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 |
|---|---|---|
| 31720 | HCPCS | Covered |
| 94640 | HCPCS | Covered |
| 94664 | HCPCS | Covered |
| 94760 | HCPCS | Covered |
| 94761 | HCPCS | Covered |
| 94762 | HCPCS | Covered |
| 99291 | HCPCS | Covered |
| 99292 | HCPCS | Covered |
| A15.0 | ICD10CM | Covered |
| A22.1 | ICD10CM | Covered |
| A37.01 | ICD10CM | Covered |
| A37.11 | ICD10CM | Covered |
| A37.81 | ICD10CM | Covered |
| A37.91 | ICD10CM | Covered |
| A48.1 | ICD10CM | Covered |
| B25.0 | ICD10CM | Covered |
| B44.0 | ICD10CM | Covered |
| B77.81 | ICD10CM | Covered |
| C34.11 | ICD10CM | Covered |
| C34.12 | ICD10CM | Covered |
| C34.2 | ICD10CM | Covered |
| C34.31 | ICD10CM | Covered |
| C34.32 | ICD10CM | Covered |
| C34.80 | ICD10CM | Covered |
| C34.81 | ICD10CM | Covered |
| C34.82 | ICD10CM | Covered |
| C34.91 | ICD10CM | Covered |
| C34.92 | ICD10CM | Covered |
| C38.4 | ICD10CM | Covered |
| C45.0 | ICD10CM | Covered |
| C78.01 | ICD10CM | Covered |
| C78.02 | ICD10CM | Covered |
| C78.2 | ICD10CM | Covered |
| C78.39 | ICD10CM | Covered |
| E84.0 | ICD10CM | Covered |
| E84.8 | ICD10CM | Covered |
| E84.9 | ICD10CM | Covered |
| F51.19 | ICD10CM | Covered |
| G47.01 | ICD10CM | Covered |
| G47.09 | ICD10CM | Covered |
| G47.10 | ICD10CM | Covered |
| G47.11 | ICD10CM | Covered |
| G47.12 | ICD10CM | Covered |
| G47.13 | ICD10CM | Covered |
| G47.14 | ICD10CM | Covered |
| G47.19 | ICD10CM | Covered |
| G47.20 | ICD10CM | Covered |
| G47.21 | ICD10CM | Covered |
| G47.22 | ICD10CM | Covered |
| G47.23 | ICD10CM | Covered |
| G47.24 | ICD10CM | Covered |
| G47.25 | ICD10CM | Covered |
| G47.26 | ICD10CM | Covered |
| G47.27 | ICD10CM | Covered |
| G47.29 | ICD10CM | Covered |
| G47.30 | ICD10CM | Covered |
| G47.31 | ICD10CM | Covered |
| G47.32 | ICD10CM | Covered |
| G47.33 | ICD10CM | Covered |
| G47.34 | ICD10CM | Covered |
| G47.35 | ICD10CM | Covered |
| G47.36 | ICD10CM | Covered |
| G47.37 | ICD10CM | Covered |
| G47.39 | ICD10CM | Covered |
| G47.50 | ICD10CM | Covered |
| G47.51 | ICD10CM | Covered |
| G47.52 | ICD10CM | Covered |
| G47.53 | ICD10CM | Covered |
| G47.54 | ICD10CM | Covered |
| G47.59 | ICD10CM | Covered |
| G47.69 | ICD10CM | Covered |
| G47.8 | ICD10CM | Covered |
| I09.81 | ICD10CM | Covered |
| I11.0 | ICD10CM | Covered |
| I26.01 | ICD10CM | Covered |
| I26.02 | ICD10CM | Covered |
| I26.03 | ICD10CM | Covered |
| I26.04 | ICD10CM | Covered |
| I26.09 | ICD10CM | Covered |
| I26.90 | ICD10CM | Covered |
| I26.92 | ICD10CM | Covered |
| I26.93 | ICD10CM | Covered |
| I26.94 | ICD10CM | Covered |
| I26.95 | ICD10CM | Covered |
| I26.96 | ICD10CM | Covered |
| I26.99 | ICD10CM | Covered |
| I27.0 | ICD10CM | Covered |
| I27.20 | ICD10CM | Covered |
| I27.21 | ICD10CM | Covered |
| I27.22 | ICD10CM | Covered |
| I27.23 | ICD10CM | Covered |
| I27.24 | ICD10CM | Covered |
| I27.29 | ICD10CM | Covered |
| I27.81 | ICD10CM | Covered |
| I27.82 | ICD10CM | Covered |
| I27.83 | ICD10CM | Covered |
| I27.840 | ICD10CM | Covered |
| I27.841 | ICD10CM | Covered |
| I27.848 | ICD10CM | Covered |
| I27.849 | ICD10CM | Covered |
| I27.89 | ICD10CM | Covered |
| I27.9 | ICD10CM | Covered |
| I50.1 | ICD10CM | Covered |
