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 |
|---|---|---|
| 51725 | HCPCS | Covered |
| 51726 | HCPCS | Covered |
| 51727 | HCPCS | Covered |
| 51728 | HCPCS | Covered |
| 51729 | HCPCS | Covered |
| 51736 | HCPCS | Covered |
| 51741 | HCPCS | Covered |
| 51792 | HCPCS | Covered |
| 51797 | HCPCS | Covered |
| A18.13 | ICD10CM | Covered |
| A52.11 | ICD10CM | Covered |
| A52.12 | ICD10CM | Covered |
| A52.13 | ICD10CM | Covered |
| A52.14 | ICD10CM | Covered |
| A52.15 | ICD10CM | Covered |
| A52.16 | ICD10CM | Covered |
| A52.17 | ICD10CM | Covered |
| A52.19 | ICD10CM | Covered |
| A52.3 | ICD10CM | Covered |
| A80.9 | ICD10CM | Covered |
| C61 | ICD10CM | Covered |
| C70.1 | ICD10CM | Covered |
| C72.0 | ICD10CM | Covered |
| C72.1 | ICD10CM | Covered |
| C79.82 | ICD10CM | Covered |
| D29.1 | ICD10CM | Covered |
| D33.4 | ICD10CM | Covered |
| D40.0 | ICD10CM | Covered |
| D49.4 | ICD10CM | Covered |
| D49.511 | ICD10CM | Covered |
| D49.512 | ICD10CM | Covered |
| D49.59 | ICD10CM | Covered |
| E10.21 | ICD10CM | Covered |
| E10.22 | ICD10CM | Covered |
| E10.29 | ICD10CM | Covered |
| E10.40 | ICD10CM | Covered |
| E10.41 | ICD10CM | Covered |
| E10.42 | ICD10CM | Covered |
| E10.43 | ICD10CM | Covered |
| E10.44 | ICD10CM | Covered |
| E10.610 | ICD10CM | Covered |
| E10.65 | ICD10CM | Covered |
| E11.21 | ICD10CM | Covered |
| E11.22 | ICD10CM | Covered |
| E11.29 | ICD10CM | Covered |
| E11.41 | ICD10CM | Covered |
| E11.42 | ICD10CM | Covered |
| E11.43 | ICD10CM | Covered |
| E11.44 | ICD10CM | Covered |
| E11.610 | ICD10CM | Covered |
| E11.65 | ICD10CM | Covered |
| F45.8 | ICD10CM | Covered |
| F98.0 | ICD10CM | Covered |
| G04.1 | ICD10CM | Covered |
| G04.90 | ICD10CM | Covered |
| G04.91 | ICD10CM | Covered |
| G12.21 | ICD10CM | Covered |
| G20.A1 | ICD10CM | Covered |
| G20.A2 | ICD10CM | Covered |
| G20.B1 | ICD10CM | Covered |
| G20.B2 | ICD10CM | Covered |
| G21.4 | ICD10CM | Covered |
| G24.1 | ICD10CM | Covered |
| G35.A | ICD10CM | Covered |
| G35.B0 | ICD10CM | Covered |
| G35.B1 | ICD10CM | Covered |
| G35.B2 | ICD10CM | Covered |
| G35.C0 | ICD10CM | Covered |
| G35.C1 | ICD10CM | Covered |
| G35.C2 | ICD10CM | Covered |
| G37.4 | ICD10CM | Covered |
| G60.9 | ICD10CM | Covered |
| G82.21 | ICD10CM | Covered |
| G82.22 | ICD10CM | Covered |
| G82.50 | ICD10CM | Covered |
| G82.51 | ICD10CM | Covered |
| G82.52 | ICD10CM | Covered |
| G82.53 | ICD10CM | Covered |
| G82.54 | ICD10CM | Covered |
| G83.4 | ICD10CM | Covered |
| M46.41 | ICD10CM | Covered |
| M46.42 | ICD10CM | Covered |
| M46.43 | ICD10CM | Covered |
| M46.44 | ICD10CM | Covered |
| M46.45 | ICD10CM | Covered |
| M46.46 | ICD10CM | Covered |
| M46.47 | ICD10CM | Covered |
| M50.80 | ICD10CM | Covered |
| M50.81 | ICD10CM | Covered |
| M50.821 | ICD10CM | Covered |
