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 |
| 46900 | HCPCS | Covered |
| 46916 | HCPCS | Covered |
| 54050 | HCPCS | Covered |
| 54055 | HCPCS | Covered |
| 54056 | HCPCS | Covered |
| 54057 | HCPCS | Covered |
| 54060 | HCPCS | Covered |
| 54065 | HCPCS | Covered |
| 56501 | HCPCS | Covered |
| 56515 | HCPCS | Covered |
| A54.02 | ICD10CM | Covered |
| A54.1 | ICD10CM | Covered |
| A63.0 | ICD10CM | Covered |
| B07.0 | ICD10CM | Covered |
| B07.8 | ICD10CM | Covered |
| B08.1 | ICD10CM | Covered |
| C44.00 | ICD10CM | Covered |
| C44.01 | ICD10CM | Covered |
| C44.02 | ICD10CM | Covered |
| C44.09 | ICD10CM | Covered |
| C44.1021 | ICD10CM | Covered |
| C44.1022 | ICD10CM | Covered |
| C44.1091 | ICD10CM | Covered |
| C44.1092 | ICD10CM | Covered |
| C44.1121 | ICD10CM | Covered |
| C44.1122 | ICD10CM | Covered |
| C44.1191 | ICD10CM | Covered |
| C44.1192 | ICD10CM | Covered |
| C44.1221 | ICD10CM | Covered |
| C44.1222 | ICD10CM | Covered |
| C44.1291 | ICD10CM | Covered |
| C44.1292 | ICD10CM | Covered |
| C44.1921 | ICD10CM | Covered |
| C44.1922 | ICD10CM | Covered |
| C44.1991 | ICD10CM | Covered |
| C44.1992 | ICD10CM | Covered |
| C44.202 | ICD10CM | Covered |
| C44.209 | ICD10CM | Covered |
| C44.212 | ICD10CM | Covered |
| C44.219 | ICD10CM | Covered |
| C44.222 | ICD10CM | Covered |
| C44.229 | ICD10CM | Covered |
| C44.292 | ICD10CM | Covered |
| C44.299 | ICD10CM | Covered |
| C44.301 | ICD10CM | Covered |
| C44.309 | ICD10CM | Covered |
| C44.311 | ICD10CM | Covered |
| C44.319 | ICD10CM | Covered |
| C44.321 | ICD10CM | Covered |
| C44.329 | ICD10CM | Covered |
| C44.391 | ICD10CM | Covered |
| C44.399 | ICD10CM | Covered |
| C44.40 | ICD10CM | Covered |
| C44.41 | ICD10CM | Covered |
| C44.42 | ICD10CM | Covered |
| C44.49 | ICD10CM | Covered |
| C44.500 | ICD10CM | Covered |
| C44.501 | ICD10CM | Covered |
| C44.509 | ICD10CM | Covered |
| C44.510 | ICD10CM | Covered |
| C44.511 | ICD10CM | Covered |
| C44.519 | ICD10CM | Covered |
| C44.520 | ICD10CM | Covered |
| C44.521 | ICD10CM | Covered |
| C44.529 | ICD10CM | Covered |
| C44.590 | ICD10CM | Covered |
| C44.591 | ICD10CM | Covered |
| C44.599 | ICD10CM | Covered |
| C44.602 | ICD10CM | Covered |
| C44.609 | ICD10CM | Covered |
| C44.612 | ICD10CM | Covered |
| C44.619 | ICD10CM | Covered |
| C44.622 | ICD10CM | Covered |
| C44.629 | ICD10CM | Covered |
| C44.692 | ICD10CM | Covered |
| C44.699 | ICD10CM | Covered |
| C44.702 | ICD10CM | Covered |
| C44.709 | ICD10CM | Covered |
| C44.712 | ICD10CM | Covered |
| C44.719 | ICD10CM | Covered |
| C44.722 | ICD10CM | Covered |
| C44.729 | ICD10CM | Covered |
| C44.792 | ICD10CM | Covered |
| C44.799 | ICD10CM | Covered |
| C44.80 | ICD10CM | Covered |
| C44.81 | ICD10CM | Covered |
| C44.82 | ICD10CM | Covered |
| C44.89 | ICD10CM | Covered |
| C51.0 | ICD10CM | Covered |
| C51.1 | ICD10CM | Covered |
| C51.2 | ICD10CM | Covered |
| C51.8 | ICD10CM | Covered |
| C51.9 | ICD10CM | Covered |
| C52 | ICD10CM | Covered |
| C57.7 | ICD10CM | Covered |
| C57.8 | ICD10CM | Covered |
| C57.9 | ICD10CM | Covered |
| C60.0 | ICD10CM | Covered |
| C60.1 | ICD10CM | Covered |
| C60.2 | ICD10CM | Covered |
| C60.8 | ICD10CM | Covered |
| C63.2 | ICD10CM | Covered |
| C63.7 | ICD10CM | Covered |
| C63.8 | ICD10CM | Covered |
| C63.9 | ICD10CM | Covered |
