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 |
|---|---|---|
| 0554T | HCPCS | Covered |
| 0555T | HCPCS | Covered |
| 0556T | HCPCS | Covered |
| 0557T | HCPCS | Covered |
| 0558T | HCPCS | Covered |
| 76977 | HCPCS | Covered |
| 77078 | HCPCS | Covered |
| 77080 | HCPCS | Covered |
| 77081 | HCPCS | Covered |
| 77085 | HCPCS | Covered |
| 78350 | HCPCS | Covered |
| 78351 | HCPCS | Covered |
| G0130 | HCPCS | Covered |
| E21.0 | ICD10CM | Covered |
| E21.3 | ICD10CM | Covered |
| E23.0 | ICD10CM | Covered |
| E24.0 | ICD10CM | Covered |
| E24.2 | ICD10CM | Covered |
| E24.3 | ICD10CM | Covered |
| E24.4 | ICD10CM | Covered |
| E24.8 | ICD10CM | Covered |
| E24.9 | ICD10CM | Covered |
| E28.310 | ICD10CM | Covered |
| E28.319 | ICD10CM | Covered |
| E28.39 | ICD10CM | Covered |
| E34.2 | ICD10CM | Covered |
| E89.40 | ICD10CM | Covered |
| E89.41 | ICD10CM | Covered |
| M48.50XA | ICD10CM | Covered |
| M48.51XA | ICD10CM | Covered |
| M48.52XA | ICD10CM | Covered |
| M48.53XA | ICD10CM | Covered |
| M48.54XA | ICD10CM | Covered |
| M48.55XA | ICD10CM | Covered |
| M48.56XA | ICD10CM | Covered |
| M48.57XA | ICD10CM | Covered |
| M48.58XA | ICD10CM | Covered |
| M80.08XA | ICD10CM | Covered |
| M80.0B1A | ICD10CM | Covered |
| M80.0B1D | ICD10CM | Covered |
| M80.0B1G | ICD10CM | Covered |
| M80.0B1K | ICD10CM | Covered |
| M80.0B1P | ICD10CM | Covered |
| M80.0B1S | ICD10CM | Covered |
| M80.0B2A | ICD10CM | Covered |
| M80.0B2D | ICD10CM | Covered |
| M80.0B2G | ICD10CM | Covered |
| M80.0B2K | ICD10CM | Covered |
| M80.0B2P | ICD10CM | Covered |
| M80.0B2S | ICD10CM | Covered |
| M80.0B9A | ICD10CM | Covered |
| M80.0B9D | ICD10CM | Covered |
| M80.88XA | ICD10CM | Covered |
| M80.8B1A | ICD10CM | Covered |
| M80.8B1D | ICD10CM | Covered |
| M80.8B1G | ICD10CM | Covered |
| M80.8B1K | ICD10CM | Covered |
| M80.8B1P | ICD10CM | Covered |
| M80.8B1S | ICD10CM | Covered |
| M80.8B2A | ICD10CM | Covered |
| M80.8B2D | ICD10CM | Covered |
| M80.8B2G | ICD10CM | Covered |
| M80.8B2K | ICD10CM | Covered |
| M80.8B2P | ICD10CM | Covered |
| M80.8B2S | ICD10CM | Covered |
| M80.8B9A | ICD10CM | Covered |
| M80.8B9D | ICD10CM | Covered |
| M80.8B9G | ICD10CM | Covered |
| M80.8B9K | ICD10CM | Covered |
| M80.8B9P | ICD10CM | Covered |
| M80.8B9S | ICD10CM | Covered |
| M81.0 | ICD10CM | Covered |
| M81.6 | ICD10CM | Covered |
| M81.8 | ICD10CM | Covered |
| M84.58XA | ICD10CM | Covered |
| M84.68XA | ICD10CM | Covered |
| M85.811 | ICD10CM | Covered |
| M85.812 | ICD10CM | Covered |
| M85.821 | ICD10CM | Covered |
| M85.822 | ICD10CM | Covered |
| M85.831 | ICD10CM | Covered |
| M85.832 | ICD10CM | Covered |
| M85.841 | ICD10CM | Covered |
| M85.842 | ICD10CM | Covered |
| M85.851 | ICD10CM | Covered |
| M85.852 | ICD10CM | Covered |
| M85.861 | ICD10CM | Covered |
| M85.862 | ICD10CM | Covered |
| M85.871 | ICD10CM | Covered |
