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 |
|---|---|---|
| 76519 | HCPCS | Covered |
| 92136 | HCPCS | Covered |
| E08.36 | ICD10CM | Covered |
| E09.36 | ICD10CM | Covered |
| E10.36 | ICD10CM | Covered |
| E11.36 | ICD10CM | Covered |
| E13.36 | ICD10CM | Covered |
| H25.011 | ICD10CM | Covered |
| H25.012 | ICD10CM | Covered |
| H25.013 | ICD10CM | Covered |
| H25.031 | ICD10CM | Covered |
| H25.032 | ICD10CM | Covered |
| H25.033 | ICD10CM | Covered |
| H25.041 | ICD10CM | Covered |
| H25.042 | ICD10CM | Covered |
| H25.043 | ICD10CM | Covered |
| H25.091 | ICD10CM | Covered |
| H25.092 | ICD10CM | Covered |
| H25.093 | ICD10CM | Covered |
| H25.11 | ICD10CM | Covered |
| H25.12 | ICD10CM | Covered |
| H25.13 | ICD10CM | Covered |
| H25.21 | ICD10CM | Covered |
| H25.22 | ICD10CM | Covered |
| H25.23 | ICD10CM | Covered |
| H25.811 | ICD10CM | Covered |
| H25.812 | ICD10CM | Covered |
| H25.813 | ICD10CM | Covered |
| H25.89 | ICD10CM | Covered |
| H25.9 | ICD10CM | Covered |
| H26.001 | ICD10CM | Covered |
| H26.002 | ICD10CM | Covered |
| H26.003 | ICD10CM | Covered |
| H26.011 | ICD10CM | Covered |
| H26.012 | ICD10CM | Covered |
| H26.013 | ICD10CM | Covered |
| H26.031 | ICD10CM | Covered |
| H26.032 | ICD10CM | Covered |
| H26.033 | ICD10CM | Covered |
| H26.041 | ICD10CM | Covered |
| H26.042 | ICD10CM | Covered |
| H26.043 | ICD10CM | Covered |
| H26.051 | ICD10CM | Covered |
| H26.052 | ICD10CM | Covered |
| H26.053 | ICD10CM | Covered |
| H26.061 | ICD10CM | Covered |
| H26.062 | ICD10CM | Covered |
| H26.063 | ICD10CM | Covered |
| H26.09 | ICD10CM | Covered |
| H26.101 | ICD10CM | Covered |
| H26.102 | ICD10CM | Covered |
| H26.103 | ICD10CM | Covered |
| H26.111 | ICD10CM | Covered |
| H26.112 | ICD10CM | Covered |
| H26.113 | ICD10CM | Covered |
| H26.121 | ICD10CM | Covered |
| H26.122 | ICD10CM | Covered |
| H26.123 | ICD10CM | Covered |
| H26.131 | ICD10CM | Covered |
| H26.132 | ICD10CM | Covered |
| H26.133 | ICD10CM | Covered |
| H26.20 | ICD10CM | Covered |
| H26.211 | ICD10CM | Covered |
| H26.212 | ICD10CM | Covered |
| H26.213 | ICD10CM | Covered |
| H26.221 | ICD10CM | Covered |
| H26.222 | ICD10CM | Covered |
| H26.223 | ICD10CM | Covered |
| H26.231 | ICD10CM | Covered |
| H26.232 | ICD10CM | Covered |
| H26.233 | ICD10CM | Covered |
| H26.31 | ICD10CM | Covered |
| H26.32 | ICD10CM | Covered |
| H26.33 | ICD10CM | Covered |
| H26.8 | ICD10CM | Covered |
| H26.9 | ICD10CM | Covered |
| H27.01 | ICD10CM | Covered |
| H27.02 | ICD10CM | Covered |
| H27.03 | ICD10CM | Covered |
| H27.10 | ICD10CM | Covered |
| H27.111 | ICD10CM | Covered |
