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 |
|---|---|---|
| 83970 | HCPCS | Covered |
| D35.1 | ICD10CM | Covered |
| E20.0 | ICD10CM | Covered |
| E20.1 | ICD10CM | Covered |
| E20.810 | ICD10CM | Covered |
| E20.811 | ICD10CM | Covered |
| E20.812 | ICD10CM | Covered |
| E20.818 | ICD10CM | Covered |
| E20.9 | ICD10CM | Covered |
| E21.0 | ICD10CM | Covered |
| E21.1 | ICD10CM | Covered |
| E21.2 | ICD10CM | Covered |
| E21.3 | ICD10CM | Covered |
| E34.2 | ICD10CM | Covered |
| E67.3 | ICD10CM | Covered |
| E83.30 | ICD10CM | Covered |
| E83.31 | ICD10CM | Covered |
| E83.32 | ICD10CM | Covered |
| E83.39 | ICD10CM | Covered |
| E83.40 | ICD10CM | Covered |
| E83.41 | ICD10CM | Covered |
| E83.42 | ICD10CM | Covered |
| E83.49 | ICD10CM | Covered |
| E83.51 | ICD10CM | Covered |
| E83.52 | ICD10CM | Covered |
| E83.59 | ICD10CM | Covered |
| E83.822 | ICD10CM | Covered |
| E89.2 | ICD10CM | Covered |
| F05 | ICD10CM | Covered |
| F06.30 | ICD10CM | Covered |
| F06.31 | ICD10CM | Covered |
| F06.32 | ICD10CM | Covered |
| F06.33 | ICD10CM | Covered |
| F06.34 | ICD10CM | Covered |
| G93.31 | ICD10CM | Covered |
| G93.32 | ICD10CM | Covered |
| G93.39 | ICD10CM | Covered |
| M62.40 | ICD10CM | Covered |
| M62.411 | ICD10CM | Covered |
| M62.412 | ICD10CM | Covered |
| M62.419 | ICD10CM | Covered |
| M62.421 | ICD10CM | Covered |
| M62.422 | ICD10CM | Covered |
| M62.429 | ICD10CM | Covered |
| M62.431 | ICD10CM | Covered |
| M62.432 | ICD10CM | Covered |
| M62.439 | ICD10CM | Covered |
| M62.441 | ICD10CM | Covered |
| M62.442 | ICD10CM | Covered |
| M62.449 | ICD10CM | Covered |
| M62.451 | ICD10CM | Covered |
| M62.452 | ICD10CM | Covered |
| M62.459 | ICD10CM | Covered |
| M62.461 | ICD10CM | Covered |
| M62.462 | ICD10CM | Covered |
| M62.469 | ICD10CM | Covered |
| M62.471 | ICD10CM | Covered |
| M62.472 | ICD10CM | Covered |
| M62.479 | ICD10CM | Covered |
| M62.48 | ICD10CM | Covered |
| M62.49 | ICD10CM | Covered |
| M62.831 | ICD10CM | Covered |
| M62.838 | ICD10CM | Covered |
| M80.011A | ICD10CM | Covered |
| M80.012A | ICD10CM | Covered |
| M80.021A | ICD10CM | Covered |
| M80.022A | ICD10CM | Covered |
| M80.031A | ICD10CM | Covered |
| M80.032A | ICD10CM | Covered |
| M80.041A | ICD10CM | Covered |
| M80.042A | ICD10CM | Covered |
| M80.051A | ICD10CM | Covered |
| M80.052A | ICD10CM | Covered |
| M80.061A | ICD10CM | Covered |
| M80.062A | ICD10CM | Covered |
| M80.071A | ICD10CM | Covered |
| M80.072A | ICD10CM | Covered |
| M80.08XA | ICD10CM | Covered |
| M80.0B1A | ICD10CM | Covered |
| M80.0B2A | ICD10CM | Covered |
| M80.811A | ICD10CM | Covered |
| M80.812A | ICD10CM | Covered |
| M80.821A | ICD10CM | Covered |
| M80.822A | ICD10CM | Covered |
| M80.831A | ICD10CM | Covered |
| M80.832A | ICD10CM | Covered |
| M80.841A | ICD10CM | Covered |
| M80.842A | ICD10CM | Covered |
| M80.851A | ICD10CM | Covered |
| M80.852A | ICD10CM | Covered |
| M80.861A | ICD10CM | Covered |
| M80.862A | ICD10CM | Covered |
| M80.871A | ICD10CM | Covered |
| M80.872A | ICD10CM | Covered |
| M80.88XA | ICD10CM | Covered |
| M80.8B1A | ICD10CM | Covered |
| M80.8B2A | ICD10CM | Covered |
| M81.0 | ICD10CM | Covered |
| M81.6 | ICD10CM | Covered |
| M81.8 | ICD10CM | Covered |
| M85.9 | ICD10CM | Covered |
| M89.9 | ICD10CM | Covered |
| M94.9 | ICD10CM | Covered |
| N18.1 | ICD10CM | Covered |
| N18.2 | ICD10CM | Covered |
| N18.31 | ICD10CM | Covered |
| N18.32 | ICD10CM | Covered |
| N18.4 | ICD10CM | Covered |
| N18.5 | ICD10CM | Covered |
| N18.6 | ICD10CM | Covered |
| N18.9 | ICD10CM | Covered |
| N19 | ICD10CM | Covered |
| N25.81 | ICD10CM | Covered |
| N25.89 | ICD10CM | Covered |
| R11.0 | ICD10CM | Covered |
| R11.10 | ICD10CM | Covered |
| R11.11 | ICD10CM | Covered |
| R11.12 | ICD10CM | Covered |
| R11.14 | ICD10CM | Covered |
| R11.15 | ICD10CM | Covered |
| R11.2 | ICD10CM | Covered |
| R13.0 | ICD10CM | Covered |
| R13.10 | ICD10CM | Covered |
| R13.11 | ICD10CM | Covered |
| R13.12 | ICD10CM | Covered |
| R13.13 | ICD10CM | Covered |
| R13.14 | ICD10CM | Covered |
| R13.19 | ICD10CM | Covered |
| R25.0 | ICD10CM | Covered |
| R25.1 | ICD10CM | Covered |
| R25.2 | ICD10CM | Covered |
| R25.3 | ICD10CM | Covered |
| R25.8 | ICD10CM | Covered |
| R25.9 | ICD10CM | Covered |
| R29.0 | ICD10CM | Covered |
| R35.89 | ICD10CM | Covered |
| R53.0 | ICD10CM | Covered |
| R53.1 | ICD10CM | Covered |
| R53.81 | ICD10CM | Covered |
| R53.83 | ICD10CM | Covered |
| Z09 | ICD10CM | Covered |
| Z48.22 | ICD10CM | Covered |
| Z94.0 | ICD10CM | Covered |