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 |
|---|---|---|
| 86001 | HCPCS | Covered |
| 86003 | HCPCS | Covered |
| 86005 | HCPCS | Covered |
| J30.0 | ICD10CM | Covered |
| J30.1 | ICD10CM | Covered |
| J30.2 | ICD10CM | Covered |
| J30.5 | ICD10CM | Covered |
| J30.81 | ICD10CM | Covered |
| J30.89 | ICD10CM | Covered |
| J30.9 | 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 |
| J45.991 | ICD10CM | Covered |
| J45.998 | ICD10CM | Covered |
| L20.0 | ICD10CM | Covered |
| L20.81 | ICD10CM | Covered |
| L20.82 | ICD10CM | Covered |
| L20.84 | ICD10CM | Covered |
| L20.89 | ICD10CM | Covered |
| L50.0 | ICD10CM | Covered |
| L50.6 | ICD10CM | Covered |
| L50.8 | ICD10CM | Covered |
| R06.2 | ICD10CM | Covered |
| T36.0X5A | ICD10CM | Covered |
| T36.1X5A | ICD10CM | Covered |
| T36.2X5A | ICD10CM | Covered |
| T36.3X5A | ICD10CM | Covered |
| T36.4X5A | ICD10CM | Covered |
| T36.5X5A | ICD10CM | Covered |
| T36.6X5A | ICD10CM | Covered |
| T36.7X5A | ICD10CM | Covered |
| T36.8X5A | ICD10CM | Covered |
| T37.0X5A | ICD10CM | Covered |
| T37.1X5A | ICD10CM | Covered |
| T37.2X5A | ICD10CM | Covered |
| T37.3X5A | ICD10CM | Covered |
| T37.4X5A | ICD10CM | Covered |
| T37.5X5A | ICD10CM | Covered |
| T37.8X5A | ICD10CM | Covered |
| T38.0X5A | ICD10CM | Covered |
| T38.1X5A | ICD10CM | Covered |
| T38.2X5A | ICD10CM | Covered |
| T38.4X5A | ICD10CM | Covered |
| T38.5X5A | ICD10CM | Covered |
| T38.6X5A | ICD10CM | Covered |
| T38.7X5A | ICD10CM | Covered |
| T38.815A | ICD10CM | Covered |
| T38.895A | ICD10CM | Covered |
| T38.995A | ICD10CM | Covered |
| T39.015A | ICD10CM | Covered |
| T39.095A | ICD10CM | Covered |
| T39.1X5A | ICD10CM | Covered |
| T39.2X5A | ICD10CM | Covered |
| T39.315A | ICD10CM | Covered |
| T39.395A | ICD10CM | Covered |
| T39.4X5A | ICD10CM | Covered |
| T39.8X5A | ICD10CM | Covered |
| T40.0X5A | ICD10CM | Covered |
| T40.2X5A | ICD10CM | Covered |
| T40.3X5A | ICD10CM | Covered |
| T40.495A | ICD10CM | Covered |
| T40.5X5A | ICD10CM | Covered |
| T40.695A | ICD10CM | Covered |
| T40.715A | ICD10CM | Covered |
| T40.725A | ICD10CM | Covered |
| T40.995A | ICD10CM | Covered |
| T41.0X5A | ICD10CM | Covered |
| T41.1X5A | ICD10CM | Covered |
| T41.295A | ICD10CM | Covered |
| T41.3X5A | ICD10CM | Covered |
| T41.5X5A | ICD10CM | Covered |
| T42.0X5A | ICD10CM | Covered |
| T42.1X5A | ICD10CM | Covered |
| T42.2X5A | ICD10CM | Covered |
| T42.3X5A | ICD10CM | Covered |
| T42.4X5A | ICD10CM | Covered |
| T42.5X5A | ICD10CM | Covered |
| T42.6X5A | ICD10CM | Covered |
| T42.8X5A | ICD10CM | Covered |
| T43.015A | ICD10CM | Covered |
| T43.025A | ICD10CM | Covered |
| T43.1X5A | ICD10CM | Covered |
| T43.215A | ICD10CM | Covered |
| T43.225A | ICD10CM | Covered |
| T43.295A | ICD10CM | Covered |
| T43.3X5A | ICD10CM | Covered |
| T43.4X5A | ICD10CM | Covered |
| T43.595A | ICD10CM | Covered |
| T43.615A | ICD10CM | Covered |
| T43.625A | ICD10CM | Covered |
