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 |
|---|---|---|
| 11200 | HCPCS | Covered |
| 11201 | HCPCS | Covered |
| 11300 | HCPCS | Covered |
| 11301 | HCPCS | Covered |
| 11302 | HCPCS | Covered |
| 11303 | HCPCS | Covered |
| 11305 | HCPCS | Covered |
| 11306 | HCPCS | Covered |
| 11307 | HCPCS | Covered |
| 11308 | HCPCS | Covered |
| 11310 | HCPCS | Covered |
| 11311 | HCPCS | Covered |
| 11312 | HCPCS | Covered |
| 11313 | HCPCS | Covered |
| 11400 | HCPCS | Covered |
| 11401 | HCPCS | Covered |
| 11402 | HCPCS | Covered |
| 11403 | HCPCS | Covered |
| 11404 | HCPCS | Covered |
| 11406 | HCPCS | Covered |
| 11420 | HCPCS | Covered |
| 11421 | HCPCS | Covered |
| 11422 | HCPCS | Covered |
| 11423 | HCPCS | Covered |
| 11424 | HCPCS | Covered |
| 11426 | HCPCS | Covered |
| 11440 | HCPCS | Covered |
| 11441 | HCPCS | Covered |
| 11442 | HCPCS | Covered |
| 11443 | HCPCS | Covered |
| 11444 | HCPCS | Covered |
| 11446 | HCPCS | Covered |
| 17000 | HCPCS | Covered |
| 17003 | HCPCS | Covered |
| 17004 | HCPCS | Covered |
| 17106 | HCPCS | Covered |
| 17107 | HCPCS | Covered |
| 17108 | HCPCS | Covered |
| 17110 | HCPCS | Covered |
| 17111 | HCPCS | Covered |
| 17340 | HCPCS | Covered |
| A63.0 | ICD10CM | Covered |
| B07.0 | ICD10CM | Covered |
| B07.8 | ICD10CM | Covered |
| B07.9 | ICD10CM | Covered |
| B08.1 | ICD10CM | Covered |
| B78.1 | ICD10CM | Covered |
| D10.0 | ICD10CM | Covered |
| D10.30 | ICD10CM | Covered |
| D10.39 | ICD10CM | Covered |
| D17.0 | ICD10CM | Covered |
| D17.1 | ICD10CM | Covered |
| D17.21 | ICD10CM | Covered |
| D17.22 | ICD10CM | Covered |
| D17.23 | ICD10CM | Covered |
| D17.24 | ICD10CM | Covered |
| D17.39 | ICD10CM | Covered |
| D18.01 | ICD10CM | Covered |
| D22.0 | ICD10CM | Covered |
| D22.111 | ICD10CM | Covered |
| D22.112 | ICD10CM | Covered |
| D22.121 | ICD10CM | Covered |
| D22.122 | ICD10CM | Covered |
| D22.21 | ICD10CM | Covered |
| D22.22 | ICD10CM | Covered |
| D22.30 | ICD10CM | Covered |
| D22.39 | ICD10CM | Covered |
| D22.4 | ICD10CM | Covered |
| D22.5 | ICD10CM | Covered |
| D22.61 | ICD10CM | Covered |
| D22.62 | ICD10CM | Covered |
| D22.71 | ICD10CM | Covered |
| D22.72 | ICD10CM | Covered |
| D22.9 | ICD10CM | Covered |
| D23.0 | ICD10CM | Covered |
| D23.111 | ICD10CM | Covered |
| D23.112 | ICD10CM | Covered |
| D23.121 | ICD10CM | Covered |
| D23.122 | ICD10CM | Covered |
| D23.21 | ICD10CM | Covered |
| D23.22 | ICD10CM | Covered |
| D23.30 | ICD10CM | Covered |
| D23.39 | ICD10CM | Covered |
| D23.4 | ICD10CM | Covered |
| D23.5 | ICD10CM | Covered |
| D23.61 | ICD10CM | Covered |
| D23.62 | ICD10CM | Covered |
| D23.71 | ICD10CM | Covered |
| D23.72 | ICD10CM | Covered |
| D23.9 | ICD10CM | Covered |
