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 |
|---|---|---|
| 93312 | HCPCS | Covered |
| 93313 | HCPCS | Covered |
| 93314 | HCPCS | Covered |
| 93315 | HCPCS | Covered |
| 93316 | HCPCS | Covered |
| 93317 | HCPCS | Covered |
| 93318 | HCPCS | Covered |
| 93355 | HCPCS | Covered |
| C8925 | HCPCS | Covered |
| C8926 | HCPCS | Covered |
| C8927 | HCPCS | Covered |
| A18.84 | ICD10CM | Covered |
| B95.61 | ICD10CM | Covered |
| B95.62 | ICD10CM | Covered |
| B95.7 | ICD10CM | Covered |
| B95.8 | ICD10CM | Covered |
| C38.0 | ICD10CM | Covered |
| C45.2 | ICD10CM | Covered |
| D15.1 | ICD10CM | Covered |
| E66.01 | ICD10CM | Covered |
| E66.09 | ICD10CM | Covered |
| E66.1 | ICD10CM | Covered |
| E66.2 | ICD10CM | Covered |
| E66.3 | ICD10CM | Covered |
| E66.811 | ICD10CM | Covered |
| E66.812 | ICD10CM | Covered |
| E66.813 | ICD10CM | Covered |
| E66.89 | ICD10CM | Covered |
| E66.9 | ICD10CM | Covered |
| I01.0 | ICD10CM | Covered |
| I01.1 | ICD10CM | Covered |
| I01.2 | ICD10CM | Covered |
| I01.8 | ICD10CM | Covered |
| I01.9 | ICD10CM | Covered |
| I05.0 | ICD10CM | Covered |
| I05.1 | ICD10CM | Covered |
| I05.2 | ICD10CM | Covered |
| I05.8 | ICD10CM | Covered |
| I05.9 | ICD10CM | Covered |
| I06.0 | ICD10CM | Covered |
| I06.1 | ICD10CM | Covered |
| I06.2 | ICD10CM | Covered |
| I06.8 | ICD10CM | Covered |
| I06.9 | ICD10CM | Covered |
| I07.0 | ICD10CM | Covered |
| I07.1 | ICD10CM | Covered |
| I07.2 | ICD10CM | Covered |
| I07.8 | ICD10CM | Covered |
| I07.9 | ICD10CM | Covered |
| I08.0 | ICD10CM | Covered |
| I08.1 | ICD10CM | Covered |
| I08.2 | ICD10CM | Covered |
| I08.3 | ICD10CM | Covered |
| I08.8 | ICD10CM | Covered |
| I08.9 | ICD10CM | Covered |
| I09.0 | ICD10CM | Covered |
| I09.1 | ICD10CM | Covered |
| I09.89 | ICD10CM | Covered |
| I20.0 | ICD10CM | Covered |
| I21.01 | ICD10CM | Covered |
| I21.02 | ICD10CM | Covered |
| I21.09 | ICD10CM | Covered |
| I21.11 | ICD10CM | Covered |
| I21.19 | ICD10CM | Covered |
| I21.21 | ICD10CM | Covered |
| I21.29 | ICD10CM | Covered |
| I21.3 | ICD10CM | Covered |
| I21.4 | ICD10CM | Covered |
| I21.9 | ICD10CM | Covered |
| I21.A1 | ICD10CM | Covered |
| I21.A9 | ICD10CM | Covered |
| I22.0 | ICD10CM | Covered |
| I22.1 | ICD10CM | Covered |
| I22.2 | ICD10CM | Covered |
| I22.8 | ICD10CM | Covered |
| I22.9 | ICD10CM | Covered |
| I23.1 | ICD10CM | Covered |
| I23.2 | ICD10CM | Covered |
| I23.4 | ICD10CM | Covered |
| I23.5 | ICD10CM | Covered |
| I24.0 | ICD10CM | Covered |
| I24.1 | ICD10CM | Covered |
| I24.89 | ICD10CM | Covered |
| I24.9 | ICD10CM | Covered |
| I25.10 | ICD10CM | Covered |
| I25.110 | ICD10CM | Covered |
| I25.111 | ICD10CM | Covered |
| I25.118 | ICD10CM | Covered |
