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 |
| 17110 | HCPCS | Covered |
| 17111 | HCPCS | Covered |
| A63.0 | ICD10CM | Covered |
| B07.0 | ICD10CM | Covered |
| B07.8 | ICD10CM | Covered |
| B07.9 | ICD10CM | Covered |
| B08.1 | ICD10CM | Covered |
| B78.1 | ICD10CM | Covered |
| C44.00 | ICD10CM | Covered |
| C44.01 | ICD10CM | Covered |
| C44.02 | ICD10CM | Covered |
| C44.09 | ICD10CM | Covered |
| C44.101 | 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 |
| C44.291 | ICD10CM | Covered |
| C44.292 | ICD10CM | Covered |
| C44.299 | ICD10CM | Covered |
| C44.300 | ICD10CM | Covered |
| C44.301 | ICD10CM | Covered |
| C44.309 | ICD10CM | Covered |
| C44.310 | ICD10CM | Covered |
| C44.311 | ICD10CM | Covered |
| C44.319 | ICD10CM | Covered |
| C44.320 | ICD10CM | Covered |
| C44.321 | ICD10CM | Covered |
| C44.329 | ICD10CM | Covered |
| C44.390 | 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 |
| C44.601 | 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 |
| C44.691 | ICD10CM | Covered |
| C44.692 | ICD10CM | Covered |
| C44.699 | ICD10CM | Covered |
| C44.701 | 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 |
| C44.791 | 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 |
| C44.90 | ICD10CM | Covered |
| C44.91 | ICD10CM | Covered |
| C44.92 | ICD10CM | Covered |
| C44.99 | ICD10CM | Covered |
| C4A.0 | ICD10CM | Covered |
| C4A.111 | ICD10CM | Covered |
| C4A.112 | ICD10CM | Covered |
| C4A.121 | ICD10CM | Covered |
| C4A.122 | ICD10CM | Covered |
| C4A.21 | ICD10CM | Covered |
| C4A.22 | ICD10CM | Covered |
| C4A.31 | ICD10CM | Covered |
| C4A.39 | ICD10CM | Covered |
| C4A.4 | ICD10CM | Covered |
| C4A.51 | ICD10CM | Covered |
| C4A.52 | ICD10CM | Covered |
| C4A.59 | ICD10CM | Covered |
| C4A.61 | ICD10CM | Covered |
| C4A.62 | ICD10CM | Covered |
| C4A.71 | ICD10CM | Covered |
| C4A.72 | ICD10CM | Covered |
| C4A.8 | ICD10CM | Covered |
| C4A.9 | 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 |
| C60.9 | 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 |
| 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 |
| D04.30 | 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 |
| D04.9 | ICD10CM | Covered |
| D10.0 | 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 |
| D18.01 | 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 |
| D22.9 | 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 |
| D23.70 | ICD10CM | Covered |
| D23.71 | ICD10CM | Covered |
| D23.72 | ICD10CM | Covered |
| D23.9 | ICD10CM | Covered |
| D28.0 | ICD10CM | Covered |
| D29.0 | ICD10CM | Covered |
| D29.4 | ICD10CM | Covered |
| D48.5 | ICD10CM | Covered |
| D49.2 | ICD10CM | Covered |
| D49.511 | ICD10CM | Covered |
| D49.512 | ICD10CM | Covered |
| D49.519 | ICD10CM | Covered |
| D49.59 | ICD10CM | Covered |
| D86.3 | ICD10CM | Covered |
| D86.89 | ICD10CM | Covered |
| D86.9 | ICD10CM | Covered |
| E83.2 | 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 |
| H61.009 | 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 |
| I78.1 | ICD10CM | Covered |
| K12.2 | ICD10CM | Covered |
| K64.4 | ICD10CM | Covered |
| L02.01 | ICD10CM | Covered |
| L02.11 | ICD10CM | Covered |
| L02.211 | ICD10CM | Covered |
| L02.212 | ICD10CM | Covered |