| T43.635A | ICD10CM | Covered |
| T43.651A | ICD10CM | Covered |
| T43.651D | ICD10CM | Covered |
| T43.651S | ICD10CM | Covered |
| T43.652A | ICD10CM | Covered |
| T43.652D | ICD10CM | Covered |
| T43.652S | ICD10CM | Covered |
| T43.653A | ICD10CM | Covered |
| T43.653D | ICD10CM | Covered |
| T43.653S | ICD10CM | Covered |
| T43.654A | ICD10CM | Covered |
| T43.654D | ICD10CM | Covered |
| T43.654S | ICD10CM | Covered |
| T43.655A | ICD10CM | Covered |
| T43.655D | ICD10CM | Covered |
| T43.655S | ICD10CM | Covered |
| T43.656A | ICD10CM | Covered |
| T43.656D | ICD10CM | Covered |
| T43.656S | ICD10CM | Covered |
| T43.695A | ICD10CM | Covered |
| T43.8X5A | ICD10CM | Covered |
| T44.0X5A | ICD10CM | Covered |
| T44.1X5A | ICD10CM | Covered |
| T44.2X5A | ICD10CM | Covered |
| T44.3X5A | ICD10CM | Covered |
| T44.4X5A | ICD10CM | Covered |
| T44.5X5A | ICD10CM | Covered |
| T44.6X5A | ICD10CM | Covered |
| T44.7X5A | ICD10CM | Covered |
| T44.8X5A | ICD10CM | Covered |
| T44.995A | ICD10CM | Covered |
| T45.0X5A | ICD10CM | Covered |
| T45.1X5A | ICD10CM | Covered |
| T45.2X5A | ICD10CM | Covered |
| T45.3X5A | ICD10CM | Covered |
| T45.4X5A | ICD10CM | Covered |
| T45.515A | ICD10CM | Covered |
| T45.525A | ICD10CM | Covered |
| T45.615A | ICD10CM | Covered |
| T45.625A | ICD10CM | Covered |
| T45.695A | ICD10CM | Covered |
| T45.7X5A | ICD10CM | Covered |
| T45.8X5A | ICD10CM | Covered |
| T46.0X5A | ICD10CM | Covered |
| T46.1X5A | ICD10CM | Covered |
| T46.2X5A | ICD10CM | Covered |
| T46.3X5A | ICD10CM | Covered |
| T46.4X5A | ICD10CM | Covered |
| T46.5X5A | ICD10CM | Covered |
| T46.6X5A | ICD10CM | Covered |
| T46.7X5A | ICD10CM | Covered |
| T46.8X5A | ICD10CM | Covered |
| T46.995A | ICD10CM | Covered |
| T47.0X5A | ICD10CM | Covered |
| T47.1X5A | ICD10CM | Covered |
| T47.2X5A | ICD10CM | Covered |
| T47.3X5A | ICD10CM | Covered |
| T47.4X5A | ICD10CM | Covered |
| T47.5X5A | ICD10CM | Covered |
| T47.6X5A | ICD10CM | Covered |
| T47.7X5A | ICD10CM | Covered |
| T47.8X5A | ICD10CM | Covered |
| T48.0X5A | ICD10CM | Covered |
| T48.1X5A | ICD10CM | Covered |
| T48.295A | ICD10CM | Covered |
| T48.3X5A | ICD10CM | Covered |
| T48.4X5A | ICD10CM | Covered |
| T48.5X5A | ICD10CM | Covered |
| T48.6X5A | ICD10CM | Covered |
| T48.995A | ICD10CM | Covered |
| T49.0X5A | ICD10CM | Covered |
| T49.1X5A | ICD10CM | Covered |
| T49.2X5A | ICD10CM | Covered |
| T49.3X5A | ICD10CM | Covered |
| T49.4X5A | ICD10CM | Covered |
| T49.5X5A | ICD10CM | Covered |
| T49.6X5A | ICD10CM | Covered |
| T49.7X5A | ICD10CM | Covered |
| T49.8X5A | ICD10CM | Covered |
| T50.0X5A | ICD10CM | Covered |
| T50.1X5A | ICD10CM | Covered |
| T50.2X5A | ICD10CM | Covered |
| T50.3X5A | ICD10CM | Covered |
| T50.4X5A | ICD10CM | Covered |
| T50.5X5A | ICD10CM | Covered |
| T50.6X5A | ICD10CM | Covered |
| T50.7X5A | ICD10CM | Covered |
| T50.8X5A | ICD10CM | Covered |
| T50.905A | ICD10CM | Covered |
| T50.995A | ICD10CM | Covered |
