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 |
|---|---|---|
| 95700 | HCPCS | Covered |
| 95705 | HCPCS | Covered |
| 95708 | HCPCS | Covered |
| 95717 | HCPCS | Covered |
| 95719 | HCPCS | Covered |
| 95721 | HCPCS | Covered |
| 95812 | HCPCS | Covered |
| 95813 | HCPCS | Covered |
| 95816 | HCPCS | Covered |
| 95819 | HCPCS | Covered |
| 95822 | HCPCS | Covered |
| A17.82 | ICD10CM | Covered |
| A39.81 | ICD10CM | Covered |
| A42.82 | ICD10CM | Covered |
| A50.42 | ICD10CM | Covered |
| A52.14 | ICD10CM | Covered |
| A83.0 | ICD10CM | Covered |
| A83.1 | ICD10CM | Covered |
| A83.2 | ICD10CM | Covered |
| A83.3 | ICD10CM | Covered |
| A83.4 | ICD10CM | Covered |
| A83.5 | ICD10CM | Covered |
| A83.8 | ICD10CM | Covered |
| A83.9 | ICD10CM | Covered |
| A84.0 | ICD10CM | Covered |
| A84.1 | ICD10CM | Covered |
| A84.89 | ICD10CM | Covered |
| A84.9 | ICD10CM | Covered |
| A85.0 | ICD10CM | Covered |
| A85.1 | ICD10CM | Covered |
| A85.2 | ICD10CM | Covered |
| A85.8 | ICD10CM | Covered |
| A92.2 | ICD10CM | Covered |
| A92.31 | ICD10CM | Covered |
| A92.5 | ICD10CM | Covered |
| B01.11 | ICD10CM | Covered |
| B02.0 | ICD10CM | Covered |
| B05.0 | ICD10CM | Covered |
| B06.01 | ICD10CM | Covered |
| B10.01 | ICD10CM | Covered |
| B10.09 | ICD10CM | Covered |
| B26.2 | ICD10CM | Covered |
| B94.1 | ICD10CM | Covered |
| F44.4 | ICD10CM | Covered |
| F44.5 | ICD10CM | Covered |
| F44.6 | ICD10CM | Covered |
| F44.7 | ICD10CM | Covered |
| G04.00 | ICD10CM | Covered |
| G04.01 | ICD10CM | Covered |
| G04.02 | ICD10CM | Covered |
| G04.30 | ICD10CM | Covered |
| G04.31 | ICD10CM | Covered |
| G04.81 | ICD10CM | Covered |
| G04.90 | ICD10CM | Covered |
| G05.3 | ICD10CM | Covered |
| G40.001 | ICD10CM | Covered |
| G40.009 | ICD10CM | Covered |
| G40.011 | ICD10CM | Covered |
| G40.019 | ICD10CM | Covered |
| G40.101 | ICD10CM | Covered |
| G40.109 | ICD10CM | Covered |
| G40.111 | ICD10CM | Covered |
| G40.119 | ICD10CM | Covered |
| G40.201 | ICD10CM | Covered |
| G40.209 | ICD10CM | Covered |
| G40.211 | ICD10CM | Covered |
| G40.219 | ICD10CM | Covered |
| G40.301 | ICD10CM | Covered |
| G40.309 | ICD10CM | Covered |
| G40.311 | ICD10CM | Covered |
| G40.319 | ICD10CM | Covered |
| G40.501 | ICD10CM | Covered |
| G40.509 | ICD10CM | Covered |
| G40.801 | ICD10CM | Covered |
| G40.802 | ICD10CM | Covered |
| G40.803 | ICD10CM | Covered |
| G40.804 | ICD10CM | Covered |
| G40.811 | ICD10CM | Covered |
| G40.812 | ICD10CM | Covered |
| G40.813 | ICD10CM | Covered |
| G40.814 | ICD10CM | Covered |
| G40.821 | ICD10CM | Covered |
| G40.822 | ICD10CM | Covered |
| G40.823 | ICD10CM | Covered |
| G40.824 | ICD10CM | Covered |
| G40.833 | ICD10CM | Covered |
| G40.834 | ICD10CM | Covered |
| G40.841 | ICD10CM | Covered |
| G40.842 | ICD10CM | Covered |
| G40.843 | ICD10CM | Covered |
| G40.844 | ICD10CM | Covered |
| G40.89 | ICD10CM | Covered |
| G40.901 | ICD10CM | Covered |
| G40.909 | ICD10CM | Covered |
| G40.911 | ICD10CM | Covered |
| G40.919 | ICD10CM | Covered |
| G40.A01 | ICD10CM | Covered |
| G40.A09 | ICD10CM | Covered |
| G40.A11 | ICD10CM | Covered |
| G40.A19 | ICD10CM | Covered |
| G40.B01 | ICD10CM | Covered |
| G40.B09 | ICD10CM | Covered |