| L02.213 | ICD10CM | Covered |
| L02.214 | ICD10CM | Covered |
| L02.215 | ICD10CM | Covered |
| L02.216 | ICD10CM | Covered |
| L02.31 | ICD10CM | Covered |
| L02.411 | ICD10CM | Covered |
| L02.412 | ICD10CM | Covered |
| L02.413 | ICD10CM | Covered |
| L02.414 | ICD10CM | Covered |
| L02.415 | ICD10CM | Covered |
| L02.416 | ICD10CM | Covered |
| L02.511 | ICD10CM | Covered |
| L02.512 | ICD10CM | Covered |
| L02.611 | ICD10CM | Covered |
| L02.612 | ICD10CM | Covered |
| L02.811 | ICD10CM | Covered |
| L02.818 | ICD10CM | Covered |
| L03.111 | ICD10CM | Covered |
| L03.112 | ICD10CM | Covered |
| L03.113 | ICD10CM | Covered |
| L03.114 | ICD10CM | Covered |
| L03.115 | ICD10CM | Covered |
| L03.116 | ICD10CM | Covered |
| L03.121 | ICD10CM | Covered |
| L03.122 | ICD10CM | Covered |
| L03.123 | ICD10CM | Covered |
| L03.124 | ICD10CM | Covered |
| L03.125 | ICD10CM | Covered |
| L03.126 | ICD10CM | Covered |
| L03.211 | ICD10CM | Covered |
| L03.212 | ICD10CM | Covered |
| L03.221 | ICD10CM | Covered |
| L03.222 | ICD10CM | Covered |
| L03.311 | ICD10CM | Covered |
| L03.312 | ICD10CM | Covered |
| L03.313 | ICD10CM | Covered |
| L03.314 | ICD10CM | Covered |
| L03.315 | ICD10CM | Covered |
| L03.316 | ICD10CM | Covered |
| L03.317 | ICD10CM | Covered |
| L03.321 | ICD10CM | Covered |
| L03.322 | ICD10CM | Covered |
| L03.323 | ICD10CM | Covered |
| L03.324 | ICD10CM | Covered |
| L03.325 | ICD10CM | Covered |
| L03.326 | ICD10CM | Covered |
| L03.327 | ICD10CM | Covered |
| L03.811 | ICD10CM | Covered |
| L03.818 | ICD10CM | Covered |
| L03.891 | ICD10CM | Covered |
| L03.898 | ICD10CM | Covered |
| L08.82 | ICD10CM | Covered |
| L08.89 | ICD10CM | Covered |
| L08.9 | ICD10CM | Covered |
| L11.0 | ICD10CM | Covered |
| L12.30 | ICD10CM | Covered |
| L12.31 | ICD10CM | Covered |
| L12.8 | ICD10CM | Covered |
| L26 | ICD10CM | Covered |
| L28.0 | ICD10CM | Covered |
| L28.1 | ICD10CM | Covered |
| L29.9 | ICD10CM | Covered |
| L30.4 | ICD10CM | Covered |
| L53.8 | ICD10CM | Covered |
| L53.9 | ICD10CM | Covered |
| L54 | ICD10CM | Covered |
| L56.5 | 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 |
| L82.0 | ICD10CM | Covered |
| L82.1 | ICD10CM | Covered |
| L85.0 | ICD10CM | Covered |
| L85.1 | ICD10CM | Covered |
| L85.2 | ICD10CM | Covered |
| L85.8 | ICD10CM | Covered |
| L85.9 | ICD10CM | Covered |
| L86 | ICD10CM | Covered |
| L87.0 | ICD10CM | Covered |
| L87.2 | ICD10CM | Covered |
| L87.9 | ICD10CM | Covered |
| L90.5 | ICD10CM | Covered |
| L90.9 | ICD10CM | Covered |
| L91.0 | ICD10CM | Covered |
| L91.8 | ICD10CM | Covered |
| L91.9 | ICD10CM | Covered |
| L92.0 | ICD10CM | Covered |
| L92.8 | ICD10CM | Covered |
| L94.9 | ICD10CM | Covered |
| L95.1 | ICD10CM | Covered |
| L98.0 | ICD10CM | Covered |
| L98.2 | ICD10CM | Covered |
| L98.3 | ICD10CM | Covered |
| Q17.0 | ICD10CM | Covered |
| Q81.0 | ICD10CM | Covered |
| Q81.1 | ICD10CM | Covered |
| Q81.2 | ICD10CM | Covered |
| Q81.8 | ICD10CM | Covered |
| Q81.9 | ICD10CM | Covered |
| Q82.8 | ICD10CM | Covered |
| R20.0 | ICD10CM | Covered |
| R20.1 | ICD10CM | Covered |
| R20.2 | ICD10CM | Covered |
| R20.3 | ICD10CM | Covered |
| R20.8 | ICD10CM | Covered |
| R58 | ICD10CM | Covered |