| D28.0 | ICD10CM | Covered |
| D28.1 | ICD10CM | Covered |
| D29.0 | ICD10CM | Covered |
| D29.4 | ICD10CM | Covered |
| D37.01 | ICD10CM | Covered |
| D37.02 | ICD10CM | Covered |
| D37.04 | ICD10CM | Covered |
| D37.05 | ICD10CM | Covered |
| D37.09 | ICD10CM | Covered |
| D39.8 | ICD10CM | Covered |
| D39.9 | ICD10CM | Covered |
| D40.8 | ICD10CM | Covered |
| D40.9 | ICD10CM | Covered |
| D48.5 | ICD10CM | Covered |
| D49.2 | ICD10CM | Covered |
| D80.0 | ICD10CM | Covered |
| D80.1 | ICD10CM | Covered |
| D80.2 | ICD10CM | Covered |
| D80.3 | ICD10CM | Covered |
| D80.4 | ICD10CM | Covered |
| D80.5 | ICD10CM | Covered |
| D80.6 | ICD10CM | Covered |
| D80.7 | ICD10CM | Covered |
| D80.8 | ICD10CM | Covered |
| D81.0 | ICD10CM | Covered |
| D81.1 | ICD10CM | Covered |
| D81.2 | ICD10CM | Covered |
| D81.4 | ICD10CM | Covered |
| D81.6 | ICD10CM | Covered |
| D81.7 | ICD10CM | Covered |
| D81.89 | ICD10CM | Covered |
| D82.0 | ICD10CM | Covered |
| D82.1 | ICD10CM | Covered |
| D83.0 | ICD10CM | Covered |
| D83.1 | ICD10CM | Covered |
| D83.2 | ICD10CM | Covered |
| D83.8 | ICD10CM | Covered |
| D84.81 | ICD10CM | Covered |
| D84.821 | ICD10CM | Covered |
| D84.822 | ICD10CM | Covered |
| D84.89 | ICD10CM | Covered |
| D89.82 | ICD10CM | Covered |
| D89.89 | ICD10CM | Covered |
| E83.2 | ICD10CM | Covered |
| H00.11 | ICD10CM | Covered |
| H00.12 | ICD10CM | Covered |
| H00.14 | ICD10CM | Covered |
| H00.15 | ICD10CM | Covered |
| H02.61 | ICD10CM | Covered |
| H02.62 | ICD10CM | Covered |
| H02.64 | ICD10CM | Covered |
| H02.65 | ICD10CM | Covered |
| H02.821 | ICD10CM | Covered |
| H02.822 | ICD10CM | Covered |
| H02.824 | ICD10CM | Covered |
| H02.825 | ICD10CM | Covered |
| H02.881 | ICD10CM | Covered |
| H02.882 | ICD10CM | Covered |
| H02.884 | ICD10CM | Covered |
| H02.885 | ICD10CM | Covered |
| H02.88A | ICD10CM | Covered |
| H02.88B | ICD10CM | Covered |
| H02.89 | ICD10CM | Covered |
| H10.401 | ICD10CM | Covered |
| H10.402 | ICD10CM | Covered |
| H10.403 | ICD10CM | Covered |
| H10.421 | ICD10CM | Covered |
| H10.422 | ICD10CM | Covered |
| H10.423 | ICD10CM | Covered |
| H10.431 | ICD10CM | Covered |
| H10.432 | ICD10CM | Covered |
| H10.433 | ICD10CM | Covered |
| H10.9 | ICD10CM | Covered |
| H53.40 | ICD10CM | Covered |
| H53.451 | ICD10CM | Covered |
| H53.452 | ICD10CM | Covered |
| H53.453 | ICD10CM | Covered |
| H53.71 | ICD10CM | Covered |
| H53.72 | ICD10CM | Covered |
| H53.8 | ICD10CM | Covered |
| H53.9 | ICD10CM | Covered |
| H54.61 | ICD10CM | Covered |
| H54.62 | ICD10CM | Covered |
| K09.8 | ICD10CM | Covered |
| K12.2 | ICD10CM | Covered |
| K13.21 | ICD10CM | Covered |
| K13.3 | ICD10CM | Covered |
| K13.5 | ICD10CM | Covered |
| K64.4 | ICD10CM | Covered |