| H27.112 | ICD10CM | Covered |
| H27.113 | ICD10CM | Covered |
| H27.121 | ICD10CM | Covered |
| H27.122 | ICD10CM | Covered |
| H27.123 | ICD10CM | Covered |
| H27.131 | ICD10CM | Covered |
| H27.132 | ICD10CM | Covered |
| H27.133 | ICD10CM | Covered |
| H28 | ICD10CM | Covered |
| H40.021 | ICD10CM | Covered |
| H40.022 | ICD10CM | Covered |
| H40.023 | ICD10CM | Covered |
| H40.061 | ICD10CM | Covered |
| H40.062 | ICD10CM | Covered |
| H40.063 | ICD10CM | Covered |
| H40.1110 | ICD10CM | Covered |
| H40.1111 | ICD10CM | Covered |
| H40.1112 | ICD10CM | Covered |
| H40.1113 | ICD10CM | Covered |
| H40.1114 | ICD10CM | Covered |
| H40.1120 | ICD10CM | Covered |
| H40.1121 | ICD10CM | Covered |
| H40.1122 | ICD10CM | Covered |
| H40.1123 | ICD10CM | Covered |
| H40.1124 | ICD10CM | Covered |
| H40.1130 | ICD10CM | Covered |
| H40.1131 | ICD10CM | Covered |
| H40.1132 | ICD10CM | Covered |
| H40.1133 | ICD10CM | Covered |
| H40.1134 | ICD10CM | Covered |
| H40.1210 | ICD10CM | Covered |
| H40.1211 | ICD10CM | Covered |
| H40.1212 | ICD10CM | Covered |
| H40.1213 | ICD10CM | Covered |
| H40.1214 | ICD10CM | Covered |
| H40.1220 | ICD10CM | Covered |
| H40.1221 | ICD10CM | Covered |
| H40.1222 | ICD10CM | Covered |
| H40.1223 | ICD10CM | Covered |
| H40.1224 | ICD10CM | Covered |
| H40.1230 | ICD10CM | Covered |
| H40.1231 | ICD10CM | Covered |
| H40.1232 | ICD10CM | Covered |
| H40.1233 | ICD10CM | Covered |
| H40.1234 | ICD10CM | Covered |
| H40.1310 | ICD10CM | Covered |
| H40.1311 | ICD10CM | Covered |
| H40.1312 | ICD10CM | Covered |
| H40.1313 | ICD10CM | Covered |
| H40.1314 | ICD10CM | Covered |
| H40.1320 | ICD10CM | Covered |
| H40.1321 | ICD10CM | Covered |
| H40.1322 | ICD10CM | Covered |
| H40.1323 | ICD10CM | Covered |
| H40.1324 | ICD10CM | Covered |
| H40.1330 | ICD10CM | Covered |
| H40.1331 | ICD10CM | Covered |
| H40.1332 | ICD10CM | Covered |
| H40.1333 | ICD10CM | Covered |
| H40.1334 | ICD10CM | Covered |
| H40.1410 | ICD10CM | Covered |
| H40.1411 | ICD10CM | Covered |
| H40.1412 | ICD10CM | Covered |
| H40.1413 | ICD10CM | Covered |
| H40.1414 | ICD10CM | Covered |
| H40.1420 | ICD10CM | Covered |
| H40.1421 | ICD10CM | Covered |
| H40.1422 | ICD10CM | Covered |
| H40.1423 | ICD10CM | Covered |
| H40.1424 | ICD10CM | Covered |
| H40.1430 | ICD10CM | Covered |
| H40.1431 | ICD10CM | Covered |
| H40.1432 | ICD10CM | Covered |
| H40.1433 | ICD10CM | Covered |
| H40.1434 | ICD10CM | Covered |
| H40.2210 | ICD10CM | Covered |
| H40.2211 | ICD10CM | Covered |
| H40.2212 | ICD10CM | Covered |
| H40.2213 | ICD10CM | Covered |
| H40.2214 | ICD10CM | Covered |