| I50.20 | ICD10CM | Covered |
| I50.21 | ICD10CM | Covered |
| I50.22 | ICD10CM | Covered |
| I50.23 | ICD10CM | Covered |
| I50.30 | ICD10CM | Covered |
| I50.31 | ICD10CM | Covered |
| I50.32 | ICD10CM | Covered |
| I50.33 | ICD10CM | Covered |
| I50.40 | 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 |
| I78.0 | ICD10CM | Covered |
| J04.10 | ICD10CM | Covered |
| J04.11 | ICD10CM | Covered |
| J04.2 | ICD10CM | Covered |
| J05.0 | ICD10CM | Covered |
| J05.10 | ICD10CM | Covered |
| J05.11 | ICD10CM | Covered |
| J10.00 | ICD10CM | Covered |
| J10.08 | ICD10CM | Covered |
| J11.00 | ICD10CM | Covered |
| J11.08 | ICD10CM | Covered |
| J12.0 | ICD10CM | Covered |
| J12.1 | ICD10CM | Covered |
| J12.2 | ICD10CM | Covered |
| J12.3 | ICD10CM | Covered |
| J12.81 | ICD10CM | Covered |
| J12.82 | ICD10CM | Covered |
| J12.89 | ICD10CM | Covered |
| J12.9 | ICD10CM | Covered |
| J14 | ICD10CM | Covered |
| J15.0 | ICD10CM | Covered |
| J15.1 | ICD10CM | Covered |
| J15.20 | ICD10CM | Covered |
| J15.211 | ICD10CM | Covered |
| J15.212 | ICD10CM | Covered |
| J15.29 | ICD10CM | Covered |
| J15.3 | ICD10CM | Covered |
| J15.4 | ICD10CM | Covered |
| J15.5 | ICD10CM | Covered |
| J15.69 | ICD10CM | Covered |
| J15.7 | ICD10CM | Covered |
| J15.8 | ICD10CM | Covered |
| J15.9 | ICD10CM | Covered |
| J16.0 | ICD10CM | Covered |
| J16.8 | ICD10CM | Covered |
| J17 | ICD10CM | Covered |
| J18.0 | ICD10CM | Covered |
| J18.8 | ICD10CM | Covered |
| J18.9 | ICD10CM | Covered |
| J20.0 | ICD10CM | Covered |
| J20.1 | ICD10CM | Covered |
| J20.2 | ICD10CM | Covered |
| J20.3 | ICD10CM | Covered |
| J20.4 | ICD10CM | Covered |
| J20.5 | ICD10CM | Covered |
| J20.6 | ICD10CM | Covered |
| J20.7 | ICD10CM | Covered |
| J20.8 | ICD10CM | Covered |
| J20.9 | ICD10CM | Covered |
| J21.0 | ICD10CM | Covered |
| J21.1 | ICD10CM | Covered |
| J21.8 | ICD10CM | Covered |
| J21.9 | ICD10CM | Covered |
| J39.8 | ICD10CM | Covered |
| J41.0 | ICD10CM | Covered |
| J41.1 | ICD10CM | Covered |
| J41.8 | ICD10CM | Covered |
| J42 | ICD10CM | Covered |
| J43.0 | ICD10CM | Covered |
| J43.1 | ICD10CM | Covered |
| J43.2 | ICD10CM | Covered |
| J43.8 | ICD10CM | Covered |
| J43.9 | ICD10CM | Covered |
| J44.0 | ICD10CM | Covered |
| J44.1 | ICD10CM | Covered |
| J44.9 | ICD10CM | Covered |
| J45.20 | ICD10CM | Covered |
| J45.21 | ICD10CM | Covered |
| J45.22 | ICD10CM | Covered |
| J45.30 | ICD10CM | Covered |
| J45.31 | ICD10CM | Covered |
| J45.32 | ICD10CM | Covered |
| J45.40 | ICD10CM | Covered |
| J45.41 | ICD10CM | Covered |
| J45.42 | ICD10CM | Covered |
| J45.50 | ICD10CM | Covered |
| J45.51 | ICD10CM | Covered |
| J45.52 | ICD10CM | Covered |
| J45.901 | ICD10CM | Covered |
| J45.902 | ICD10CM | Covered |
| J45.909 | ICD10CM | Covered |
| J45.990 | ICD10CM | Covered |
| J45.991 | ICD10CM | Covered |
| J45.998 | ICD10CM | Covered |
| J47.0 | ICD10CM | Covered |
| J47.1 | ICD10CM | Covered |
| J47.9 | ICD10CM | Covered |
| J60 | ICD10CM | Covered |
| J61 | ICD10CM | Covered |
| J62.0 | ICD10CM | Covered |
| J62.8 | ICD10CM | Covered |
| J63.0 | ICD10CM | Covered |
| J63.1 | ICD10CM | Covered |
| J63.2 | ICD10CM | Covered |
| J63.3 | ICD10CM | Covered |
| J63.4 | ICD10CM | Covered |
