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 |
|---|---|---|
| 87505 | HCPCS | Covered |
| 87506 | HCPCS | Covered |
| 87507 | HCPCS | Covered |
| B20 | ICD10CM | Covered |
| D80.0 | ICD10CM | Covered |
| D80.1 | ICD10CM | Covered |
| D80.2 | ICD10CM | Covered |
| D80.3 | ICD10CM | Covered |
| D80.4 | ICD10CM | Covered |
| D80.5 | ICD10CM | Covered |
| D80.6 | ICD10CM | Covered |
| D80.8 | ICD10CM | Covered |
| D81.0 | ICD10CM | Covered |
| D81.1 | ICD10CM | Covered |
| D81.2 | ICD10CM | Covered |
| D81.31 | ICD10CM | Covered |
| D81.4 | ICD10CM | Covered |
| D81.5 | ICD10CM | Covered |
| D81.6 | ICD10CM | Covered |
| D81.7 | ICD10CM | Covered |
| D81.810 | ICD10CM | Covered |
| D81.818 | ICD10CM | Covered |
| D81.89 | ICD10CM | Covered |
| D82.0 | ICD10CM | Covered |
| D82.1 | ICD10CM | Covered |
| D82.2 | ICD10CM | Covered |
| D82.3 | ICD10CM | Covered |
| D82.4 | ICD10CM | Covered |
| D82.8 | ICD10CM | Covered |
| D83.0 | ICD10CM | Covered |
| D83.1 | ICD10CM | Covered |
| D83.2 | ICD10CM | Covered |
| D83.8 | ICD10CM | Covered |
| D84.0 | ICD10CM | Covered |
| D84.1 | ICD10CM | Covered |
| D84.81 | ICD10CM | Covered |
| D84.821 | ICD10CM | Covered |
| D84.822 | ICD10CM | Covered |
| D84.89 | ICD10CM | Covered |
| D89.0 | ICD10CM | Covered |
| D89.1 | ICD10CM | Covered |
| D89.3 | ICD10CM | Covered |
| D89.41 | ICD10CM | Covered |
| D89.42 | ICD10CM | Covered |
| D89.43 | ICD10CM | Covered |
| D89.49 | ICD10CM | Covered |
| D89.810 | ICD10CM | Covered |
| D89.811 | ICD10CM | Covered |
| D89.812 | ICD10CM | Covered |
| D89.82 | ICD10CM | Covered |
| D89.89 | ICD10CM | Covered |
| R19.7 | ICD10CM | Covered |
| Z94.0 | ICD10CM | Covered |
| Z94.1 | ICD10CM | Covered |
| Z94.2 | ICD10CM | Covered |
| Z94.3 | ICD10CM | Covered |
| Z94.4 | ICD10CM | Covered |
| Z94.5 | ICD10CM | Covered |
| Z94.6 | ICD10CM | Covered |
| Z94.81 | ICD10CM | Covered |
| Z94.82 | ICD10CM | Covered |
| Z94.83 | ICD10CM | Covered |
| Z94.84 | ICD10CM | Covered |