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 |
|---|---|---|
| 0001U | HCPCS | Covered |
| 0084U | HCPCS | Covered |
| 0180U | HCPCS | Covered |
| 0181U | HCPCS | Covered |
| 0182U | HCPCS | Covered |
| 0183U | HCPCS | Covered |
| 0184U | HCPCS | Covered |
| 0185U | HCPCS | Covered |
| 0186U | HCPCS | Covered |
| 0187U | HCPCS | Covered |
| 0188U | HCPCS | Covered |
| 0189U | HCPCS | Covered |
| 0190U | HCPCS | Covered |
| 0191U | HCPCS | Covered |
| 0192U | HCPCS | Covered |
| 0193U | HCPCS | Covered |
| 0194U | HCPCS | Covered |
| 0195U | HCPCS | Covered |
| 0196U | HCPCS | Covered |
| 0197U | HCPCS | Covered |
| 0198U | HCPCS | Covered |
| 0199U | HCPCS | Covered |
| 0200U | HCPCS | Covered |
| 0201U | HCPCS | Covered |
| 0221U | HCPCS | Covered |
| 0222U | HCPCS | Covered |
| 81105 | HCPCS | Covered |
| 81106 | HCPCS | Covered |
| 81107 | HCPCS | Covered |
| 81108 | HCPCS | Covered |
| 81109 | HCPCS | Covered |
| 81110 | HCPCS | Covered |
| 81111 | HCPCS | Covered |
| 81112 | HCPCS | Covered |
| 81403 | HCPCS | Covered |
| C85.80 | ICD10CM | Covered |
| C85.89 | ICD10CM | Covered |
| C85.90 | ICD10CM | Covered |
| C85.91 | ICD10CM | Covered |
| C85.92 | ICD10CM | Covered |
| C85.93 | ICD10CM | Covered |
| C85.94 | ICD10CM | Covered |
| C85.95 | ICD10CM | Covered |
| C85.96 | ICD10CM | Covered |
| C85.97 | ICD10CM | Covered |
| C85.98 | ICD10CM | Covered |
| C85.99 | ICD10CM | Covered |
| C90.00 | ICD10CM | Covered |
| C90.01 | ICD10CM | Covered |
| C90.02 | ICD10CM | Covered |
| C91.00 | ICD10CM | Covered |
| C91.01 | ICD10CM | Covered |
| C91.02 | ICD10CM | Covered |
| C92.60 | ICD10CM | Covered |
| C92.61 | ICD10CM | Covered |
| C92.62 | ICD10CM | Covered |
| C92.A0 | ICD10CM | Covered |
| C92.A1 | ICD10CM | Covered |
| C92.A2 | ICD10CM | Covered |
| D46.C | ICD10CM | Covered |
| D46.Z | ICD10CM | Covered |
| D51.0 | ICD10CM | Covered |
| D53.9 | ICD10CM | Covered |
| D55.0 | ICD10CM | Covered |
| D55.1 | ICD10CM | Covered |
| D55.29 | ICD10CM | Covered |
| D55.3 | ICD10CM | Covered |
| D55.8 | ICD10CM | Covered |
| D55.9 | ICD10CM | Covered |
| D56.0 | ICD10CM | Covered |
| D56.1 | ICD10CM | Covered |
| D56.2 | ICD10CM | Covered |
| D56.3 | ICD10CM | Covered |
| D56.5 | ICD10CM | Covered |
| D56.8 | ICD10CM | Covered |
| D56.9 | ICD10CM | Covered |
| D57.00 | ICD10CM | Covered |
| D57.01 | ICD10CM | Covered |
| D57.02 | ICD10CM | Covered |
| D57.03 | ICD10CM | Covered |
| D57.04 | ICD10CM | Covered |
| D57.09 | ICD10CM | Covered |
| D57.1 | ICD10CM | Covered |
| D57.20 | ICD10CM | Covered |
| D57.211 | ICD10CM | Covered |
| D57.212 | ICD10CM | Covered |
| D57.213 | ICD10CM | Covered |
| D57.214 | ICD10CM | Covered |
| D57.218 | ICD10CM | Covered |
| D57.219 | ICD10CM | Covered |
| D57.3 | ICD10CM | Covered |
| D57.40 | ICD10CM | Covered |
| D57.411 | ICD10CM | Covered |
| D57.412 | ICD10CM | Covered |
| D57.413 | ICD10CM | Covered |
| D57.414 | ICD10CM | Covered |
| D57.418 | ICD10CM | Covered |
| D57.419 | ICD10CM | Covered |
| D57.42 | ICD10CM | Covered |
| D57.431 | ICD10CM | Covered |
| D57.432 | ICD10CM | Covered |
| D57.433 | ICD10CM | Covered |
| D57.434 | ICD10CM | Covered |
| D57.438 | ICD10CM | Covered |
| D57.439 | ICD10CM | Covered |
| D57.44 | ICD10CM | Covered |
| D57.451 | ICD10CM | Covered |
| D57.452 | ICD10CM | Covered |
| D57.453 | ICD10CM | Covered |
| D57.454 | ICD10CM | Covered |
| D57.458 | ICD10CM | Covered |
| D57.459 | ICD10CM | Covered |
| D57.80 | ICD10CM | Covered |
| D57.811 | ICD10CM | Covered |
| D57.812 | ICD10CM | Covered |
| D57.813 | ICD10CM | Covered |
| D57.814 | ICD10CM | Covered |
| D57.818 | ICD10CM | Covered |
| D57.819 | ICD10CM | Covered |
| D58.0 | ICD10CM | Covered |
| D58.1 | ICD10CM | Covered |
| D58.9 | ICD10CM | Covered |
| D59.0 | ICD10CM | Covered |
| D59.10 | ICD10CM | Covered |
| D59.11 | ICD10CM | Covered |
| D59.12 | ICD10CM | Covered |
| D59.13 | ICD10CM | Covered |
| D59.19 | ICD10CM | Covered |
| D59.9 | ICD10CM | Covered |
| D60.0 | ICD10CM | Covered |
| D60.1 | ICD10CM | Covered |
| D60.8 | ICD10CM | Covered |
| D60.9 | ICD10CM | Covered |
| D61.01 | ICD10CM | Covered |
| D61.02 | ICD10CM | Covered |
| D61.03 | ICD10CM | Covered |
| D61.09 | ICD10CM | Covered |
| D61.1 | ICD10CM | Covered |
| D61.2 | ICD10CM | Covered |
| D61.3 | ICD10CM | Covered |
| D61.89 | ICD10CM | Covered |
| D63.0 | ICD10CM | Covered |
| D63.1 | ICD10CM | Covered |
| D63.8 | ICD10CM | Covered |
| D64.0 | ICD10CM | Covered |
| D64.1 | ICD10CM | Covered |
| D64.2 | ICD10CM | Covered |
| D64.3 | ICD10CM | Covered |
| D64.4 | ICD10CM | Covered |
| D64.89 | ICD10CM | Covered |
| Z85.72 | ICD10CM | Covered |