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 |
|---|---|---|
| 82306 | HCPCS | Covered |
| E20.0 | ICD10CM | Covered |
| E20.810 | ICD10CM | Covered |
| E20.811 | ICD10CM | Covered |
| E20.812 | ICD10CM | Covered |
| E20.818 | ICD10CM | Covered |
| E20.819 | ICD10CM | Covered |
| E20.89 | ICD10CM | Covered |
| E20.9 | ICD10CM | Covered |
| E21.0 | ICD10CM | Covered |
| E21.1 | ICD10CM | Covered |
| E21.2 | ICD10CM | Covered |
| E21.3 | ICD10CM | Covered |
| E41 | ICD10CM | Covered |
| E43 | ICD10CM | Covered |
| E55.0 | ICD10CM | Covered |
| E55.9 | ICD10CM | Covered |
| E67.3 | ICD10CM | Covered |
| E67.8 | ICD10CM | Covered |
| E68 | ICD10CM | Covered |
| E83.31 | ICD10CM | Covered |
| E83.32 | ICD10CM | Covered |
| E83.39 | ICD10CM | Covered |
| E83.51 | ICD10CM | Covered |
| E83.52 | ICD10CM | Covered |
| E84.0 | ICD10CM | Covered |
| E84.11 | ICD10CM | Covered |
| E84.19 | ICD10CM | Covered |
| E84.8 | ICD10CM | Covered |
| E89.2 | ICD10CM | Covered |
| K50.00 | ICD10CM | Covered |
| K50.011 | ICD10CM | Covered |
| K50.012 | ICD10CM | Covered |
| K50.013 | ICD10CM | Covered |
| K50.014 | ICD10CM | Covered |
| K50.018 | ICD10CM | Covered |
| K50.111 | ICD10CM | Covered |
| K50.112 | ICD10CM | Covered |
| K50.113 | ICD10CM | Covered |
| K50.114 | ICD10CM | Covered |
| K50.118 | ICD10CM | Covered |
| K50.80 | ICD10CM | Covered |
| K50.811 | ICD10CM | Covered |
| K50.812 | ICD10CM | Covered |
| K50.813 | ICD10CM | Covered |
| K50.814 | ICD10CM | Covered |
| K50.818 | ICD10CM | Covered |
| K50.90 | ICD10CM | Covered |
| K50.911 | ICD10CM | Covered |
| K50.912 | ICD10CM | Covered |
| K50.913 | ICD10CM | Covered |
| K50.914 | ICD10CM | Covered |
| K50.918 | ICD10CM | Covered |
| K51.00 | ICD10CM | Covered |
| K51.011 | ICD10CM | Covered |
| K51.012 | ICD10CM | Covered |
| K51.013 | ICD10CM | Covered |
| K51.014 | ICD10CM | Covered |
| K51.018 | ICD10CM | Covered |
| K51.20 | ICD10CM | Covered |
| K51.211 | ICD10CM | Covered |
| K51.212 | ICD10CM | Covered |
| K51.213 | ICD10CM | Covered |
| K51.214 | ICD10CM | Covered |
| K51.218 | ICD10CM | Covered |
| K51.30 | ICD10CM | Covered |
| K51.311 | ICD10CM | Covered |
| K51.312 | ICD10CM | Covered |
| K51.313 | ICD10CM | Covered |
| K51.314 | ICD10CM | Covered |
| K51.318 | ICD10CM | Covered |
| K51.40 | ICD10CM | Covered |
| K51.411 | ICD10CM | Covered |
| K51.412 | ICD10CM | Covered |
| K51.413 | ICD10CM | Covered |
| K51.414 | ICD10CM | Covered |
| K51.418 | ICD10CM | Covered |
| K51.50 | ICD10CM | Covered |
| K51.511 | ICD10CM | Covered |
| K51.512 | ICD10CM | Covered |
| K51.513 | ICD10CM | Covered |
| K51.514 | ICD10CM | Covered |
| K51.518 | ICD10CM | Covered |
| K52.0 | ICD10CM | Covered |
| K70.2 | ICD10CM | Covered |
| K70.30 | ICD10CM | Covered |
| K70.31 | ICD10CM | Covered |
| K74.1 | ICD10CM | Covered |
| K74.2 | ICD10CM | Covered |
| K74.3 | ICD10CM | Covered |
| K74.4 | ICD10CM | Covered |