| I25.119 | ICD10CM | Covered |
| I25.700 | ICD10CM | Covered |
| I25.701 | ICD10CM | Covered |
| I25.708 | ICD10CM | Covered |
| I25.709 | ICD10CM | Covered |
| I25.710 | ICD10CM | Covered |
| I25.711 | ICD10CM | Covered |
| I25.718 | ICD10CM | Covered |
| I25.719 | ICD10CM | Covered |
| I25.720 | ICD10CM | Covered |
| I25.721 | ICD10CM | Covered |
| I25.728 | ICD10CM | Covered |
| I25.729 | ICD10CM | Covered |
| I25.730 | ICD10CM | Covered |
| I25.731 | ICD10CM | Covered |
| I25.738 | ICD10CM | Covered |
| I25.739 | ICD10CM | Covered |
| I25.750 | ICD10CM | Covered |
| I25.751 | ICD10CM | Covered |
| I25.758 | ICD10CM | Covered |
| I25.759 | ICD10CM | Covered |
| I25.760 | ICD10CM | Covered |
| I25.761 | ICD10CM | Covered |
| I25.768 | ICD10CM | Covered |
| I25.769 | ICD10CM | Covered |
| I25.790 | ICD10CM | Covered |
| I25.791 | ICD10CM | Covered |
| I25.798 | ICD10CM | Covered |
| I25.799 | ICD10CM | Covered |
| I25.810 | ICD10CM | Covered |
| I25.811 | ICD10CM | Covered |
| I25.812 | ICD10CM | Covered |
| I25.84 | ICD10CM | Covered |
| I26.01 | ICD10CM | Covered |
| I26.02 | ICD10CM | Covered |
| I26.03 | ICD10CM | Covered |
| I26.04 | ICD10CM | Covered |
| I26.09 | ICD10CM | Covered |
| I26.90 | ICD10CM | Covered |
| I26.92 | ICD10CM | Covered |
| I26.93 | ICD10CM | Covered |
| I26.94 | ICD10CM | Covered |
| I26.95 | ICD10CM | Covered |
| I26.96 | ICD10CM | Covered |
| I26.99 | ICD10CM | Covered |
| I31.0 | ICD10CM | Covered |
| I31.1 | ICD10CM | Covered |
| I31.2 | ICD10CM | Covered |
| I31.31 | ICD10CM | Covered |
| I31.39 | ICD10CM | Covered |
| I31.4 | ICD10CM | Covered |
| I31.8 | ICD10CM | Covered |
| I31.9 | ICD10CM | Covered |
| I33.0 | ICD10CM | Covered |
| I33.9 | ICD10CM | Covered |
| I34.0 | ICD10CM | Covered |
| I34.1 | ICD10CM | Covered |
| I34.2 | ICD10CM | Covered |
| I34.81 | ICD10CM | Covered |
| I34.89 | ICD10CM | Covered |
| I34.9 | ICD10CM | Covered |
| I35.0 | ICD10CM | Covered |
| I35.1 | ICD10CM | Covered |
| I35.2 | ICD10CM | Covered |
| I35.8 | ICD10CM | Covered |
| I35.9 | ICD10CM | Covered |
| I36.0 | ICD10CM | Covered |
| I36.1 | ICD10CM | Covered |
| I36.2 | ICD10CM | Covered |
| I36.8 | ICD10CM | Covered |
| I36.9 | ICD10CM | Covered |
| I37.0 | ICD10CM | Covered |
| I37.1 | ICD10CM | Covered |
| I37.2 | ICD10CM | Covered |
| I37.8 | ICD10CM | Covered |
| I37.9 | ICD10CM | Covered |
| I38 | ICD10CM | Covered |
| I39 | ICD10CM | Covered |
| I42.0 | ICD10CM | Covered |
| I42.1 | ICD10CM | Covered |
| I42.2 | ICD10CM | Covered |
| I42.3 | ICD10CM | Covered |
| I42.4 | ICD10CM | Covered |
| I42.5 | ICD10CM | Covered |
| I42.6 | ICD10CM | Covered |
| I42.7 | ICD10CM | Covered |
| I42.8 | ICD10CM | Covered |