| L02.01 | ICD10CM | Covered |
| L02.11 | ICD10CM | Covered |
| L02.211 | ICD10CM | Covered |
| L02.212 | ICD10CM | Covered |
| L02.213 | ICD10CM | Covered |
| L02.214 | ICD10CM | Covered |
| L02.215 | ICD10CM | Covered |
| L02.216 | ICD10CM | Covered |
| L02.217 | ICD10CM | Covered |
| L02.227 | ICD10CM | Covered |
| L02.31 | ICD10CM | Covered |
| L02.411 | ICD10CM | Covered |
| L02.412 | ICD10CM | Covered |
| L02.413 | ICD10CM | Covered |
| L02.414 | ICD10CM | Covered |
| L02.415 | ICD10CM | Covered |
| L02.416 | ICD10CM | Covered |
| L02.511 | ICD10CM | Covered |
| L02.512 | ICD10CM | Covered |
| L02.611 | ICD10CM | Covered |
| L02.612 | ICD10CM | Covered |
| L02.811 | ICD10CM | Covered |
| L02.818 | ICD10CM | Covered |
| L03.111 | ICD10CM | Covered |
| L03.112 | ICD10CM | Covered |
| L03.113 | ICD10CM | Covered |
| L03.114 | ICD10CM | Covered |
| L03.115 | ICD10CM | Covered |
| L03.116 | ICD10CM | Covered |
| L03.121 | ICD10CM | Covered |
| L03.122 | ICD10CM | Covered |
| L03.123 | ICD10CM | Covered |
| L03.124 | ICD10CM | Covered |
| L03.125 | ICD10CM | Covered |
| L03.126 | ICD10CM | Covered |
| L03.211 | ICD10CM | Covered |
| L03.212 | ICD10CM | Covered |
| L03.221 | ICD10CM | Covered |
| L03.222 | ICD10CM | Covered |
| L03.311 | ICD10CM | Covered |
| L03.312 | ICD10CM | Covered |
| L03.313 | ICD10CM | Covered |
| L03.314 | ICD10CM | Covered |
| L03.315 | ICD10CM | Covered |
| L03.316 | ICD10CM | Covered |
| L03.317 | ICD10CM | Covered |
| L03.31A | ICD10CM | Covered |
| L03.321 | ICD10CM | Covered |
| L03.322 | ICD10CM | Covered |
| L03.323 | ICD10CM | Covered |
| L03.324 | ICD10CM | Covered |
| L03.325 | ICD10CM | Covered |
| L03.326 | ICD10CM | Covered |
| L03.327 | ICD10CM | Covered |
| L03.32A | ICD10CM | Covered |
| L03.811 | ICD10CM | Covered |
| L03.818 | ICD10CM | Covered |
| L03.891 | ICD10CM | Covered |
| L03.898 | ICD10CM | Covered |
| L08.82 | ICD10CM | Covered |
| L08.89 | ICD10CM | Covered |
| L08.9 | ICD10CM | Covered |
| L11.0 | ICD10CM | Covered |
| L11.1 | ICD10CM | Covered |
| L11.8 | ICD10CM | Covered |
| L26 | ICD10CM | Covered |
| L28.1 | ICD10CM | Covered |
| L29.9 | ICD10CM | Covered |
| L30.0 | ICD10CM | Covered |
| L30.2 | ICD10CM | Covered |
| L30.4 | ICD10CM | Covered |
| L30.8 | ICD10CM | Covered |
| L50.9 | ICD10CM | Covered |
| L53.8 | ICD10CM | Covered |
| L54 | ICD10CM | Covered |
| L57.0 | ICD10CM | Covered |
| L57.2 | ICD10CM | Covered |
| L57.4 | ICD10CM | Covered |
| L66.4 | ICD10CM | Covered |
| L70.0 | ICD10CM | Covered |
| L72.0 | ICD10CM | Covered |
| L72.11 | ICD10CM | Covered |
| L72.12 | ICD10CM | Covered |
| L72.2 | ICD10CM | Covered |
| L72.3 | ICD10CM | Covered |
| L72.8 | ICD10CM | Covered |
| L82.0 | ICD10CM | Covered |
| L82.1 | ICD10CM | Covered |