| G40.B11 | ICD10CM | Covered |
| G40.B19 | ICD10CM | Covered |
| G90.81 | ICD10CM | Covered |
| G90.89 | ICD10CM | Covered |
| G93.45 | ICD10CM | Covered |
| G93.5 | ICD10CM | Covered |
| G93.6 | ICD10CM | Covered |
| H55.00 | ICD10CM | Covered |
| I60.01 | ICD10CM | Covered |
| I60.02 | ICD10CM | Covered |
| I60.11 | ICD10CM | Covered |
| I60.12 | ICD10CM | Covered |
| I60.2 | ICD10CM | Covered |
| I60.31 | ICD10CM | Covered |
| I60.32 | ICD10CM | Covered |
| I60.4 | ICD10CM | Covered |
| I60.51 | ICD10CM | Covered |
| I60.52 | ICD10CM | Covered |
| I60.6 | ICD10CM | Covered |
| I60.8 | ICD10CM | Covered |
| I60.9 | ICD10CM | Covered |
| I61.0 | ICD10CM | Covered |
| I61.1 | ICD10CM | Covered |
| I61.2 | ICD10CM | Covered |
| I61.3 | ICD10CM | Covered |
| I61.4 | ICD10CM | Covered |
| I61.5 | ICD10CM | Covered |
| I61.6 | ICD10CM | Covered |
| I61.8 | ICD10CM | Covered |
| I62.9 | ICD10CM | Covered |
| I67.1 | ICD10CM | Covered |
| R00.0 | ICD10CM | Covered |
| R06.81 | ICD10CM | Covered |
| R25.1 | ICD10CM | Covered |
| R25.2 | ICD10CM | Covered |
| R25.3 | ICD10CM | Covered |
| R25.8 | ICD10CM | Covered |
| R25.9 | ICD10CM | Covered |
| R29.90 | ICD10CM | Covered |
| R40.0 | ICD10CM | Covered |
| R40.1 | ICD10CM | Covered |
| R40.20 | ICD10CM | Covered |
| R40.2110 | ICD10CM | Covered |
| R40.2111 | ICD10CM | Covered |
| R40.2112 | ICD10CM | Covered |
| R40.2113 | ICD10CM | Covered |
| R40.2114 | ICD10CM | Covered |
| R40.2120 | ICD10CM | Covered |
| R40.2121 | ICD10CM | Covered |
| R40.2122 | ICD10CM | Covered |
| R40.2123 | ICD10CM | Covered |
| R40.2124 | ICD10CM | Covered |
| R40.2210 | ICD10CM | Covered |
| R40.2211 | ICD10CM | Covered |
| R40.2212 | ICD10CM | Covered |
| R40.2213 | ICD10CM | Covered |
| R40.2214 | ICD10CM | Covered |
| R40.2220 | ICD10CM | Covered |
| R40.2221 | ICD10CM | Covered |
| R40.2222 | ICD10CM | Covered |
| R40.2223 | ICD10CM | Covered |
| R40.2224 | ICD10CM | Covered |
| R40.2310 | ICD10CM | Covered |
| R40.2311 | ICD10CM | Covered |
| R40.2312 | ICD10CM | Covered |
| R40.2313 | ICD10CM | Covered |
| R40.2314 | ICD10CM | Covered |
| R40.2320 | ICD10CM | Covered |
| R40.2321 | ICD10CM | Covered |
| R40.2322 | ICD10CM | Covered |
| R40.2323 | ICD10CM | Covered |
| R40.2324 | ICD10CM | Covered |
| R40.2340 | ICD10CM | Covered |
| R40.2341 | ICD10CM | Covered |
| R40.2342 | ICD10CM | Covered |
| R40.2343 | ICD10CM | Covered |
| R40.2344 | ICD10CM | Covered |
| R40.2350 | ICD10CM | Covered |
| R40.2351 | ICD10CM | Covered |
| R40.2352 | ICD10CM | Covered |
| R40.2353 | ICD10CM | Covered |
| R40.2354 | ICD10CM | Covered |
| R40.2361 | ICD10CM | Covered |
| R40.2362 | ICD10CM | Covered |
| R40.2363 | ICD10CM | Covered |
| R40.2364 | ICD10CM | Covered |
| R40.2A | ICD10CM | Covered |
| R40.4 | ICD10CM | Covered |
| R41.0 | ICD10CM | Covered |
| R41.3 | ICD10CM | Covered |
| R41.82 | ICD10CM | Covered |
| R41.85 | ICD10CM | Covered |
| R45.1 | ICD10CM | Covered |
| R47.01 | ICD10CM | Covered |
| R55 | ICD10CM | Covered |
| R56.1 | ICD10CM | Covered |
| R56.9 | ICD10CM | Covered |
| S06.0XAA | ICD10CM | Covered |
| S06.0XAD | ICD10CM | Covered |
| S06.0XAS | ICD10CM | Covered |
| S06.1X0S | ICD10CM | Covered |