| I42.9 | ICD10CM | Covered |
| I43 | ICD10CM | Covered |
| I48.0 | ICD10CM | Covered |
| I48.11 | ICD10CM | Covered |
| I48.19 | ICD10CM | Covered |
| I48.20 | ICD10CM | Covered |
| I48.21 | ICD10CM | Covered |
| I48.3 | ICD10CM | Covered |
| I48.4 | ICD10CM | Covered |
| I48.91 | ICD10CM | Covered |
| I48.92 | ICD10CM | Covered |
| I51.0 | ICD10CM | Covered |
| I51.1 | ICD10CM | Covered |
| I51.2 | ICD10CM | Covered |
| I51.3 | ICD10CM | Covered |
| I63.40 | ICD10CM | Covered |
| I63.411 | ICD10CM | Covered |
| I63.412 | ICD10CM | Covered |
| I63.413 | ICD10CM | Covered |
| I63.419 | ICD10CM | Covered |
| I63.421 | ICD10CM | Covered |
| I63.422 | ICD10CM | Covered |
| I63.423 | ICD10CM | Covered |
| I63.429 | ICD10CM | Covered |
| I63.431 | ICD10CM | Covered |
| I63.432 | ICD10CM | Covered |
| I63.433 | ICD10CM | Covered |
| I63.439 | ICD10CM | Covered |
| I63.441 | ICD10CM | Covered |
| I63.442 | ICD10CM | Covered |
| I63.443 | ICD10CM | Covered |
| I63.449 | ICD10CM | Covered |
| I63.49 | ICD10CM | Covered |
| I66.01 | ICD10CM | Covered |
| I66.02 | ICD10CM | Covered |
| I66.03 | ICD10CM | Covered |
| I66.09 | ICD10CM | Covered |
| I66.11 | ICD10CM | Covered |
| I66.12 | ICD10CM | Covered |
| I66.13 | ICD10CM | Covered |
| I66.19 | ICD10CM | Covered |
| I66.21 | ICD10CM | Covered |
| I66.22 | ICD10CM | Covered |
| I66.23 | ICD10CM | Covered |
| I66.29 | ICD10CM | Covered |
| I66.3 | ICD10CM | Covered |
| I66.8 | ICD10CM | Covered |
| I66.9 | ICD10CM | Covered |
| I71.00 | ICD10CM | Covered |
| I71.010 | ICD10CM | Covered |
| I71.011 | ICD10CM | Covered |
| I71.012 | ICD10CM | Covered |
| I71.019 | ICD10CM | Covered |
| I71.02 | ICD10CM | Covered |
| I71.03 | ICD10CM | Covered |
| I74.01 | ICD10CM | Covered |
| I74.09 | ICD10CM | Covered |
| I74.10 | ICD10CM | Covered |
| I74.11 | ICD10CM | Covered |
| I74.19 | ICD10CM | Covered |
| I74.2 | ICD10CM | Covered |
| I74.3 | ICD10CM | Covered |
| I74.4 | ICD10CM | Covered |
| I74.5 | ICD10CM | Covered |
| I74.8 | ICD10CM | Covered |
| I74.9 | ICD10CM | Covered |
| I82.220 | ICD10CM | Covered |
| I82.221 | ICD10CM | Covered |
| I95.9 | ICD10CM | Covered |
| I97.0 | ICD10CM | Covered |
| J44.9 | ICD10CM | Covered |
| M32.11 | ICD10CM | Covered |
| M95.4 | ICD10CM | Covered |
| M99.82 | ICD10CM | Covered |
| M99.88 | ICD10CM | Covered |
| Q20.0 | ICD10CM | Covered |
| Q20.1 | ICD10CM | Covered |
| Q20.2 | ICD10CM | Covered |
| Q20.3 | ICD10CM | Covered |
| Q20.4 | ICD10CM | Covered |
| Q20.5 | ICD10CM | Covered |
| Q20.6 | ICD10CM | Covered |
| Q20.8 | ICD10CM | Covered |
| Q20.9 | ICD10CM | Covered |
| Q21.0 | ICD10CM | Covered |
| Q21.10 | ICD10CM | Covered |
| Q21.11 | ICD10CM | Covered |
| Q21.12 | ICD10CM | Covered |