| T50.A15A | ICD10CM | Covered |
| T50.A25A | ICD10CM | Covered |
| T50.A95A | ICD10CM | Covered |
| T50.B15A | ICD10CM | Covered |
| T50.B95A | ICD10CM | Covered |
| T50.Z15A | ICD10CM | Covered |
| T50.Z95A | ICD10CM | Covered |
| T63.011A | ICD10CM | Covered |
| T63.012A | ICD10CM | Covered |
| T63.013A | ICD10CM | Covered |
| T63.014A | ICD10CM | Covered |
| T63.021A | ICD10CM | Covered |
| T63.022A | ICD10CM | Covered |
| T63.023A | ICD10CM | Covered |
| T63.024A | ICD10CM | Covered |
| T63.031A | ICD10CM | Covered |
| T63.032A | ICD10CM | Covered |
| T63.033A | ICD10CM | Covered |
| T63.034A | ICD10CM | Covered |
| T63.041A | ICD10CM | Covered |
| T63.042A | ICD10CM | Covered |
| T63.043A | ICD10CM | Covered |
| T63.044A | ICD10CM | Covered |
| T63.061A | ICD10CM | Covered |
| T63.062A | ICD10CM | Covered |
| T63.063A | ICD10CM | Covered |
| T63.064A | ICD10CM | Covered |
| T63.071A | ICD10CM | Covered |
| T63.072A | ICD10CM | Covered |
| T63.073A | ICD10CM | Covered |
| T63.074A | ICD10CM | Covered |
| T63.081A | ICD10CM | Covered |
| T63.082A | ICD10CM | Covered |
| T63.083A | ICD10CM | Covered |
| T63.084A | ICD10CM | Covered |
| T63.091A | ICD10CM | Covered |
| T63.092A | ICD10CM | Covered |
| T63.093A | ICD10CM | Covered |
| T63.094A | ICD10CM | Covered |
| T63.111A | ICD10CM | Covered |
| T63.112A | ICD10CM | Covered |
| T63.113A | ICD10CM | Covered |
| T63.114A | ICD10CM | Covered |
| T63.121A | ICD10CM | Covered |
| T63.122A | ICD10CM | Covered |
| T63.123A | ICD10CM | Covered |
| T63.124A | ICD10CM | Covered |
| T63.191A | ICD10CM | Covered |
| T63.192A | ICD10CM | Covered |
| T63.193A | ICD10CM | Covered |
| T63.194A | ICD10CM | Covered |
| T63.2X1A | ICD10CM | Covered |
| T63.2X2A | ICD10CM | Covered |
| T63.2X3A | ICD10CM | Covered |
| T63.2X4A | ICD10CM | Covered |
| T63.311A | ICD10CM | Covered |
| T63.312A | ICD10CM | Covered |
| T63.313A | ICD10CM | Covered |
| T63.314A | ICD10CM | Covered |
| T63.321A | ICD10CM | Covered |
| T63.322A | ICD10CM | Covered |
| T63.323A | ICD10CM | Covered |
| T63.324A | ICD10CM | Covered |
| T63.331A | ICD10CM | Covered |
| T63.332A | ICD10CM | Covered |
| T63.333A | ICD10CM | Covered |
| T63.334A | ICD10CM | Covered |
| T63.391A | ICD10CM | Covered |
| T63.392A | ICD10CM | Covered |
| T63.393A | ICD10CM | Covered |
| T63.394A | ICD10CM | Covered |
| T63.411A | ICD10CM | Covered |
| T63.412A | ICD10CM | Covered |
| T63.413A | ICD10CM | Covered |
| T63.414A | ICD10CM | Covered |
| T63.421A | ICD10CM | Covered |
| T63.422A | ICD10CM | Covered |
| T63.423A | ICD10CM | Covered |
| T63.424A | ICD10CM | Covered |
| T63.431A | ICD10CM | Covered |
| T63.432A | ICD10CM | Covered |
| T63.433A | ICD10CM | Covered |
| T63.434A | ICD10CM | Covered |
| T63.441A | ICD10CM | Covered |
| T63.442A | ICD10CM | Covered |
| T63.444A | ICD10CM | Covered |
| T63.451A | ICD10CM | Covered |
| T63.452A | ICD10CM | Covered |
| T63.453A | ICD10CM | Covered |
| T63.454A | ICD10CM | Covered |