| M50.822 | ICD10CM | Covered |
| M50.823 | ICD10CM | Covered |
| M50.83 | ICD10CM | Covered |
| M50.91 | ICD10CM | Covered |
| M50.921 | ICD10CM | Covered |
| M50.922 | ICD10CM | Covered |
| M50.93 | ICD10CM | Covered |
| M51.84 | ICD10CM | Covered |
| M51.85 | ICD10CM | Covered |
| M51.86 | ICD10CM | Covered |
| M51.87 | ICD10CM | Covered |
| N13.1 | ICD10CM | Covered |
| N13.2 | ICD10CM | Covered |
| N13.39 | ICD10CM | Covered |
| N13.71 | ICD10CM | Covered |
| N13.721 | ICD10CM | Covered |
| N13.731 | ICD10CM | Covered |
| N30.10 | ICD10CM | Covered |
| N30.11 | ICD10CM | Covered |
| N31.0 | ICD10CM | Covered |
| N31.1 | ICD10CM | Covered |
| N31.2 | ICD10CM | Covered |
| N31.8 | ICD10CM | Covered |
| N32.0 | ICD10CM | Covered |
| N32.81 | ICD10CM | Covered |
| N35.010 | ICD10CM | Covered |
| N35.011 | ICD10CM | Covered |
| N35.012 | ICD10CM | Covered |
| N35.013 | ICD10CM | Covered |
| N35.016 | ICD10CM | Covered |
| N35.021 | ICD10CM | Covered |
| N35.028 | ICD10CM | Covered |
| N35.811 | ICD10CM | Covered |
| N35.812 | ICD10CM | Covered |
| N35.813 | ICD10CM | Covered |
| N35.814 | ICD10CM | Covered |
| N35.816 | ICD10CM | Covered |
| N35.82 | ICD10CM | Covered |
| N36.0 | ICD10CM | Covered |
| N36.1 | ICD10CM | Covered |
| N36.41 | ICD10CM | Covered |
| N36.42 | ICD10CM | Covered |
| N36.43 | ICD10CM | Covered |
| N36.44 | ICD10CM | Covered |
| N36.8 | ICD10CM | Covered |
| N37 | ICD10CM | Covered |
| N39.3 | ICD10CM | Covered |
| N39.41 | ICD10CM | Covered |
| N39.42 | ICD10CM | Covered |
| N39.43 | ICD10CM | Covered |
| N39.44 | ICD10CM | Covered |
| N39.45 | ICD10CM | Covered |
| N39.46 | ICD10CM | Covered |
| N39.490 | ICD10CM | Covered |
| N39.498 | ICD10CM | Covered |
| N40.1 | ICD10CM | Covered |
| N40.3 | ICD10CM | Covered |
| N42.81 | ICD10CM | Covered |
| N42.82 | ICD10CM | Covered |
| N42.83 | ICD10CM | Covered |
| N42.89 | ICD10CM | Covered |
| N81.0 | ICD10CM | Covered |
| N81.11 | ICD10CM | Covered |
| N81.12 | ICD10CM | Covered |
| N81.6 | ICD10CM | Covered |
| N81.81 | ICD10CM | Covered |
| N81.9 | ICD10CM | Covered |
| N82.0 | ICD10CM | Covered |
| N82.1 | ICD10CM | Covered |
| N99.110 | ICD10CM | Covered |
| N99.111 | ICD10CM | Covered |
| N99.112 | ICD10CM | Covered |
| N99.113 | ICD10CM | Covered |
| N99.116 | ICD10CM | Covered |
| N99.12 | ICD10CM | Covered |
| Q05.0 | ICD10CM | Covered |
| Q05.1 | ICD10CM | Covered |
| Q05.2 | ICD10CM | Covered |
| Q05.3 | ICD10CM | Covered |
| Q05.5 | ICD10CM | Covered |
| Q05.6 | ICD10CM | Covered |
| Q05.7 | ICD10CM | Covered |
| Q05.8 | ICD10CM | Covered |
| Q07.00 | ICD10CM | Covered |
| Q07.01 | ICD10CM | Covered |
| Q07.02 | ICD10CM | Covered |
| Q07.03 | ICD10CM | Covered |
| Q62.11 | ICD10CM | Covered |
| Q62.12 | ICD10CM | Covered |
| Q62.2 | ICD10CM | Covered |
| Q62.39 | ICD10CM | Covered |