| J63.5 | ICD10CM | Covered |
| J63.6 | ICD10CM | Covered |
| J64 | ICD10CM | Covered |
| J65 | ICD10CM | Covered |
| J66.0 | ICD10CM | Covered |
| J66.1 | ICD10CM | Covered |
| J66.2 | ICD10CM | Covered |
| J66.8 | ICD10CM | Covered |
| J67.0 | ICD10CM | Covered |
| J67.1 | ICD10CM | Covered |
| J67.2 | ICD10CM | Covered |
| J67.3 | ICD10CM | Covered |
| J67.4 | ICD10CM | Covered |
| J67.5 | ICD10CM | Covered |
| J67.6 | ICD10CM | Covered |
| J67.7 | ICD10CM | Covered |
| J67.8 | ICD10CM | Covered |
| J67.9 | ICD10CM | Covered |
| J68.0 | ICD10CM | Covered |
| J68.4 | ICD10CM | Covered |
| J68.8 | ICD10CM | Covered |
| J68.9 | ICD10CM | Covered |
| J69.0 | ICD10CM | Covered |
| J70.1 | ICD10CM | Covered |
| J70.5 | ICD10CM | Covered |
| J80 | ICD10CM | Covered |
| J82.81 | ICD10CM | Covered |
| J82.82 | ICD10CM | Covered |
| J82.83 | ICD10CM | Covered |
| J84.10 | ICD10CM | Covered |
| J84.111 | ICD10CM | Covered |
| J84.112 | ICD10CM | Covered |
| J84.113 | ICD10CM | Covered |
| J84.114 | ICD10CM | Covered |
| J84.115 | ICD10CM | Covered |
| J84.116 | ICD10CM | Covered |
| J84.117 | ICD10CM | Covered |
| J84.170 | ICD10CM | Covered |
| J84.178 | ICD10CM | Covered |
| J84.2 | ICD10CM | Covered |
| J84.89 | ICD10CM | Covered |
| J90 | ICD10CM | Covered |
| J91.0 | ICD10CM | Covered |
| J91.8 | ICD10CM | Covered |
| J94.0 | ICD10CM | Covered |
| J94.2 | ICD10CM | Covered |
| J94.8 | ICD10CM | Covered |
| J95.84 | ICD10CM | Covered |
| J95.860 | ICD10CM | Covered |
| J95.861 | ICD10CM | Covered |
| J95.862 | ICD10CM | Covered |
| J95.863 | ICD10CM | Covered |
| J95.87 | ICD10CM | Covered |
| J98.01 | ICD10CM | Covered |
| J98.09 | ICD10CM | Covered |
| J98.11 | ICD10CM | Covered |
| J98.19 | ICD10CM | Covered |
| J98.2 | ICD10CM | Covered |
| J98.4 | ICD10CM | Covered |
| J98.51 | ICD10CM | Covered |
| J98.59 | ICD10CM | Covered |
| M05.10 | ICD10CM | Covered |
| M05.111 | ICD10CM | Covered |
| M05.112 | ICD10CM | Covered |
| M05.121 | ICD10CM | Covered |
| M05.122 | ICD10CM | Covered |
| M05.131 | ICD10CM | Covered |
| M05.132 | ICD10CM | Covered |
| M05.141 | ICD10CM | Covered |
| M05.142 | ICD10CM | Covered |
| M05.151 | ICD10CM | Covered |
| M05.152 | ICD10CM | Covered |
| M05.161 | ICD10CM | Covered |
| M05.162 | ICD10CM | Covered |
| M05.171 | ICD10CM | Covered |
| M05.172 | ICD10CM | Covered |
| M05.19 | ICD10CM | Covered |
| Q25.72 | ICD10CM | Covered |
| Q33.4 | ICD10CM | Covered |
| R05.1 | ICD10CM | Covered |
| R05.2 | ICD10CM | Covered |
| R06.00 | ICD10CM | Covered |
| R06.03 | ICD10CM | Covered |
| R06.09 | ICD10CM | Covered |
| R06.2 | ICD10CM | Covered |
| R06.89 | ICD10CM | Covered |
| R09.01 | ICD10CM | Covered |
| R09.02 | ICD10CM | Covered |
| R09.89 | ICD10CM | Covered |
| R23.0 | ICD10CM | Covered |
| R40.0 | ICD10CM | Covered |
| R40.1 | ICD10CM | Covered |
| R41.0 | ICD10CM | Covered |
| R41.82 | ICD10CM | Covered |
| R68.13 | ICD10CM | Covered |
| T78.2XXA | ICD10CM | Covered |
| T78.2XXD | ICD10CM | Covered |
| T78.2XXS | ICD10CM | Covered |
| T88.6XXA | ICD10CM | Covered |
| T88.6XXD | ICD10CM | Covered |
| T88.6XXS | ICD10CM | Covered |
| U09.9 | ICD10CM | Covered |
| Z85.118 | ICD10CM | Covered |
| Z85.12 | ICD10CM | Covered |
| Z86.74 | ICD10CM | Covered |