| D03.111 | ICD10CM | Covered |
| D03.112 | ICD10CM | Covered |
| D03.121 | ICD10CM | Covered |
| D03.122 | ICD10CM | Covered |
| D03.21 | ICD10CM | Covered |
| D03.22 | ICD10CM | Covered |
| D03.39 | ICD10CM | Covered |
| D03.51 | ICD10CM | Covered |
| D03.52 | ICD10CM | Covered |
| D03.59 | ICD10CM | Covered |
| D03.61 | ICD10CM | Covered |
| D03.62 | ICD10CM | Covered |
| D03.71 | ICD10CM | Covered |
| D03.72 | ICD10CM | Covered |
| D03.8 | ICD10CM | Covered |
| D04.0 | ICD10CM | Covered |
| D04.111 | ICD10CM | Covered |
| D04.112 | ICD10CM | Covered |
| D04.121 | ICD10CM | Covered |
| D04.122 | ICD10CM | Covered |
| D04.21 | ICD10CM | Covered |
| D04.22 | ICD10CM | Covered |
| D04.39 | ICD10CM | Covered |
| D04.4 | ICD10CM | Covered |
| D04.5 | ICD10CM | Covered |
| D04.61 | ICD10CM | Covered |
| D04.62 | ICD10CM | Covered |
| D04.71 | ICD10CM | Covered |
| D04.72 | ICD10CM | Covered |
| D04.8 | ICD10CM | Covered |
| D07.1 | ICD10CM | Covered |
| D07.4 | 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 |
| D18.09 | ICD10CM | Covered |
| D18.1 | ICD10CM | Covered |
| D21.0 | 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 |
| D22.39 | 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 |
| 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 |
| D23.39 | 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 |
| D28.0 | ICD10CM | Covered |
| D28.1 | ICD10CM | Covered |
| D29.0 | ICD10CM | Covered |
| D29.4 | ICD10CM | Covered |
| D37.01 | ICD10CM | Covered |
| D48.5 | ICD10CM | Covered |
| D49.2 | ICD10CM | Covered |
| D49.59 | 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 |
| H61.001 | ICD10CM | Covered |
| H61.002 | ICD10CM | Covered |
| H61.003 | ICD10CM | Covered |
| H61.011 | ICD10CM | Covered |
| H61.012 | ICD10CM | Covered |
| H61.013 | ICD10CM | Covered |
| H61.021 | ICD10CM | Covered |
| H61.022 | ICD10CM | Covered |
| H61.023 | ICD10CM | Covered |
| H61.031 | ICD10CM | Covered |
| H61.032 | ICD10CM | Covered |
| H61.033 | ICD10CM | Covered |
| L28.0 | ICD10CM | Covered |
| L28.1 | ICD10CM | Covered |
| L28.2 | ICD10CM | Covered |
| L29.9 | ICD10CM | Covered |
| L44.8 | ICD10CM | Covered |
| L45 | ICD10CM | Covered |
| L56.5 | ICD10CM | Covered |
| L57.0 | ICD10CM | Covered |
| L57.8 | ICD10CM | Covered |
| L66.11 | ICD10CM | Covered |
| L66.19 | 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 |
| L81.4 | ICD10CM | Covered |
| L82.0 | ICD10CM | Covered |
| L82.1 | ICD10CM | Covered |
| L85.0 | ICD10CM | Covered |
| L85.1 | ICD10CM | Covered |
| L85.2 | ICD10CM | Covered |
| L85.3 | ICD10CM | Covered |
| L85.8 | ICD10CM | Covered |
| L87.0 | ICD10CM | Covered |
| L90.5 | ICD10CM | Covered |
| L91.0 | ICD10CM | Covered |
| L91.8 | ICD10CM | Covered |
| L92.0 | ICD10CM | Covered |
| L92.8 | ICD10CM | Covered |
| L95.1 | ICD10CM | Covered |
| L98.0 | ICD10CM | Covered |
| N48.89 | ICD10CM | Covered |
| N75.0 | ICD10CM | Covered |
| N90.0 | ICD10CM | Covered |
| N90.1 | ICD10CM | Covered |
| N90.3 | ICD10CM | Covered |
| N90.7 | ICD10CM | Covered |
| Q82.5 | ICD10CM | Covered |
| Q85.01 | ICD10CM | Covered |
| Q85.02 | ICD10CM | Covered |
| Q85.09 | ICD10CM | Covered |
| R20.8 | ICD10CM | Covered |
| R23.3 | ICD10CM | Covered |
| R23.8 | ICD10CM | Covered |
| R52 | ICD10CM | Covered |
| R58 | ICD10CM | Covered |