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 |
|---|---|---|
| 43644 | HCPCS | Covered |
| 43645 | HCPCS | Covered |
| 43770 | HCPCS | Covered |
| 43775 | HCPCS | Covered |
| 43845 | HCPCS | Covered |
| 43846 | HCPCS | Covered |
| 43847 | HCPCS | Covered |
| A18.84 | ICD10CM | Covered |
| E11.00 | ICD10CM | Covered |
| E11.01 | ICD10CM | Covered |
| E11.10 | ICD10CM | Covered |
| E11.11 | ICD10CM | Covered |
| E11.21 | ICD10CM | Covered |
| E11.22 | ICD10CM | Covered |
| E11.29 | ICD10CM | Covered |
| E11.311 | ICD10CM | Covered |
| E11.319 | ICD10CM | Covered |
| E11.3211 | ICD10CM | Covered |
| E11.3212 | ICD10CM | Covered |
| E11.3213 | ICD10CM | Covered |
| E11.3219 | ICD10CM | Covered |
| E11.3291 | ICD10CM | Covered |
| E11.3292 | ICD10CM | Covered |
| E11.3293 | ICD10CM | Covered |
| E11.3299 | ICD10CM | Covered |
| E11.3311 | ICD10CM | Covered |
| E11.3312 | ICD10CM | Covered |
| E11.3313 | ICD10CM | Covered |
| E11.3319 | ICD10CM | Covered |
| E11.3391 | ICD10CM | Covered |
| E11.3392 | ICD10CM | Covered |
| E11.3393 | ICD10CM | Covered |
| E11.3399 | ICD10CM | Covered |
| E11.3411 | ICD10CM | Covered |
| E11.3412 | ICD10CM | Covered |
| E11.3413 | ICD10CM | Covered |
| E11.3419 | ICD10CM | Covered |
| E11.3491 | ICD10CM | Covered |
| E11.3492 | ICD10CM | Covered |
| E11.3493 | ICD10CM | Covered |
| E11.3499 | ICD10CM | Covered |
| E11.3511 | ICD10CM | Covered |
| E11.3512 | ICD10CM | Covered |
| E11.3513 | ICD10CM | Covered |
| E11.3519 | ICD10CM | Covered |
| E11.3521 | ICD10CM | Covered |
| E11.3522 | ICD10CM | Covered |
| E11.3523 | ICD10CM | Covered |
| E11.3529 | ICD10CM | Covered |
| E11.3531 | ICD10CM | Covered |
| E11.3532 | ICD10CM | Covered |
| E11.3533 | ICD10CM | Covered |
| E11.3539 | ICD10CM | Covered |
| E11.3541 | ICD10CM | Covered |
| E11.3542 | ICD10CM | Covered |
| E11.3543 | ICD10CM | Covered |
| E11.3549 | ICD10CM | Covered |
| E11.3551 | ICD10CM | Covered |
| E11.3552 | ICD10CM | Covered |
| E11.3553 | ICD10CM | Covered |
| E11.3559 | ICD10CM | Covered |
| E11.3591 | ICD10CM | Covered |
| E11.3592 | ICD10CM | Covered |
| E11.3593 | ICD10CM | Covered |
| E11.3599 | ICD10CM | Covered |
| E11.36 | ICD10CM | Covered |
| E11.37X1 | ICD10CM | Covered |
| E11.37X2 | ICD10CM | Covered |
| E11.37X3 | ICD10CM | Covered |
| E11.37X9 | ICD10CM | Covered |
| E11.39 | ICD10CM | Covered |
| E11.40 | ICD10CM | Covered |
| E11.41 | ICD10CM | Covered |
| E11.42 | ICD10CM | Covered |
| E11.43 | ICD10CM | Covered |
| E11.44 | ICD10CM | Covered |
| E11.49 | ICD10CM | Covered |
| E11.51 | ICD10CM | Covered |
| E11.52 | ICD10CM | Covered |
| E11.59 | ICD10CM | Covered |
| E11.610 | ICD10CM | Covered |
| E11.618 | ICD10CM | Covered |
| E11.620 | ICD10CM | Covered |
| E11.621 | ICD10CM | Covered |
| E11.622 | ICD10CM | Covered |
| E11.628 | ICD10CM | Covered |
| E11.630 | ICD10CM | Covered |
| E11.638 | ICD10CM | Covered |
| E11.641 | ICD10CM | Covered |
| E11.649 | ICD10CM | Covered |