| Q21.19 | ICD10CM | Covered |
| Q21.20 | ICD10CM | Covered |
| Q21.21 | ICD10CM | Covered |
| Q21.22 | ICD10CM | Covered |
| Q21.23 | ICD10CM | Covered |
| Q21.3 | ICD10CM | Covered |
| Q21.4 | ICD10CM | Covered |
| Q21.8 | ICD10CM | Covered |
| Q21.9 | ICD10CM | Covered |
| Q22.0 | ICD10CM | Covered |
| Q22.1 | ICD10CM | Covered |
| Q22.2 | ICD10CM | Covered |
| Q22.3 | ICD10CM | Covered |
| Q22.4 | ICD10CM | Covered |
| Q22.5 | ICD10CM | Covered |
| Q22.6 | ICD10CM | Covered |
| Q22.8 | ICD10CM | Covered |
| Q22.9 | ICD10CM | Covered |
| Q23.0 | ICD10CM | Covered |
| Q23.1 | ICD10CM | Covered |
| Q23.2 | ICD10CM | Covered |
| Q23.3 | ICD10CM | Covered |
| Q23.4 | ICD10CM | Covered |
| Q23.81 | ICD10CM | Covered |
| Q23.82 | ICD10CM | Covered |
| Q23.88 | ICD10CM | Covered |
| Q23.9 | ICD10CM | Covered |
| Q24.0 | ICD10CM | Covered |
| Q24.1 | ICD10CM | Covered |
| Q24.2 | ICD10CM | Covered |
| Q24.3 | ICD10CM | Covered |
| Q24.4 | ICD10CM | Covered |
| Q24.5 | ICD10CM | Covered |
| Q24.6 | ICD10CM | Covered |
| Q24.8 | ICD10CM | Covered |
| Q24.9 | ICD10CM | Covered |
| Q25.0 | ICD10CM | Covered |
| Q25.1 | ICD10CM | Covered |
| Q25.21 | ICD10CM | Covered |
| Q25.29 | ICD10CM | Covered |
| Q25.5 | ICD10CM | Covered |
| Q25.6 | ICD10CM | Covered |
| Q25.71 | ICD10CM | Covered |
| Q25.72 | ICD10CM | Covered |
| Q25.79 | ICD10CM | Covered |
| Q67.6 | ICD10CM | Covered |
| Q67.7 | ICD10CM | Covered |
| Q67.8 | ICD10CM | Covered |
| R57.0 | ICD10CM | Covered |
| R57.1 | ICD10CM | Covered |
| R57.8 | ICD10CM | Covered |
| R57.9 | ICD10CM | Covered |
| R65.21 | ICD10CM | Covered |
| R78.81 | ICD10CM | Covered |
| S21.309A | ICD10CM | Covered |
| S21.309D | ICD10CM | Covered |
| S21.309S | ICD10CM | Covered |
| S26.00XA | ICD10CM | Covered |
| S26.00XD | ICD10CM | Covered |
| S26.00XS | ICD10CM | Covered |
| S26.01XA | ICD10CM | Covered |
| S26.01XD | ICD10CM | Covered |
| S26.01XS | ICD10CM | Covered |
| S26.020A | ICD10CM | Covered |
| S26.020D | ICD10CM | Covered |
| S26.020S | ICD10CM | Covered |
| S26.021A | ICD10CM | Covered |
| S26.021D | ICD10CM | Covered |
| S26.021S | ICD10CM | Covered |
| S26.022A | ICD10CM | Covered |
| S26.022D | ICD10CM | Covered |
| S26.022S | ICD10CM | Covered |
| S26.09XA | ICD10CM | Covered |
| S26.09XD | ICD10CM | Covered |
| S26.09XS | ICD10CM | Covered |
| S26.10XA | ICD10CM | Covered |
| S26.10XD | ICD10CM | Covered |
| S26.10XS | ICD10CM | Covered |
| S26.11XA | ICD10CM | Covered |
| S26.11XD | ICD10CM | Covered |
| S26.11XS | ICD10CM | Covered |
| S26.12XA | ICD10CM | Covered |
| S26.12XD | ICD10CM | Covered |
| S26.12XS | ICD10CM | Covered |
| S26.19XA | ICD10CM | Covered |
| S26.19XD | ICD10CM | Covered |