| M85.872 | ICD10CM | Covered |
| M85.88 | ICD10CM | Covered |
| M85.89 | ICD10CM | Covered |
| N95.8 | ICD10CM | Covered |
| N95.9 | ICD10CM | Covered |
| Q78.0 | ICD10CM | Covered |
| Q96.0 | ICD10CM | Covered |
| Q96.1 | ICD10CM | Covered |
| Q96.2 | ICD10CM | Covered |
| Q96.3 | ICD10CM | Covered |
| Q96.4 | ICD10CM | Covered |
| Q96.8 | ICD10CM | Covered |
| Q96.9 | ICD10CM | Covered |
| S12.000A | ICD10CM | Covered |
| S12.000B | ICD10CM | Covered |
| S12.001A | ICD10CM | Covered |
| S12.001B | ICD10CM | Covered |
| S12.01XA | ICD10CM | Covered |
| S12.01XB | ICD10CM | Covered |
| S12.02XA | ICD10CM | Covered |
| S12.02XB | ICD10CM | Covered |
| S12.030A | ICD10CM | Covered |
| S12.030B | ICD10CM | Covered |
| S12.031A | ICD10CM | Covered |
| S12.031B | ICD10CM | Covered |
| S12.040A | ICD10CM | Covered |
| S12.040B | ICD10CM | Covered |
| S12.041A | ICD10CM | Covered |
| S12.041B | ICD10CM | Covered |
| S12.090A | ICD10CM | Covered |
| S12.090B | ICD10CM | Covered |
| S12.091A | ICD10CM | Covered |
| S12.091B | ICD10CM | Covered |
| S12.100A | ICD10CM | Covered |
| S12.100B | ICD10CM | Covered |
| S12.101A | ICD10CM | Covered |
| S12.101B | ICD10CM | Covered |
| S12.110A | ICD10CM | Covered |
| S12.110B | ICD10CM | Covered |
| S12.111A | ICD10CM | Covered |
| S12.111B | ICD10CM | Covered |
| S12.112A | ICD10CM | Covered |
| S12.112B | ICD10CM | Covered |
| S12.120A | ICD10CM | Covered |
| S12.120B | ICD10CM | Covered |
| S12.121A | ICD10CM | Covered |
| S12.121B | ICD10CM | Covered |
| S12.130A | ICD10CM | Covered |
| S12.130B | ICD10CM | Covered |
| S12.131A | ICD10CM | Covered |
| S12.131B | ICD10CM | Covered |
| S12.14XA | ICD10CM | Covered |
| S12.14XB | ICD10CM | Covered |
| S12.150A | ICD10CM | Covered |
| S12.150B | ICD10CM | Covered |
| S12.151A | ICD10CM | Covered |
| S12.151B | ICD10CM | Covered |
| S12.190A | ICD10CM | Covered |
| S12.190B | ICD10CM | Covered |
| S12.191A | ICD10CM | Covered |
| S12.191B | ICD10CM | Covered |
| S12.200A | ICD10CM | Covered |
| S12.200B | ICD10CM | Covered |
| S12.201A | ICD10CM | Covered |
| S12.201B | ICD10CM | Covered |
| S12.230A | ICD10CM | Covered |
| S12.230B | ICD10CM | Covered |
| S12.231A | ICD10CM | Covered |
| S12.231B | ICD10CM | Covered |
| S12.24XA | ICD10CM | Covered |
| S12.24XB | ICD10CM | Covered |
| S12.250A | ICD10CM | Covered |
| S12.250B | ICD10CM | Covered |
| S12.251A | ICD10CM | Covered |
| S12.251B | ICD10CM | Covered |
| S12.290A | ICD10CM | Covered |
| S12.290B | ICD10CM | Covered |
| S12.291A | ICD10CM | Covered |
| S12.291B | ICD10CM | Covered |
| S12.300A | ICD10CM | Covered |
| S12.300B | ICD10CM | Covered |
| S12.301A | ICD10CM | Covered |
| S12.301B | ICD10CM | Covered |
| S12.330A | ICD10CM | Covered |
| S12.330B | ICD10CM | Covered |
| S12.331A | ICD10CM | Covered |
| S12.331B | ICD10CM | Covered |
| S12.34XA | ICD10CM | Covered |
| S12.34XB | ICD10CM | Covered |