| E11.65 | ICD10CM | Covered |
| E11.69 | ICD10CM | Covered |
| E11.8 | ICD10CM | Covered |
| E11.9 | ICD10CM | Covered |
| E13.00 | ICD10CM | Covered |
| E13.01 | ICD10CM | Covered |
| E13.10 | ICD10CM | Covered |
| E13.11 | ICD10CM | Covered |
| E13.21 | ICD10CM | Covered |
| E13.22 | ICD10CM | Covered |
| E13.29 | ICD10CM | Covered |
| E13.311 | ICD10CM | Covered |
| E13.319 | ICD10CM | Covered |
| E13.3211 | ICD10CM | Covered |
| E13.3212 | ICD10CM | Covered |
| E13.3213 | ICD10CM | Covered |
| E13.3219 | ICD10CM | Covered |
| E13.3291 | ICD10CM | Covered |
| E13.3292 | ICD10CM | Covered |
| E13.3293 | ICD10CM | Covered |
| E13.3299 | ICD10CM | Covered |
| E13.3311 | ICD10CM | Covered |
| E13.3312 | ICD10CM | Covered |
| E13.3313 | ICD10CM | Covered |
| E13.3319 | ICD10CM | Covered |
| E13.3391 | ICD10CM | Covered |
| E13.3392 | ICD10CM | Covered |
| E13.3393 | ICD10CM | Covered |
| E13.3399 | ICD10CM | Covered |
| E13.3411 | ICD10CM | Covered |
| E13.3412 | ICD10CM | Covered |
| E13.3413 | ICD10CM | Covered |
| E13.3419 | ICD10CM | Covered |
| E13.3491 | ICD10CM | Covered |
| E13.3492 | ICD10CM | Covered |
| E13.3493 | ICD10CM | Covered |
| E13.3499 | ICD10CM | Covered |
| E13.3511 | ICD10CM | Covered |
| E13.3512 | ICD10CM | Covered |
| E13.3513 | ICD10CM | Covered |
| E13.3519 | ICD10CM | Covered |
| E13.3521 | ICD10CM | Covered |
| E13.3522 | ICD10CM | Covered |
| E13.3523 | ICD10CM | Covered |
| E13.3529 | ICD10CM | Covered |
| E13.3531 | ICD10CM | Covered |
| E13.3532 | ICD10CM | Covered |
| E13.3533 | ICD10CM | Covered |
| E13.3539 | ICD10CM | Covered |
| E13.3541 | ICD10CM | Covered |
| E13.3542 | ICD10CM | Covered |
| E13.3543 | ICD10CM | Covered |
| E13.3549 | ICD10CM | Covered |
| E13.3551 | ICD10CM | Covered |
| E13.3552 | ICD10CM | Covered |
| E13.3553 | ICD10CM | Covered |
| E13.3559 | ICD10CM | Covered |
| E13.3591 | ICD10CM | Covered |
| E13.3592 | ICD10CM | Covered |
| E13.3593 | ICD10CM | Covered |
| E13.3599 | ICD10CM | Covered |
| E13.36 | ICD10CM | Covered |
| E13.37X1 | ICD10CM | Covered |
| E13.37X2 | ICD10CM | Covered |
| E13.37X3 | ICD10CM | Covered |
| E13.37X9 | ICD10CM | Covered |
| E13.39 | ICD10CM | Covered |
| E13.40 | ICD10CM | Covered |
| E13.41 | ICD10CM | Covered |
| E13.42 | ICD10CM | Covered |
| E13.43 | ICD10CM | Covered |
| E13.44 | ICD10CM | Covered |
| E13.49 | ICD10CM | Covered |
| E13.51 | ICD10CM | Covered |
| E13.52 | ICD10CM | Covered |
| E13.59 | ICD10CM | Covered |
| E13.610 | ICD10CM | Covered |
| E13.618 | ICD10CM | Covered |
| E13.620 | ICD10CM | Covered |
| E13.621 | ICD10CM | Covered |
| E13.622 | ICD10CM | Covered |
| E13.628 | ICD10CM | Covered |
| E13.630 | ICD10CM | Covered |
| E13.638 | ICD10CM | Covered |
| E13.641 | ICD10CM | Covered |
| E13.649 | ICD10CM | Covered |
| E13.65 | ICD10CM | Covered |
| E13.69 | ICD10CM | Covered |
| E13.8 | ICD10CM | Covered |
| E13.9 | ICD10CM | Covered |
| E66.01 | ICD10CM | Covered |
| E66.2 | ICD10CM | Covered |