| T63.461A | ICD10CM | Covered |
| T63.462A | ICD10CM | Covered |
| T63.463A | ICD10CM | Covered |
| T63.464A | ICD10CM | Covered |
| T63.481A | ICD10CM | Covered |
| T63.482A | ICD10CM | Covered |
| T63.483A | ICD10CM | Covered |
| T63.484A | ICD10CM | Covered |
| T63.511A | ICD10CM | Covered |
| T63.512A | ICD10CM | Covered |
| T63.513A | ICD10CM | Covered |
| T63.514A | ICD10CM | Covered |
| T63.591A | ICD10CM | Covered |
| T63.592A | ICD10CM | Covered |
| T63.593A | ICD10CM | Covered |
| T63.594A | ICD10CM | Covered |
| T63.611A | ICD10CM | Covered |
| T63.612A | ICD10CM | Covered |
| T63.613A | ICD10CM | Covered |
| T63.614A | ICD10CM | Covered |
| T63.621A | ICD10CM | Covered |
| T63.622A | ICD10CM | Covered |
| T63.623A | ICD10CM | Covered |
| T63.624A | ICD10CM | Covered |
| T63.631A | ICD10CM | Covered |
| T63.632A | ICD10CM | Covered |
| T63.633A | ICD10CM | Covered |
| T63.634A | ICD10CM | Covered |
| T63.691A | ICD10CM | Covered |
| T63.692A | ICD10CM | Covered |
| T63.693A | ICD10CM | Covered |
| T63.694A | ICD10CM | Covered |
| T63.711A | ICD10CM | Covered |
| T63.712A | ICD10CM | Covered |
| T63.713A | ICD10CM | Covered |
| T63.714A | ICD10CM | Covered |
| T63.791A | ICD10CM | Covered |
| T63.792A | ICD10CM | Covered |
| T63.793A | ICD10CM | Covered |
| T63.794A | ICD10CM | Covered |
| T63.811A | ICD10CM | Covered |
| T63.812A | ICD10CM | Covered |
| T63.813A | ICD10CM | Covered |
| T63.814A | ICD10CM | Covered |
| T63.821A | ICD10CM | Covered |
| T63.822A | ICD10CM | Covered |
| T63.823A | ICD10CM | Covered |
| T63.824A | ICD10CM | Covered |
| T63.831A | ICD10CM | Covered |
| T63.832A | ICD10CM | Covered |
| T63.833A | ICD10CM | Covered |
| T63.834A | ICD10CM | Covered |
| T63.891A | ICD10CM | Covered |
| T63.892A | ICD10CM | Covered |
| T63.893A | ICD10CM | Covered |
| T63.894A | ICD10CM | Covered |
| T78.00XA | ICD10CM | Covered |
| T78.01XA | ICD10CM | Covered |
| T78.02XA | ICD10CM | Covered |
| T78.03XA | ICD10CM | Covered |
| T78.04XA | ICD10CM | Covered |
| T78.05XA | ICD10CM | Covered |
| T78.06XA | ICD10CM | Covered |
| T78.070A | ICD10CM | Covered |
| T78.070D | ICD10CM | Covered |
| T78.070S | ICD10CM | Covered |
| T78.071A | ICD10CM | Covered |
| T78.071D | ICD10CM | Covered |
| T78.071S | ICD10CM | Covered |
| T78.080A | ICD10CM | Covered |
| T78.080D | ICD10CM | Covered |
| T78.080S | ICD10CM | Covered |
| T78.081A | ICD10CM | Covered |
| T78.081D | ICD10CM | Covered |
| T78.081S | ICD10CM | Covered |
| T78.09XA | ICD10CM | Covered |
| T78.2XXA | ICD10CM | Covered |
| T78.3XXA | ICD10CM | Covered |
| T78.40XA | ICD10CM | Covered |
| T78.49XA | ICD10CM | Covered |
| T88.59XA | ICD10CM | Covered |
| T88.6XXA | ICD10CM | Covered |
| Z91.0111 | ICD10CM | Covered |
| Z91.0112 | ICD10CM | Covered |
| Z91.0120 | ICD10CM | Covered |
| Z91.0121 | ICD10CM | Covered |
| Z91.0122 | ICD10CM | Covered |
| Z91.014 | ICD10CM | Covered |
| Z91.048 | ICD10CM | Covered |
| Z91.09 | ICD10CM | Covered |