| Q64.11 | ICD10CM | Covered |
| Q64.2 | ICD10CM | Covered |
| Q64.31 | ICD10CM | Covered |
| Q64.32 | ICD10CM | Covered |
| Q64.33 | ICD10CM | Covered |
| Q64.5 | ICD10CM | Covered |
| Q64.6 | ICD10CM | Covered |
| Q64.71 | ICD10CM | Covered |
| Q64.72 | ICD10CM | Covered |
| Q64.73 | ICD10CM | Covered |
| Q64.74 | ICD10CM | Covered |
| Q64.75 | ICD10CM | Covered |
| R30.0 | ICD10CM | Covered |
| R32 | ICD10CM | Covered |
| R33.0 | ICD10CM | Covered |
| R33.8 | ICD10CM | Covered |
| R33.9 | ICD10CM | Covered |
| R34 | ICD10CM | Covered |
| R35.0 | ICD10CM | Covered |
| R35.1 | ICD10CM | Covered |
| R39.11 | ICD10CM | Covered |
| R39.12 | ICD10CM | Covered |
| R39.13 | ICD10CM | Covered |
| R39.14 | ICD10CM | Covered |
| R39.16 | ICD10CM | Covered |
| S12.000A | ICD10CM | Covered |
| S12.000B | ICD10CM | Covered |
| S12.001A | ICD10CM | Covered |
| S12.001B | ICD10CM | Covered |
| S12.100A | ICD10CM | Covered |
| S12.100B | ICD10CM | Covered |
| S12.101A | ICD10CM | Covered |
| S12.101B | ICD10CM | Covered |
| S12.200A | ICD10CM | Covered |
| S12.200B | ICD10CM | Covered |
| S12.201A | ICD10CM | Covered |
| S12.201B | ICD10CM | Covered |
| S12.300A | ICD10CM | Covered |
| S12.300B | ICD10CM | Covered |
| S12.301A | ICD10CM | Covered |
| S12.301B | ICD10CM | Covered |
| S12.400A | ICD10CM | Covered |
| S12.400B | ICD10CM | Covered |
| S12.401A | ICD10CM | Covered |
| S12.401B | ICD10CM | Covered |
| S12.500A | ICD10CM | Covered |
| S12.500B | ICD10CM | Covered |
| S12.501A | ICD10CM | Covered |
| S12.501B | ICD10CM | Covered |
| S12.600A | ICD10CM | Covered |
| S12.600B | ICD10CM | Covered |
| S12.601A | ICD10CM | Covered |
| S12.601B | ICD10CM | Covered |
| S14.0XXA | ICD10CM | Covered |
| S14.101A | ICD10CM | Covered |
| S14.102A | ICD10CM | Covered |
| S14.103A | ICD10CM | Covered |
| S14.104A | ICD10CM | Covered |
| S14.105A | ICD10CM | Covered |
| S14.106A | ICD10CM | Covered |
| S14.107A | ICD10CM | Covered |
| S14.108A | ICD10CM | Covered |
| S14.111A | ICD10CM | Covered |
| S14.112A | ICD10CM | Covered |
| S14.113A | ICD10CM | Covered |
| S14.114A | ICD10CM | Covered |
| S14.115A | ICD10CM | Covered |
| S14.116A | ICD10CM | Covered |
| S14.117A | ICD10CM | Covered |
| S14.118A | ICD10CM | Covered |
| S14.121A | ICD10CM | Covered |
| S14.122A | ICD10CM | Covered |
| S14.123A | ICD10CM | Covered |
| S14.124A | ICD10CM | Covered |
| S14.125A | ICD10CM | Covered |
| S14.126A | ICD10CM | Covered |
| S14.127A | ICD10CM | Covered |
| S14.128A | ICD10CM | Covered |
| S14.131A | ICD10CM | Covered |
| S14.132A | ICD10CM | Covered |
| S14.133A | ICD10CM | Covered |
| S14.134A | ICD10CM | Covered |
| S14.135A | ICD10CM | Covered |
| S14.136A | ICD10CM | Covered |
| S14.137A | ICD10CM | Covered |
| S14.138A | ICD10CM | Covered |
| S14.141A | ICD10CM | Covered |
| S14.142A | ICD10CM | Covered |