| K74.69 | ICD10CM | Covered |
| K76.9 | ICD10CM | Covered |
| K83.1 | ICD10CM | Covered |
| K90.0 | ICD10CM | Covered |
| K90.1 | ICD10CM | Covered |
| K90.2 | ICD10CM | Covered |
| K90.3 | ICD10CM | Covered |
| K90.41 | ICD10CM | Covered |
| K90.49 | ICD10CM | Covered |
| K90.89 | ICD10CM | Covered |
| K90.9 | ICD10CM | Covered |
| K91.2 | ICD10CM | Covered |
| M80.00XA | ICD10CM | Covered |
| M80.011A | ICD10CM | Covered |
| M80.012A | ICD10CM | Covered |
| M80.021A | ICD10CM | Covered |
| M80.022A | ICD10CM | Covered |
| M80.031A | ICD10CM | Covered |
| M80.032A | ICD10CM | Covered |
| M80.041A | ICD10CM | Covered |
| M80.042A | ICD10CM | Covered |
| M80.051A | ICD10CM | Covered |
| M80.052A | ICD10CM | Covered |
| M80.061A | ICD10CM | Covered |
| M80.062A | ICD10CM | Covered |
| M80.071A | ICD10CM | Covered |
| M80.072A | ICD10CM | Covered |
| M80.08XA | ICD10CM | Covered |
| M80.0B1A | ICD10CM | Covered |
| M80.0B1D | ICD10CM | Covered |
| M80.0B1G | ICD10CM | Covered |
| M80.0B1K | ICD10CM | Covered |
| M80.0B1P | ICD10CM | Covered |
| M80.0B1S | ICD10CM | Covered |
| M80.0B2A | ICD10CM | Covered |
| M80.0B2D | ICD10CM | Covered |
| M80.0B2G | ICD10CM | Covered |
| M80.0B2K | ICD10CM | Covered |
| M80.0B2P | ICD10CM | Covered |
| M80.0B2S | ICD10CM | Covered |
| M81.0 | ICD10CM | Covered |
| M81.6 | ICD10CM | Covered |
| M81.8 | ICD10CM | Covered |
| M83.0 | ICD10CM | Covered |
| M83.1 | ICD10CM | Covered |
| M83.2 | ICD10CM | Covered |
| M83.3 | ICD10CM | Covered |
| M83.4 | ICD10CM | Covered |
| M83.5 | ICD10CM | Covered |
| M83.8 | ICD10CM | Covered |
| M85.80 | ICD10CM | Covered |
| M85.811 | ICD10CM | Covered |
| M85.812 | ICD10CM | Covered |
| M85.821 | ICD10CM | Covered |
| M85.822 | ICD10CM | Covered |
| M85.831 | ICD10CM | Covered |
| M85.832 | ICD10CM | Covered |
| M85.841 | ICD10CM | Covered |
| M85.842 | ICD10CM | Covered |
| M85.851 | ICD10CM | Covered |
| M85.852 | ICD10CM | Covered |
| M85.861 | ICD10CM | Covered |
| M85.862 | ICD10CM | Covered |
| M85.871 | ICD10CM | Covered |
| M85.872 | ICD10CM | Covered |
| M85.88 | ICD10CM | Covered |
| M85.89 | ICD10CM | Covered |
| M89.9 | ICD10CM | Covered |
| M94.9 | ICD10CM | Covered |
| N18.30 | ICD10CM | Covered |
| N18.31 | ICD10CM | Covered |
| N18.32 | ICD10CM | Covered |
| N18.4 | ICD10CM | Covered |
| N18.5 | ICD10CM | Covered |
| N18.6 | ICD10CM | Covered |
| N25.81 | ICD10CM | Covered |
| Q78.2 | ICD10CM | Covered |
| R82.994 | ICD10CM | Covered |
| Z68.30 | ICD10CM | Covered |
| Z68.31 | ICD10CM | Covered |
| Z68.32 | ICD10CM | Covered |
| Z68.33 | ICD10CM | Covered |
| Z68.34 | ICD10CM | Covered |
| Z68.35 | ICD10CM | Covered |
| Z68.36 | ICD10CM | Covered |
| Z68.37 | ICD10CM | Covered |
| Z68.38 | ICD10CM | Covered |
| Z68.39 | ICD10CM | Covered |
| Z68.41 | ICD10CM | Covered |
| Z68.42 | ICD10CM | Covered |
| Z68.43 | ICD10CM | Covered |
| Z68.44 | ICD10CM | Covered |
| Z68.45 | ICD10CM | Covered |