| E66.812 | ICD10CM | Covered |
| E66.813 | ICD10CM | Covered |
| E78.00 | ICD10CM | Covered |
| E78.010 | ICD10CM | Covered |
| E78.011 | ICD10CM | Covered |
| E78.1 | ICD10CM | Covered |
| E78.2 | ICD10CM | Covered |
| E78.3 | ICD10CM | Covered |
| E78.41 | ICD10CM | Covered |
| E78.49 | ICD10CM | Covered |
| E78.5 | ICD10CM | Covered |
| G47.33 | ICD10CM | Covered |
| G47.36 | ICD10CM | Covered |
| G93.2 | ICD10CM | Covered |
| I10 | ICD10CM | Covered |
| I1A.0 | ICD10CM | Covered |
| I27.21 | ICD10CM | Covered |
| I27.22 | ICD10CM | Covered |
| I27.23 | ICD10CM | Covered |
| I27.24 | ICD10CM | Covered |
| I27.29 | ICD10CM | Covered |
| I27.83 | ICD10CM | Covered |
| I27.89 | ICD10CM | Covered |
| I43 | ICD10CM | Covered |
| K21.00 | ICD10CM | Covered |
| K21.01 | ICD10CM | Covered |
| K75.81 | ICD10CM | Covered |
| K76.0 | ICD10CM | Covered |
| K76.89 | ICD10CM | Covered |
| M15.3 | ICD10CM | Covered |
| M15.8 | ICD10CM | Covered |
| M16.0 | ICD10CM | Covered |
| M16.10 | ICD10CM | Covered |
| M16.11 | ICD10CM | Covered |
| M16.12 | ICD10CM | Covered |
| M16.2 | ICD10CM | Covered |
| M16.30 | ICD10CM | Covered |
| M16.31 | ICD10CM | Covered |
| M16.32 | ICD10CM | Covered |
| M16.4 | ICD10CM | Covered |
| M16.50 | ICD10CM | Covered |
| M16.51 | ICD10CM | Covered |
| M16.52 | ICD10CM | Covered |
| M16.6 | ICD10CM | Covered |
| M16.7 | ICD10CM | Covered |
| M16.9 | ICD10CM | Covered |
| M17.0 | ICD10CM | Covered |
| M17.10 | ICD10CM | Covered |
| M17.11 | ICD10CM | Covered |
| M17.12 | ICD10CM | Covered |
| M17.2 | ICD10CM | Covered |
| M17.30 | ICD10CM | Covered |
| M17.31 | ICD10CM | Covered |
| M17.32 | ICD10CM | Covered |
| M17.4 | ICD10CM | Covered |
| M17.5 | ICD10CM | Covered |
| M17.9 | ICD10CM | Covered |
| M19.071 | ICD10CM | Covered |
| M19.072 | ICD10CM | Covered |
| M19.079 | ICD10CM | Covered |
| M19.171 | ICD10CM | Covered |
| M19.172 | ICD10CM | Covered |
| M19.179 | ICD10CM | Covered |
| M19.271 | ICD10CM | Covered |
| M19.272 | ICD10CM | Covered |
| M19.279 | ICD10CM | Covered |
| M19.90 | ICD10CM | Covered |
| M48.061 | ICD10CM | Covered |
| M48.062 | ICD10CM | Covered |
| M48.07 | ICD10CM | Covered |
| M51.06 | ICD10CM | Covered |
| M51.360 | ICD10CM | Covered |
| M51.361 | ICD10CM | Covered |
| M51.362 | ICD10CM | Covered |
| M51.369 | ICD10CM | Covered |
| M51.370 | ICD10CM | Covered |
| M51.371 | ICD10CM | Covered |
| M51.372 | ICD10CM | Covered |
| M51.379 | ICD10CM | Covered |
| M99.23 | ICD10CM | Covered |
| M99.33 | ICD10CM | Covered |
| M99.43 | ICD10CM | Covered |
| M99.53 | ICD10CM | Covered |
| M99.63 | ICD10CM | Covered |
| M99.73 | ICD10CM | Covered |
| Z68.35 | ICD10CM | Covered |
| Z68.36 | ICD10CM | Covered |
| Z68.37 | ICD10CM | Covered |
| Z68.38 | ICD10CM | Covered |
| Z68.39 | ICD10CM | Covered |
| Z68.41 | ICD10CM | Covered |
| Z68.42 | ICD10CM | Covered |
| Z68.43 | ICD10CM | Covered |
| Z68.44 | ICD10CM | Covered |
| Z68.45 | ICD10CM | Covered |