| L86 | ICD10CM | Covered |
| L87.0 | ICD10CM | Covered |
| L87.1 | ICD10CM | Covered |
| L87.2 | ICD10CM | Covered |
| L87.8 | ICD10CM | Covered |
| L90.3 | ICD10CM | Covered |
| L90.4 | ICD10CM | Covered |
| L90.5 | ICD10CM | Covered |
| L90.8 | ICD10CM | Covered |
| L91.0 | ICD10CM | Covered |
| L91.8 | ICD10CM | Covered |
| L92.0 | ICD10CM | Covered |
| L92.1 | ICD10CM | Covered |
| L92.2 | ICD10CM | Covered |
| L92.3 | ICD10CM | Covered |
| L92.8 | ICD10CM | Covered |
| L92.9 | ICD10CM | Covered |
| L94.2 | ICD10CM | Covered |
| L94.8 | ICD10CM | Covered |
| L95.1 | ICD10CM | Covered |
| L98.0 | ICD10CM | Covered |
| L98.2 | ICD10CM | Covered |
| L98.3 | ICD10CM | Covered |
| L98.5 | ICD10CM | Covered |
| L98.6 | ICD10CM | Covered |
| L99 | ICD10CM | Covered |
| M10.9 | ICD10CM | Covered |
| M71.30 | ICD10CM | Covered |
| M79.601 | ICD10CM | Covered |
| M79.602 | ICD10CM | Covered |
| M79.604 | ICD10CM | Covered |
| M79.605 | ICD10CM | Covered |
| M79.621 | ICD10CM | Covered |
| M79.622 | ICD10CM | Covered |
| M79.631 | ICD10CM | Covered |
| M79.632 | ICD10CM | Covered |
| M79.641 | ICD10CM | Covered |
| M79.642 | ICD10CM | Covered |
| M79.644 | ICD10CM | Covered |
| M79.645 | ICD10CM | Covered |
| M79.651 | ICD10CM | Covered |
| M79.652 | ICD10CM | Covered |
| M79.661 | ICD10CM | Covered |
| M79.662 | ICD10CM | Covered |
| M79.671 | ICD10CM | Covered |
| M79.672 | ICD10CM | Covered |
| M79.674 | ICD10CM | Covered |
| M79.675 | ICD10CM | Covered |
| N75.0 | ICD10CM | Covered |
| N75.8 | ICD10CM | Covered |
| N84.3 | ICD10CM | Covered |
| N90.0 | ICD10CM | Covered |
| N90.1 | ICD10CM | Covered |
| Q17.0 | ICD10CM | Covered |
| Q18.1 | ICD10CM | Covered |
| Q81.0 | ICD10CM | Covered |
| Q81.1 | ICD10CM | Covered |
| Q81.2 | ICD10CM | Covered |
| Q81.8 | ICD10CM | Covered |
| Q82.1 | ICD10CM | Covered |
| Q82.2 | ICD10CM | Covered |
| Q82.3 | ICD10CM | Covered |
| Q82.5 | ICD10CM | Covered |
| Q82.8 | ICD10CM | Covered |
| Q85.01 | ICD10CM | Covered |
| Q85.03 | ICD10CM | Covered |
| Q85.09 | ICD10CM | Covered |
| R20.0 | ICD10CM | Covered |
| R20.1 | ICD10CM | Covered |
| R20.2 | ICD10CM | Covered |
| R20.3 | ICD10CM | Covered |
| R20.8 | ICD10CM | Covered |
| R22.0 | ICD10CM | Covered |
| R22.1 | ICD10CM | Covered |
| R22.2 | ICD10CM | Covered |
| R22.31 | ICD10CM | Covered |
| R22.32 | ICD10CM | Covered |
| R22.33 | ICD10CM | Covered |
| R22.41 | ICD10CM | Covered |
| R22.42 | ICD10CM | Covered |
| R22.43 | ICD10CM | Covered |
| R52 | ICD10CM | Covered |
| R58 | ICD10CM | Covered |
| T07.XXXA | ICD10CM | Covered |
| T07.XXXD | ICD10CM | Covered |
| T07.XXXS | ICD10CM | Covered |
| Z48.817 | ICD10CM | Covered |
| Z85.820 | ICD10CM | Covered |
| Z85.828 | ICD10CM | Covered |