| S12.350A | ICD10CM | Covered |
| S12.350B | ICD10CM | Covered |
| S12.351A | ICD10CM | Covered |
| S12.351B | ICD10CM | Covered |
| S12.390A | ICD10CM | Covered |
| S12.390B | ICD10CM | Covered |
| S12.391A | ICD10CM | Covered |
| S12.391B | ICD10CM | Covered |
| S12.400A | ICD10CM | Covered |
| S12.400B | ICD10CM | Covered |
| S12.401A | ICD10CM | Covered |
| S12.401B | ICD10CM | Covered |
| S12.430A | ICD10CM | Covered |
| S12.430B | ICD10CM | Covered |
| S12.431A | ICD10CM | Covered |
| S12.431B | ICD10CM | Covered |
| S12.44XA | ICD10CM | Covered |
| S12.44XB | ICD10CM | Covered |
| S12.450A | ICD10CM | Covered |
| S12.450B | ICD10CM | Covered |
| S12.451A | ICD10CM | Covered |
| S12.451B | ICD10CM | Covered |
| S12.490A | ICD10CM | Covered |
| S12.490B | ICD10CM | Covered |
| S12.491A | ICD10CM | Covered |
| S12.491B | ICD10CM | Covered |
| S12.500A | ICD10CM | Covered |
| S12.500B | ICD10CM | Covered |
| S12.501A | ICD10CM | Covered |
| S12.501B | ICD10CM | Covered |
| S12.530A | ICD10CM | Covered |
| S12.530B | ICD10CM | Covered |
| S12.531A | ICD10CM | Covered |
| S12.531B | ICD10CM | Covered |
| S12.54XA | ICD10CM | Covered |
| S12.54XB | ICD10CM | Covered |
| S12.550A | ICD10CM | Covered |
| S12.550B | ICD10CM | Covered |
| S12.551A | ICD10CM | Covered |
| S12.551B | ICD10CM | Covered |
| S12.590A | ICD10CM | Covered |
| S12.590B | ICD10CM | Covered |
| S12.591A | ICD10CM | Covered |
| S12.591B | ICD10CM | Covered |
| S12.600A | ICD10CM | Covered |
| S12.600B | ICD10CM | Covered |
| S12.601A | ICD10CM | Covered |
| S12.601B | ICD10CM | Covered |
| S12.630A | ICD10CM | Covered |
| S12.630B | ICD10CM | Covered |
| S12.631A | ICD10CM | Covered |
| S12.631B | ICD10CM | Covered |
| S12.64XA | ICD10CM | Covered |
| S12.64XB | ICD10CM | Covered |
| S12.650A | ICD10CM | Covered |
| S12.650B | ICD10CM | Covered |
| S12.651A | ICD10CM | Covered |
| S12.651B | ICD10CM | Covered |
| S12.690A | ICD10CM | Covered |
| S12.690B | ICD10CM | Covered |
| S12.691A | ICD10CM | Covered |
| S12.691B | ICD10CM | Covered |
| S12.9XXA | ICD10CM | Covered |
| S22.000A | ICD10CM | Covered |
| S22.000B | ICD10CM | Covered |
| S22.001A | ICD10CM | Covered |
| S22.001B | ICD10CM | Covered |
| S22.002A | ICD10CM | Covered |
| S22.002B | ICD10CM | Covered |
| S22.008A | ICD10CM | Covered |
| S22.008B | ICD10CM | Covered |
| S22.009A | ICD10CM | Covered |
| S22.009B | ICD10CM | Covered |
| S22.010A | ICD10CM | Covered |
| S22.010B | ICD10CM | Covered |
| S22.011A | ICD10CM | Covered |
| S22.011B | ICD10CM | Covered |
| S22.018A | ICD10CM | Covered |
| S22.018B | ICD10CM | Covered |
| S22.019A | ICD10CM | Covered |
| S22.019B | ICD10CM | Covered |
| S22.020A | ICD10CM | Covered |
| S22.020B | ICD10CM | Covered |
| S22.021A | ICD10CM | Covered |
| S22.021B | ICD10CM | Covered |
| S22.022A | ICD10CM | Covered |
| S22.022B | ICD10CM | Covered |
