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 |
|---|---|---|
| 92920 | HCPCS | Covered |
| 92924 | HCPCS | Covered |
| 92928 | HCPCS | Covered |
| 92930 | HCPCS | Covered |
| 92933 | HCPCS | Covered |
| 92937 | HCPCS | Covered |
| 92941 | HCPCS | Covered |
| 92943 | HCPCS | Covered |
| 92973 | HCPCS | Covered |
| 92978 | HCPCS | Covered |
| 92979 | HCPCS | Covered |
| 93571 | HCPCS | Covered |
| 93572 | HCPCS | Covered |
| C9600 | HCPCS | Covered |
| C9601 | HCPCS | Covered |
| C9602 | HCPCS | Covered |
| C9603 | HCPCS | Covered |
| C9604 | HCPCS | Covered |
| C9605 | HCPCS | Covered |
| C9606 | HCPCS | Covered |
| C9607 | HCPCS | Covered |
| C9608 | HCPCS | Covered |
| I20.0 | ICD10CM | Covered |
| I20.81 | ICD10CM | Covered |
| I20.89 | ICD10CM | Covered |
| I20.9 | ICD10CM | Covered |
| I21.01 | ICD10CM | Covered |
| I21.02 | ICD10CM | Covered |
| I21.09 | ICD10CM | Covered |
| I21.11 | ICD10CM | Covered |
| I21.19 | ICD10CM | Covered |
| I21.21 | ICD10CM | Covered |
| I21.29 | ICD10CM | Covered |
| I21.3 | ICD10CM | Covered |
| I21.4 | ICD10CM | Covered |
| I21.9 | ICD10CM | Covered |
| I21.A1 | ICD10CM | Covered |
| I21.A9 | ICD10CM | Covered |
| I21.B | ICD10CM | Covered |
| I22.0 | ICD10CM | Covered |
| I22.1 | ICD10CM | Covered |
| I22.2 | ICD10CM | Covered |
| I22.8 | ICD10CM | Covered |
| I22.9 | ICD10CM | Covered |
| I24.0 | ICD10CM | Covered |
| I24.81 | ICD10CM | Covered |
| I24.89 | ICD10CM | Covered |
| I24.9 | ICD10CM | Covered |
| I25.10 | ICD10CM | Covered |
| I25.110 | ICD10CM | Covered |
| I25.111 | ICD10CM | Covered |
| I25.118 | ICD10CM | Covered |
| I25.119 | ICD10CM | Covered |
| I25.3 | ICD10CM | Covered |
| I25.41 | ICD10CM | Covered |
| I25.42 | ICD10CM | Covered |
| I25.5 | ICD10CM | Covered |
| I25.6 | ICD10CM | Covered |
| I25.700 | ICD10CM | Covered |
| I25.701 | ICD10CM | Covered |
| I25.708 | ICD10CM | Covered |
| I25.709 | ICD10CM | Covered |
| I25.710 | ICD10CM | Covered |
| I25.711 | ICD10CM | Covered |
| I25.718 | ICD10CM | Covered |
| I25.719 | ICD10CM | Covered |
| I25.720 | ICD10CM | Covered |
| I25.721 | ICD10CM | Covered |
| I25.728 | ICD10CM | Covered |
| I25.729 | ICD10CM | Covered |
| I25.730 | ICD10CM | Covered |
| I25.731 | ICD10CM | Covered |
| I25.738 | ICD10CM | Covered |
| I25.739 | ICD10CM | Covered |
| I25.750 | ICD10CM | Covered |
| I25.751 | ICD10CM | Covered |
| I25.758 | ICD10CM | Covered |
| I25.759 | ICD10CM | Covered |
| I25.760 | ICD10CM | Covered |
| I25.761 | ICD10CM | Covered |
| I25.768 | ICD10CM | Covered |
| I25.769 | ICD10CM | Covered |
| I25.790 | ICD10CM | Covered |
| I25.791 | ICD10CM | Covered |
| I25.798 | ICD10CM | Covered |
| I25.799 | ICD10CM | Covered |
| I25.810 | ICD10CM | Covered |
| I25.811 | ICD10CM | Covered |
| I25.812 | ICD10CM | Covered |
| I25.82 | ICD10CM | Covered |
| I25.83 | ICD10CM | Covered |
| I25.84 | ICD10CM | Covered |
| I25.85 | ICD10CM | Covered |
| I25.89 | ICD10CM | Covered |
| I25.9 | ICD10CM | Covered |
| T82.817A | ICD10CM | Covered |
| T82.817D | ICD10CM | Covered |
| T82.817S | ICD10CM | Covered |
| T82.827A | ICD10CM | Covered |
| T82.827D | ICD10CM | Covered |
| T82.827S | ICD10CM | Covered |
| T82.837A | ICD10CM | Covered |
| T82.837D | ICD10CM | Covered |
| T82.837S | ICD10CM | Covered |
| T82.847A | ICD10CM | Covered |
| T82.847D | ICD10CM | Covered |
| T82.847S | ICD10CM | Covered |
| T82.855A | ICD10CM | Covered |
| T82.855D | ICD10CM | Covered |
| T82.855S | ICD10CM | Covered |
| T82.856A | ICD10CM | Covered |
| T82.856D | ICD10CM | Covered |
| T82.856S | ICD10CM | Covered |
| T82.857A | ICD10CM | Covered |
| T82.857D | ICD10CM | Covered |
| T82.857S | ICD10CM | Covered |
| T82.867A | ICD10CM | Covered |
| T82.867D | ICD10CM | Covered |
| T82.867S | ICD10CM | Covered |
| T82.897A | ICD10CM | Covered |
| T82.897D | ICD10CM | Covered |
| T82.897S | ICD10CM | Covered |
| T82.9XXA | ICD10CM | Covered |
| T82.9XXD | ICD10CM | Covered |
| T82.9XXS | ICD10CM | Covered |