| S14.143A | ICD10CM | Covered |
| S14.144A | ICD10CM | Covered |
| S14.145A | ICD10CM | Covered |
| S14.146A | ICD10CM | Covered |
| S14.147A | ICD10CM | Covered |
| S14.148A | ICD10CM | Covered |
| S14.151A | ICD10CM | Covered |
| S14.152A | ICD10CM | Covered |
| S14.153A | ICD10CM | Covered |
| S14.154A | ICD10CM | Covered |
| S14.155A | ICD10CM | Covered |
| S14.156A | ICD10CM | Covered |
| S14.157A | ICD10CM | Covered |
| S14.158A | ICD10CM | Covered |
| S22.019A | ICD10CM | Covered |
| S22.019B | ICD10CM | Covered |
| S22.029A | ICD10CM | Covered |
| S22.029B | ICD10CM | Covered |
| S22.039A | ICD10CM | Covered |
| S22.039B | ICD10CM | Covered |
| S22.049A | ICD10CM | Covered |
| S22.049B | ICD10CM | Covered |
| S22.059A | ICD10CM | Covered |
| S22.059B | ICD10CM | Covered |
| S22.069A | ICD10CM | Covered |
| S22.069B | ICD10CM | Covered |
| S22.079A | ICD10CM | Covered |
| S22.079B | ICD10CM | Covered |
| S22.089A | ICD10CM | Covered |
| S22.089B | ICD10CM | Covered |
| S24.0XXA | ICD10CM | Covered |
| S24.101A | ICD10CM | Covered |
| S24.102A | ICD10CM | Covered |
| S24.103A | ICD10CM | Covered |
| S24.104A | ICD10CM | Covered |
| S24.111A | ICD10CM | Covered |
| S24.112A | ICD10CM | Covered |
| S24.113A | ICD10CM | Covered |
| S24.114A | ICD10CM | Covered |
| S24.131A | ICD10CM | Covered |
| S24.132A | ICD10CM | Covered |
| S24.133A | ICD10CM | Covered |
| S24.134A | ICD10CM | Covered |
| S24.141A | ICD10CM | Covered |
| S24.142A | ICD10CM | Covered |
| S24.143A | ICD10CM | Covered |
| S24.144A | ICD10CM | Covered |
| S24.151A | ICD10CM | Covered |
| S24.152A | ICD10CM | Covered |
| S24.153A | ICD10CM | Covered |
| S24.154A | ICD10CM | Covered |
| S32.019A | ICD10CM | Covered |
| S32.019B | ICD10CM | Covered |
| S32.029A | ICD10CM | Covered |
| S32.029B | ICD10CM | Covered |
| S32.039A | ICD10CM | Covered |
| S32.039B | ICD10CM | Covered |
| S32.049A | ICD10CM | Covered |
| S32.049B | ICD10CM | Covered |
| S32.059A | ICD10CM | Covered |
| S32.10XA | ICD10CM | Covered |
| S32.10XB | ICD10CM | Covered |
| S32.2XXA | ICD10CM | Covered |
| S32.2XXB | ICD10CM | Covered |
| S34.01XA | ICD10CM | Covered |
| S34.02XA | ICD10CM | Covered |
| S34.101A | ICD10CM | Covered |
| S34.102A | ICD10CM | Covered |
| S34.103A | ICD10CM | Covered |
| S34.104A | ICD10CM | Covered |
| S34.105A | ICD10CM | Covered |
| S34.111A | ICD10CM | Covered |
| S34.112A | ICD10CM | Covered |
| S34.113A | ICD10CM | Covered |
| S34.114A | ICD10CM | Covered |
| S34.115A | ICD10CM | Covered |
| S34.121A | ICD10CM | Covered |
| S34.122A | ICD10CM | Covered |
| S34.123A | ICD10CM | Covered |
| S34.124A | ICD10CM | Covered |
| S34.125A | ICD10CM | Covered |
| S34.131A | ICD10CM | Covered |
| S34.132A | ICD10CM | Covered |
| S34.3XXA | ICD10CM | Covered |
| T79.5XXA | ICD10CM | Covered |