| S22.028A | ICD10CM | Covered |
| S22.028B | ICD10CM | Covered |
| S22.029A | ICD10CM | Covered |
| S22.029B | ICD10CM | Covered |
| S22.030A | ICD10CM | Covered |
| S22.030B | ICD10CM | Covered |
| S22.031A | ICD10CM | Covered |
| S22.031B | ICD10CM | Covered |
| S22.032A | ICD10CM | Covered |
| S22.032B | ICD10CM | Covered |
| S22.038A | ICD10CM | Covered |
| S22.038B | ICD10CM | Covered |
| S22.039A | ICD10CM | Covered |
| S22.039B | ICD10CM | Covered |
| S22.040A | ICD10CM | Covered |
| S22.040B | ICD10CM | Covered |
| S22.041A | ICD10CM | Covered |
| S22.041B | ICD10CM | Covered |
| S22.042A | ICD10CM | Covered |
| S22.042B | ICD10CM | Covered |
| S22.048A | ICD10CM | Covered |
| S22.048B | ICD10CM | Covered |
| S22.049A | ICD10CM | Covered |
| S22.049B | ICD10CM | Covered |
| S22.050A | ICD10CM | Covered |
| S22.050B | ICD10CM | Covered |
| S22.051A | ICD10CM | Covered |
| S22.051B | ICD10CM | Covered |
| S22.052A | ICD10CM | Covered |
| S22.052B | ICD10CM | Covered |
| S22.058A | ICD10CM | Covered |
| S22.058B | ICD10CM | Covered |
| S22.059A | ICD10CM | Covered |
| S22.059B | ICD10CM | Covered |
| S22.060A | ICD10CM | Covered |
| S22.060B | ICD10CM | Covered |
| S22.061A | ICD10CM | Covered |
| S22.061B | ICD10CM | Covered |
| S22.062A | ICD10CM | Covered |
| S22.062B | ICD10CM | Covered |
| S22.068A | ICD10CM | Covered |
| S22.068B | ICD10CM | Covered |
| S22.069A | ICD10CM | Covered |
| S22.069B | ICD10CM | Covered |
| S22.070A | ICD10CM | Covered |
| S22.070B | ICD10CM | Covered |
| S22.071A | ICD10CM | Covered |
| S22.071B | ICD10CM | Covered |
| S22.072A | ICD10CM | Covered |
| S22.072B | ICD10CM | Covered |
| S22.078A | ICD10CM | Covered |
| S22.078B | ICD10CM | Covered |
| S22.079A | ICD10CM | Covered |
| S22.079B | ICD10CM | Covered |
| S22.080A | ICD10CM | Covered |
| S22.080B | ICD10CM | Covered |
| S22.081A | ICD10CM | Covered |
| S22.081B | ICD10CM | Covered |
| S22.082A | ICD10CM | Covered |
| S22.082B | ICD10CM | Covered |
| S22.088A | ICD10CM | Covered |
| S22.088B | ICD10CM | Covered |
| S22.089A | ICD10CM | Covered |
| S22.089B | ICD10CM | Covered |
| S32.000A | ICD10CM | Covered |
| S32.000B | ICD10CM | Covered |
| S32.001A | ICD10CM | Covered |
| S32.001B | ICD10CM | Covered |
| S32.002A | ICD10CM | Covered |
| S32.002B | ICD10CM | Covered |
| S32.008A | ICD10CM | Covered |
| S32.008B | ICD10CM | Covered |
| S32.009A | ICD10CM | Covered |
| S32.009B | ICD10CM | Covered |
| S32.010A | ICD10CM | Covered |
| S32.010B | ICD10CM | Covered |
| S32.011A | ICD10CM | Covered |
| S32.011B | ICD10CM | Covered |
| S32.012A | ICD10CM | Covered |
| S32.012B | ICD10CM | Covered |
| S32.018A | ICD10CM | Covered |
| S32.018B | ICD10CM | Covered |
| S32.019A | ICD10CM | Covered |
| S32.019B | ICD10CM | Covered |
| S32.020A | ICD10CM | Covered |
| S32.020B | ICD10CM | Covered |
| S32.021A | ICD10CM | Covered |
| S32.021B | ICD10CM | Covered |