| S06.1X1S | ICD10CM | Covered |
| S06.1X2S | ICD10CM | Covered |
| S06.1X3S | ICD10CM | Covered |
| S06.1X4S | ICD10CM | Covered |
| S06.1X5S | ICD10CM | Covered |
| S06.1X6S | ICD10CM | Covered |
| S06.1X9S | ICD10CM | Covered |
| S06.1XAA | ICD10CM | Covered |
| S06.1XAD | ICD10CM | Covered |
| S06.1XAS | ICD10CM | Covered |
| S06.2XAA | ICD10CM | Covered |
| S06.2XAD | ICD10CM | Covered |
| S06.2XAS | ICD10CM | Covered |
| S06.30AA | ICD10CM | Covered |
| S06.30AD | ICD10CM | Covered |
| S06.30AS | ICD10CM | Covered |
| S06.31AA | ICD10CM | Covered |
| S06.31AD | ICD10CM | Covered |
| S06.31AS | ICD10CM | Covered |
| S06.32AA | ICD10CM | Covered |
| S06.32AD | ICD10CM | Covered |
| S06.32AS | ICD10CM | Covered |
| S06.33AA | ICD10CM | Covered |
| S06.33AD | ICD10CM | Covered |
| S06.33AS | ICD10CM | Covered |
| S06.34AA | ICD10CM | Covered |
| S06.34AD | ICD10CM | Covered |
| S06.34AS | ICD10CM | Covered |
| S06.35AA | ICD10CM | Covered |
| S06.35AD | ICD10CM | Covered |
| S06.35AS | ICD10CM | Covered |
| S06.36AA | ICD10CM | Covered |
| S06.36AD | ICD10CM | Covered |
| S06.36AS | ICD10CM | Covered |
| S06.37AA | ICD10CM | Covered |
| S06.37AD | ICD10CM | Covered |
| S06.37AS | ICD10CM | Covered |
| S06.38AA | ICD10CM | Covered |
| S06.38AD | ICD10CM | Covered |
| S06.38AS | ICD10CM | Covered |
| S06.4XAA | ICD10CM | Covered |
| S06.4XAD | ICD10CM | Covered |
| S06.4XAS | ICD10CM | Covered |
| S06.5XAA | ICD10CM | Covered |
| S06.5XAD | ICD10CM | Covered |
| S06.5XAS | ICD10CM | Covered |
| S06.6XAA | ICD10CM | Covered |
| S06.6XAD | ICD10CM | Covered |
| S06.6XAS | ICD10CM | Covered |
| S06.81AA | ICD10CM | Covered |
| S06.81AD | ICD10CM | Covered |
| S06.81AS | ICD10CM | Covered |
| S06.82AA | ICD10CM | Covered |
| S06.82AD | ICD10CM | Covered |
| S06.82AS | ICD10CM | Covered |
| S06.890S | ICD10CM | Covered |
| S06.891S | ICD10CM | Covered |
| S06.892S | ICD10CM | Covered |
| S06.893S | ICD10CM | Covered |
| S06.894S | ICD10CM | Covered |
| S06.895S | ICD10CM | Covered |
| S06.896S | ICD10CM | Covered |
| S06.89AA | ICD10CM | Covered |
| S06.89AD | ICD10CM | Covered |
| S06.89AS | ICD10CM | Covered |
| S06.8A0A | ICD10CM | Covered |
| S06.8A0D | ICD10CM | Covered |
| S06.8A0S | ICD10CM | Covered |
| S06.8A1A | ICD10CM | Covered |
| S06.8A1D | ICD10CM | Covered |
| S06.8A1S | ICD10CM | Covered |
| S06.8A2A | ICD10CM | Covered |
| S06.8A2D | ICD10CM | Covered |
| S06.8A2S | ICD10CM | Covered |
| S06.8A3A | ICD10CM | Covered |
| S06.8A3D | ICD10CM | Covered |
| S06.8A3S | ICD10CM | Covered |
| S06.8A4A | ICD10CM | Covered |
| S06.8A4D | ICD10CM | Covered |
| S06.8A4S | ICD10CM | Covered |
| S06.8A5A | ICD10CM | Covered |
| S06.8A5D | ICD10CM | Covered |
| S06.8A5S | ICD10CM | Covered |
| S06.8A6A | ICD10CM | Covered |
| S06.8A6D | ICD10CM | Covered |
| S06.8A6S | ICD10CM | Covered |
| S06.8A7A | ICD10CM | Covered |
| S06.8A8A | ICD10CM | Covered |
| S06.8A9A | ICD10CM | Covered |
| S06.8A9D | ICD10CM | Covered |
| S06.8A9S | ICD10CM | Covered |
| S06.8AAA | ICD10CM | Covered |
| S06.8AAD | ICD10CM | Covered |
| S06.8AAS | ICD10CM | Covered |
| S06.9XAA | ICD10CM | Covered |
| S06.9XAD | ICD10CM | Covered |
| S06.9XAS | ICD10CM | Covered |