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 |
|---|---|---|
| 94760 | HCPCS | Covered |
| 94761 | HCPCS | Covered |
| 94762 | HCPCS | Covered |
| C34.00 | ICD10CM | Covered |
| C34.01 | ICD10CM | Covered |
| C34.02 | ICD10CM | Covered |
| C34.10 | ICD10CM | Covered |
| C34.11 | ICD10CM | Covered |
| C34.12 | ICD10CM | Covered |
| C34.2 | ICD10CM | Covered |
| C34.30 | ICD10CM | Covered |
| C34.31 | ICD10CM | Covered |
| C34.32 | ICD10CM | Covered |
| C34.80 | ICD10CM | Covered |
| C34.81 | ICD10CM | Covered |
| C34.82 | ICD10CM | Covered |
| C34.90 | ICD10CM | Covered |
| C34.91 | ICD10CM | Covered |
| C34.92 | ICD10CM | Covered |
| G47.30 | ICD10CM | Covered |
| I01.8 | ICD10CM | Covered |
| I09.81 | ICD10CM | Covered |
| I11.0 | ICD10CM | Covered |
| I13.0 | ICD10CM | Covered |
| I13.2 | ICD10CM | Covered |
| I16.0 | ICD10CM | Covered |
| I16.1 | ICD10CM | Covered |
| I16.9 | ICD10CM | Covered |
| I50.1 | ICD10CM | Covered |
| I50.20 | ICD10CM | Covered |
| I50.21 | ICD10CM | Covered |
| I50.22 | ICD10CM | Covered |
| I50.23 | ICD10CM | Covered |
| I50.30 | ICD10CM | Covered |
| I50.31 | ICD10CM | Covered |
| I50.32 | ICD10CM | Covered |
| I50.33 | ICD10CM | Covered |
| I50.40 | ICD10CM | Covered |
| I50.41 | ICD10CM | Covered |
| I50.42 | ICD10CM | Covered |
| I50.43 | ICD10CM | Covered |
| I50.810 | ICD10CM | Covered |
| I50.811 | ICD10CM | Covered |
| I50.812 | ICD10CM | Covered |
| I50.813 | ICD10CM | Covered |
| I50.814 | ICD10CM | Covered |
| I50.82 | ICD10CM | Covered |
| I50.83 | ICD10CM | Covered |
| I50.84 | ICD10CM | Covered |
| I50.89 | ICD10CM | Covered |
| I50.9 | ICD10CM | Covered |
| J43.0 | ICD10CM | Covered |
| J43.1 | ICD10CM | Covered |
| J43.2 | ICD10CM | Covered |
| J43.8 | ICD10CM | Covered |
| J43.9 | ICD10CM | Covered |
| J44.0 | ICD10CM | Covered |
| J44.1 | ICD10CM | Covered |
| J44.81 | ICD10CM | Covered |
| J44.89 | ICD10CM | Covered |
| J44.9 | 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 |
| J45.990 | ICD10CM | Covered |
| J45.991 | ICD10CM | Covered |
| J45.998 | ICD10CM | Covered |
| J47.1 | ICD10CM | Covered |
| J47.9 | ICD10CM | Covered |
| J4A.0 | ICD10CM | Covered |
| J4A.8 | ICD10CM | Covered |
| J80 | ICD10CM | Covered |
| J84.10 | ICD10CM | Covered |
| J95.1 | ICD10CM | Covered |
| J95.2 | ICD10CM | Covered |
| J95.3 | ICD10CM | Covered |
| J95.821 | ICD10CM | Covered |
| J95.822 | ICD10CM | Covered |
| J96.00 | ICD10CM | Covered |
| J96.01 | ICD10CM | Covered |
| J96.02 | ICD10CM | Covered |
| J96.10 | ICD10CM | Covered |
| J96.11 | ICD10CM | Covered |
| J96.12 | ICD10CM | Covered |
| J96.20 | ICD10CM | Covered |
| J96.21 | ICD10CM | Covered |
| J96.22 | ICD10CM | Covered |
| J98.4 | ICD10CM | Covered |
| R06.00 | ICD10CM | Covered |
| R06.02 | ICD10CM | Covered |
| R06.03 | ICD10CM | Covered |
| R06.09 | ICD10CM | Covered |
| R06.2 | ICD10CM | Covered |
| R06.3 | ICD10CM | Covered |
| R06.81 | ICD10CM | Covered |
| R06.82 | ICD10CM | Covered |
| R06.83 | ICD10CM | Covered |
| R06.89 | ICD10CM | Covered |