| S32.022A | ICD10CM | Covered |
| S32.022B | ICD10CM | Covered |
| S32.028A | ICD10CM | Covered |
| S32.028B | ICD10CM | Covered |
| S32.029A | ICD10CM | Covered |
| S32.029B | ICD10CM | Covered |
| S32.030A | ICD10CM | Covered |
| S32.030B | ICD10CM | Covered |
| S32.031A | ICD10CM | Covered |
| S32.031B | ICD10CM | Covered |
| S32.032A | ICD10CM | Covered |
| S32.032B | ICD10CM | Covered |
| S32.038A | ICD10CM | Covered |
| S32.038B | ICD10CM | Covered |
| S32.039A | ICD10CM | Covered |
| S32.039B | ICD10CM | Covered |
| S32.040A | ICD10CM | Covered |
| S32.040B | ICD10CM | Covered |
| S32.041A | ICD10CM | Covered |
| S32.041B | ICD10CM | Covered |
| S32.042A | ICD10CM | Covered |
| S32.042B | ICD10CM | Covered |
| S32.048A | ICD10CM | Covered |
| S32.048B | ICD10CM | Covered |
| S32.049A | ICD10CM | Covered |
| S32.049B | ICD10CM | Covered |
| S32.050A | ICD10CM | Covered |
| S32.050B | ICD10CM | Covered |
| S32.051A | ICD10CM | Covered |
| S32.051B | ICD10CM | Covered |
| S32.052A | ICD10CM | Covered |
| S32.052B | ICD10CM | Covered |
| S32.058A | ICD10CM | Covered |
| S32.058B | ICD10CM | Covered |
| S32.059A | ICD10CM | Covered |
| S32.059B | ICD10CM | Covered |
| S32.10XA | ICD10CM | Covered |
| S32.10XB | ICD10CM | Covered |
| S32.110A | ICD10CM | Covered |
| S32.110B | ICD10CM | Covered |
| S32.111A | ICD10CM | Covered |
| S32.111B | ICD10CM | Covered |
| S32.112A | ICD10CM | Covered |
| S32.112B | ICD10CM | Covered |
| S32.119A | ICD10CM | Covered |
| S32.119B | ICD10CM | Covered |
| S32.120A | ICD10CM | Covered |
| S32.120B | ICD10CM | Covered |
| S32.121A | ICD10CM | Covered |
| S32.121B | ICD10CM | Covered |
| S32.122A | ICD10CM | Covered |
| S32.122B | ICD10CM | Covered |
| S32.129A | ICD10CM | Covered |
| S32.129B | ICD10CM | Covered |
| S32.130A | ICD10CM | Covered |
| S32.130B | ICD10CM | Covered |
| S32.131A | ICD10CM | Covered |
| S32.131B | ICD10CM | Covered |
| S32.139A | ICD10CM | Covered |
| S32.139B | ICD10CM | Covered |
| S32.14XA | ICD10CM | Covered |
| S32.14XB | ICD10CM | Covered |
| S32.15XA | ICD10CM | Covered |
| S32.15XB | ICD10CM | Covered |
| S32.16XA | ICD10CM | Covered |
| S32.16XB | ICD10CM | Covered |
| S32.17XA | ICD10CM | Covered |
| S32.17XB | ICD10CM | Covered |
| S32.19XA | ICD10CM | Covered |
| S32.19XB | ICD10CM | Covered |
| S32.2XXA | ICD10CM | Covered |
| S32.2XXB | ICD10CM | Covered |
| T38.0X5A | ICD10CM | Covered |
| T38.0X5S | ICD10CM | Covered |
| T50.0X5A | ICD10CM | Covered |
| T50.0X5S | ICD10CM | Covered |
| Z09 | ICD10CM | Covered |
| Z78.0 | ICD10CM | Covered |
| Z79.3 | ICD10CM | Covered |
| Z79.51 | ICD10CM | Covered |
| Z79.52 | ICD10CM | Covered |
| Z79.811 | ICD10CM | Covered |
| Z79.818 | ICD10CM | Covered |
| Z79.83 | ICD10CM | Covered |
| Z79.85 | ICD10CM | Covered |
| Z90.721 | ICD10CM | Covered |
| Z90.722 | ICD10CM | Covered |
| Z90.79 | ICD10CM | Covered |