| S26.19XS | ICD10CM | Covered |
| S26.90XA | ICD10CM | Covered |
| S26.90XD | ICD10CM | Covered |
| S26.90XS | ICD10CM | Covered |
| S26.91XA | ICD10CM | Covered |
| S26.91XD | ICD10CM | Covered |
| S26.91XS | ICD10CM | Covered |
| S26.92XA | ICD10CM | Covered |
| S26.92XD | ICD10CM | Covered |
| S26.92XS | ICD10CM | Covered |
| S26.99XA | ICD10CM | Covered |
| S26.99XD | ICD10CM | Covered |
| S26.99XS | ICD10CM | Covered |
| T80.0XXA | ICD10CM | Covered |
| T80.0XXD | ICD10CM | Covered |
| T80.0XXS | ICD10CM | Covered |
| T81.718A | ICD10CM | Covered |
| T81.718D | ICD10CM | Covered |
| T81.718S | ICD10CM | Covered |
| T81.72XA | ICD10CM | Covered |
| T81.72XD | ICD10CM | Covered |
| T81.72XS | ICD10CM | Covered |
| T82.01XA | ICD10CM | Covered |
| T82.01XD | ICD10CM | Covered |
| T82.01XS | ICD10CM | Covered |
| T82.02XA | ICD10CM | Covered |
| T82.02XD | ICD10CM | Covered |
| T82.02XS | ICD10CM | Covered |
| T82.03XA | ICD10CM | Covered |
| T82.03XD | ICD10CM | Covered |
| T82.03XS | ICD10CM | Covered |
| T82.09XA | ICD10CM | Covered |
| T82.09XD | ICD10CM | Covered |
| T82.09XS | ICD10CM | Covered |
| T82.211A | ICD10CM | Covered |
| T82.211D | ICD10CM | Covered |
| T82.211S | ICD10CM | Covered |
| T82.212A | ICD10CM | Covered |
| T82.212D | ICD10CM | Covered |
| T82.212S | ICD10CM | Covered |
| T82.213A | ICD10CM | Covered |
| T82.213D | ICD10CM | Covered |
| T82.213S | ICD10CM | Covered |
| T82.218A | ICD10CM | Covered |
| T82.218D | ICD10CM | Covered |
| T82.218S | ICD10CM | Covered |
| T82.6XXA | ICD10CM | Covered |
| T82.6XXD | ICD10CM | Covered |
| T82.6XXS | ICD10CM | Covered |
| T82.7XXA | ICD10CM | Covered |
| T82.7XXD | ICD10CM | Covered |
| T82.7XXS | ICD10CM | Covered |
| T82.817A | ICD10CM | Covered |
| T82.817D | ICD10CM | Covered |
| T82.817S | ICD10CM | Covered |
| T82.827A | ICD10CM | Covered |
| T82.827D | ICD10CM | Covered |
| T82.827S | ICD10CM | Covered |
| T82.837A | ICD10CM | Covered |
| T82.837D | ICD10CM | Covered |
| T82.837S | ICD10CM | Covered |
| T82.847A | ICD10CM | Covered |
| T82.847D | ICD10CM | Covered |
| T82.847S | ICD10CM | Covered |
| T82.857A | ICD10CM | Covered |
| T82.857D | ICD10CM | Covered |
| T82.857S | ICD10CM | Covered |
| T82.867A | ICD10CM | Covered |
| T82.867D | ICD10CM | Covered |
| T82.867S | ICD10CM | Covered |
| T82.897A | ICD10CM | Covered |
| T82.897D | ICD10CM | Covered |
| T82.897S | ICD10CM | Covered |
| T82.9XXA | ICD10CM | Covered |
| T82.9XXD | ICD10CM | Covered |
| T82.9XXS | ICD10CM | Covered |
| Z48.21 | ICD10CM | Covered |
| Z48.280 | ICD10CM | Covered |
| Z94.1 | ICD10CM | Covered |
| Z94.3 | ICD10CM | Covered |
| Z95.2 | ICD10CM | Covered |
| Z95.3 | ICD10CM | Covered |
| Z95.4 | ICD10CM | Covered |