13.3311 | ICD10CM | Covered |
| E13.3312 | ICD10CM | Covered |
| E13.3313 | ICD10CM | Covered |
| E13.3391 | ICD10CM | Covered |
| E13.3392 | ICD10CM | Covered |
| E13.3393 | ICD10CM | Covered |
| E13.3411 | ICD10CM | Covered |
| E13.3412 | ICD10CM | Covered |
| E13.3413 | ICD10CM | Covered |
| E13.3491 | ICD10CM | Covered |
| E13.3492 | ICD10CM | Covered |
| E13.3493 | ICD10CM | Covered |
| E13.3511 | ICD10CM | Covered |
| E13.3512 | ICD10CM | Covered |
| E13.3513 | ICD10CM | Covered |
| E13.3521 | ICD10CM | Covered |
| E13.3522 | ICD10CM | Covered |
| E13.3523 | ICD10CM | Covered |
| E13.3531 | ICD10CM | Covered |
| E13.3532 | ICD10CM | Covered |
| E13.3533 | ICD10CM | Covered |
| E13.3541 | ICD10CM | Covered |
| E13.3542 | ICD10CM | Covered |
| E13.3543 | ICD10CM | Covered |
| E13.3551 | ICD10CM | Covered |
| E13.3552 | ICD10CM | Covered |
| E13.3553 | ICD10CM | Covered |
| E13.3591 | ICD10CM | Covered |
| E13.3592 | ICD10CM | Covered |
| E13.3593 | ICD10CM | Covered |
| H21.1X1 | ICD10CM | Covered |
| H21.1X2 | ICD10CM | Covered |
| H21.1X3 | ICD10CM | Covered |
| H30.20 | ICD10CM | Covered |
| H30.21 | ICD10CM | Covered |
| H30.22 | ICD10CM | Covered |
| H30.23 | ICD10CM | Covered |
| H34.10 | ICD10CM | Covered |
| H34.11 | ICD10CM | Covered |
| H34.12 | ICD10CM | Covered |
| H34.13 | ICD10CM | Covered |
| H34.231 | ICD10CM | Covered |
| H34.232 | ICD10CM | Covered |
| H34.233 | ICD10CM | Covered |
| H34.239 | ICD10CM | Covered |
| H34.8110 | ICD10CM | Covered |
| H34.8111 | ICD10CM | Covered |
| H34.8112 | ICD10CM | Covered |
| H34.8120 | ICD10CM | Covered |
| H34.8121 | ICD10CM | Covered |
| H34.8122 | ICD10CM | Covered |
| H34.8130 | ICD10CM | Covered |
| H34.8131 | ICD10CM | Covered |
| H34.8132 | ICD10CM | Covered |
| H34.8310 | ICD10CM | Covered |
| H34.8311 | ICD10CM | Covered |
| H34.8312 | ICD10CM | Covered |
| H34.8320 | ICD10CM | Covered |
| H34.8321 | ICD10CM | Covered |
| H34.8322 | ICD10CM | Covered |
| H34.8330 | ICD10CM | Covered |
| H34.8331 | ICD10CM | Covered |
| H34.8332 | ICD10CM | Covered |
| H34.9 | ICD10CM | Covered |
| H35.00 | ICD10CM | Covered |
| H35.011 | ICD10CM | Covered |
| H35.012 | ICD10CM | Covered |
| H35.013 | ICD10CM | Covered |
| H35.021 | ICD10CM | Covered |
| H35.022 | ICD10CM | Covered |
| H35.023 | ICD10CM | Covered |
| H35.031 | ICD10CM | Covered |
| H35.032 | ICD10CM | Covered |
| H35.033 | ICD10CM | Covered |
| H35.051 | ICD10CM | Covered |
| H35.052 | ICD10CM | Covered |
| H35.053 | ICD10CM | Covered |
| H35.061 | ICD10CM | Covered |
| H35.062 | ICD10CM | Covered |
| H35.063 | ICD10CM | Covered |
| H35.071 | ICD10CM | Covered |
| H35.072 | ICD10CM | Covered |
| H35.073 | ICD10CM | Covered |
| H35.101 | ICD10CM | Covered |
| H35.102 | ICD10CM | Covered |
| H35.103 | ICD10CM | Covered |
| H35.111 | ICD10CM | Covered |
| H35.112 | ICD10CM | Covered |
| H35.113 | ICD10CM | Covered |
| H35.121 | ICD10CM | Covered |
| H35.122 | ICD10CM | Covered |
| H35.123 | ICD10CM | Covered |
| H35.131 | ICD10CM | Covered |
| H35.132 | ICD10CM | Covered |
| H35.133 | ICD10CM | Covered |
| H35.141 | ICD10CM | Covered |
| H35.142 | ICD10CM | Covered |
| H35.143 | ICD10CM | Covered |
| H35.151 | ICD10CM | Covered |
| H35.152 | ICD10CM | Covered |
| H35.153 | ICD10CM | Covered |
| H35.21 | ICD10CM | Covered |
| H35.22 | ICD10CM | Covered |
| H35.23 | ICD10CM | Covered |
| H35.82 | ICD10CM | Covered |
| H40.51X1 | ICD10CM | Covered |
| H40.51X2 | ICD10CM | Covered |
| H40.51X3 | ICD10CM | Covered |
| H40.51X4 | ICD10CM | Covered |
| H40.52X1 | ICD10CM | Covered |
| H40.52X2 | ICD10CM | Covered |
| H40.52X3 | ICD10CM | Covered |
| H40.52X4 | ICD10CM | Covered |
| H40.53X1 | ICD10CM | Covered |
| H40.53X2 | ICD10CM | Covered |
| H40.53X3 | ICD10CM | Covered |
| H40.53X4 | ICD10CM | Covered |
| H40.89 | ICD10CM | Covered |
| H43.11 | ICD10CM | Covered |
| H43.12 | ICD10CM | Covered |
| H43.13 | ICD10CM | Covered |