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 |
|---|---|---|
| 93260 | HCPCS | Covered |
| 93261 | HCPCS | Covered |
| 93279 | HCPCS | Covered |
| 93280 | HCPCS | Covered |
| 93281 | HCPCS | Covered |
| 93282 | HCPCS | Covered |
| 93283 | HCPCS | Covered |
| 93284 | HCPCS | Covered |
| 93286 | HCPCS | Covered |
| 93287 | HCPCS | Covered |
| 93288 | HCPCS | Covered |
| 93289 | HCPCS | Covered |
| 93292 | HCPCS | Covered |
| 93293 | HCPCS | Covered |
| 93294 | HCPCS | Covered |
| 93295 | HCPCS | Covered |
| 93296 | HCPCS | Covered |
| 93724 | HCPCS | 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 |
| I21.9 | ICD10CM | Covered |
| I22.0 | ICD10CM | Covered |
| I22.1 | ICD10CM | Covered |
| I22.2 | ICD10CM | Covered |
| I22.8 | ICD10CM | Covered |
| I22.9 | ICD10CM | Covered |
| I25.10 | ICD10CM | Covered |
| I25.2 | ICD10CM | Covered |
| I25.5 | ICD10CM | Covered |
| I25.6 | ICD10CM | Covered |
| I25.810 | ICD10CM | Covered |
| I25.811 | ICD10CM | Covered |
| I25.812 | ICD10CM | Covered |
| I25.89 | ICD10CM | Covered |
| I25.9 | ICD10CM | Covered |
| I42.0 | ICD10CM | Covered |
| I44.1 | ICD10CM | Covered |
| I44.2 | ICD10CM | Covered |
| I44.4 | ICD10CM | Covered |
| I44.5 | ICD10CM | Covered |
| I44.60 | ICD10CM | Covered |
| I44.69 | ICD10CM | Covered |
| I44.7 | ICD10CM | Covered |
| I45.0 | ICD10CM | Covered |
| I45.10 | ICD10CM | Covered |
| I45.19 | ICD10CM | Covered |
| I45.2 | ICD10CM | Covered |
| I45.3 | ICD10CM | Covered |
| I45.6 | ICD10CM | Covered |
| I45.81 | ICD10CM | Covered |
| I45.9 | ICD10CM | Covered |
| I46.2 | ICD10CM | Covered |
| I46.8 | ICD10CM | Covered |
| I46.9 | ICD10CM | Covered |
| I47.0 | ICD10CM | Covered |
| I47.11 | ICD10CM | Covered |
| I47.19 | ICD10CM | Covered |
| I47.21 | ICD10CM | Covered |
| I47.29 | ICD10CM | Covered |
| I47.9 | ICD10CM | Covered |
| I48.0 | ICD10CM | Covered |
| I48.11 | ICD10CM | Covered |
| I48.19 | ICD10CM | Covered |
| I48.20 | ICD10CM | Covered |
| I48.21 | ICD10CM | Covered |
| I48.3 | ICD10CM | Covered |
| I48.4 | ICD10CM | Covered |
| I48.91 | ICD10CM | Covered |
| I48.92 | ICD10CM | Covered |
| I49.01 | ICD10CM | Covered |
| I49.02 | ICD10CM | Covered |
| I49.2 | ICD10CM | Covered |
| I49.3 | ICD10CM | Covered |
| I49.5 | ICD10CM | Covered |
| I49.8 | ICD10CM | Covered |
| I49.9 | ICD10CM | Covered |
| I50.1 | ICD10CM | Covered |
| I50.20 | ICD10CM | Covered |
| I50.21 | ICD10CM | Covered |
| I50.22 | ICD10CM | Covered |
| I50.23 | ICD10CM | Covered |
| I50.41 | ICD10CM | Covered |
| I50.42 | ICD10CM | Covered |
| I50.43 | ICD10CM | Covered |
| I50.810 | 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 |
| I50.9 | ICD10CM | Covered |
| R00.1 | ICD10CM | Covered |
| R00.2 | ICD10CM | Covered |
| R55 | ICD10CM | Covered |
| R93.1 | ICD10CM | Covered |
| R93.89 | ICD10CM | Covered |
| T82.110A | ICD10CM | Covered |
| T82.110D | ICD10CM | Covered |
| T82.110S | ICD10CM | Covered |
| T82.111A | ICD10CM | Covered |
| T82.111D | ICD10CM | Covered |
| T82.111S | ICD10CM | Covered |
| T82.118A | ICD10CM | Covered |
| T82.118D | ICD10CM | Covered |
| T82.118S | ICD10CM | Covered |
| T82.119A | ICD10CM | Covered |
| T82.119D | ICD10CM | Covered |
| T82.119S | ICD10CM | Covered |
| T82.120A | ICD10CM | Covered |
| T82.120D | ICD10CM | Covered |
| T82.120S | ICD10CM | Covered |
| T82.121A | ICD10CM | Covered |
| T82.121D | ICD10CM | Covered |
| T82.121S | ICD10CM | Covered |
| T82.128A | ICD10CM | Covered |
| T82.128D | ICD10CM | Covered |
| T82.128S | ICD10CM | Covered |
| T82.129A | ICD10CM | Covered |
| T82.129D | ICD10CM | Covered |
| T82.129S | ICD10CM | Covered |
| T82.190A | ICD10CM | Covered |
| T82.190D | ICD10CM | Covered |
| T82.190S | ICD10CM | Covered |
| T82.191A | ICD10CM | Covered |
| T82.191D | ICD10CM | Covered |
| T82.191S | ICD10CM | Covered |
| T82.198A | ICD10CM | Covered |
| T82.198D | ICD10CM | Covered |
| T82.198S | ICD10CM | Covered |
| T82.199A | ICD10CM | Covered |
| T82.199D | ICD10CM | Covered |
| T82.199S | ICD10CM | Covered |
| T82.221A | ICD10CM | Covered |
| T82.222A | ICD10CM | Covered |
| T82.223A | ICD10CM | Covered |
| T82.228A | ICD10CM | Covered |
| T82.512A | ICD10CM | Covered |
| T82.514A | ICD10CM | Covered |
| T82.518A | ICD10CM | Covered |
| T82.522A | ICD10CM | Covered |
| T82.524A | ICD10CM | Covered |
| T82.528A | ICD10CM | Covered |
| T82.529A | ICD10CM | Covered |
| T82.532A | ICD10CM | Covered |
| T82.534A | ICD10CM | Covered |
| T82.538A | ICD10CM | Covered |
| T82.592A | ICD10CM | Covered |
| T82.594A | ICD10CM | Covered |
| T82.598A | ICD10CM | Covered |
| T82.817A | ICD10CM | Covered |
| T82.827A | ICD10CM | Covered |
| T82.837A | ICD10CM | Covered |
| T82.847A | ICD10CM | Covered |
| T82.857A | ICD10CM | Covered |
| T82.867A | ICD10CM | Covered |
| T82.897A | ICD10CM | Covered |
| T82.9XXA | ICD10CM | Covered |
| Z45.010 | ICD10CM | Covered |
| Z45.018 | ICD10CM | Covered |
| Z45.02 | ICD10CM | Covered |
| Z45.09 | ICD10CM | Covered |
| Z86.74 | ICD10CM | Covered |
| Z95.0 | ICD10CM | Covered |
| Z95.810 | ICD10CM | Covered |
| Z95.818 | ICD10CM | Covered |
| Z95.9 | ICD10CM | Covered |