| H40.2220 | ICD10CM | Covered |
| H40.2221 | ICD10CM | Covered |
| H40.2222 | ICD10CM | Covered |
| H40.2223 | ICD10CM | Covered |
| H40.2224 | ICD10CM | Covered |
| H40.2230 | ICD10CM | Covered |
| H40.2231 | ICD10CM | Covered |
| H40.2232 | ICD10CM | Covered |
| H40.2233 | ICD10CM | Covered |
| H40.2234 | ICD10CM | Covered |
| H40.2290 | ICD10CM | Covered |
| H40.2291 | ICD10CM | Covered |
| H40.2292 | ICD10CM | Covered |
| H40.2293 | ICD10CM | Covered |
| H40.2294 | ICD10CM | Covered |
| H40.31X0 | ICD10CM | Covered |
| H40.31X1 | ICD10CM | Covered |
| H40.31X2 | ICD10CM | Covered |
| H40.31X3 | ICD10CM | Covered |
| H40.31X4 | ICD10CM | Covered |
| H40.32X0 | ICD10CM | Covered |
| H40.32X1 | ICD10CM | Covered |
| H40.32X2 | ICD10CM | Covered |
| H40.32X3 | ICD10CM | Covered |
| H40.32X4 | ICD10CM | Covered |
| H40.33X0 | ICD10CM | Covered |
| H40.33X1 | ICD10CM | Covered |
| H40.33X2 | ICD10CM | Covered |
| H40.33X3 | ICD10CM | Covered |
| H40.33X4 | ICD10CM | Covered |
| H40.41X0 | ICD10CM | Covered |
| H40.41X1 | ICD10CM | Covered |
| H40.41X2 | ICD10CM | Covered |
| H40.41X3 | ICD10CM | Covered |
| H40.41X4 | ICD10CM | Covered |
| H40.42X0 | ICD10CM | Covered |
| H40.42X1 | ICD10CM | Covered |
| H40.42X2 | ICD10CM | Covered |
| H40.42X3 | ICD10CM | Covered |
| H40.42X4 | ICD10CM | Covered |
| H40.43X0 | ICD10CM | Covered |
| H40.43X1 | ICD10CM | Covered |
| H40.43X2 | ICD10CM | Covered |
| H40.43X3 | ICD10CM | Covered |
| H40.43X4 | ICD10CM | Covered |
| H40.51X0 | ICD10CM | Covered |
| H40.51X1 | ICD10CM | Covered |
| H40.51X2 | ICD10CM | Covered |
| H40.51X3 | ICD10CM | Covered |
| H40.51X4 | ICD10CM | Covered |
| H40.52X0 | ICD10CM | Covered |
| H40.52X1 | ICD10CM | Covered |
| H40.52X2 | ICD10CM | Covered |
| H40.52X3 | ICD10CM | Covered |
| H40.52X4 | ICD10CM | Covered |
| H40.53X0 | ICD10CM | Covered |
| H40.53X1 | ICD10CM | Covered |
| H40.53X2 | ICD10CM | Covered |
| H40.53X3 | ICD10CM | Covered |
| H40.53X4 | ICD10CM | Covered |
| H43.821 | ICD10CM | Covered |
| H43.822 | ICD10CM | Covered |
| H43.823 | ICD10CM | Covered |
| Q12.0 | ICD10CM | Covered |
| Q12.1 | ICD10CM | Covered |
| Q12.2 | ICD10CM | Covered |
| Q12.3 | ICD10CM | Covered |
| Q12.4 | ICD10CM | Covered |
| Q12.8 | ICD10CM | Covered |
| Q12.9 | ICD10CM | Covered |
| T85.21XA | ICD10CM | Covered |
| T85.22XA | ICD10CM | Covered |
| T85.29XA | ICD10CM | Covered |
| T85.72XA | ICD10CM | Covered |
| T85.79XA | ICD10CM | Covered |
| T86.8421 | ICD10CM | Covered |
| T86.8422 | ICD10CM | Covered |
| T86.8423 | ICD10CM | Covered |
| Z79.83 | ICD10CM | Covered |
| Z79.85 | ICD10CM | Covered |
| Z96.1 | ICD10CM | Covered |