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 |
|---|---|---|
| 31570 | HCPCS | Covered |
| 31573 | HCPCS | Covered |
| 43201 | HCPCS | Covered |
| 43236 | HCPCS | Covered |
| 46505 | HCPCS | Covered |
| 52287 | HCPCS | Covered |
| 64611 | HCPCS | Covered |
| 64612 | HCPCS | Covered |
| 64615 | HCPCS | Covered |
| 64616 | HCPCS | Covered |
| 64617 | HCPCS | Covered |
| 64642 | HCPCS | Covered |
| 64643 | HCPCS | Covered |
| 64644 | HCPCS | Covered |
| 64645 | HCPCS | Covered |
| 64646 | HCPCS | Covered |
| 64647 | HCPCS | Covered |
| 64650 | HCPCS | Covered |
| 64653 | HCPCS | Covered |
| 67345 | HCPCS | Covered |
| 76536 | HCPCS | Covered |
| 76881 | HCPCS | Covered |
| 76882 | HCPCS | Covered |
| 76942 | HCPCS | Covered |
| 95873 | HCPCS | Covered |
| 95874 | HCPCS | Covered |
| J0585 | HCPCS | Covered |
| J0586 | HCPCS | Covered |
| J0587 | HCPCS | Covered |
| J0588 | HCPCS | Covered |
| J0589 | HCPCS | Covered |
| G04.1 | ICD10CM | Covered |
| G11.4 | ICD10CM | Covered |
| G24.02 | ICD10CM | Covered |
| G24.09 | ICD10CM | Covered |
| G24.1 | ICD10CM | Covered |
| G24.2 | ICD10CM | Covered |
| G24.3 | ICD10CM | Covered |
| G24.4 | ICD10CM | Covered |
| G24.5 | ICD10CM | Covered |
| G24.8 | ICD10CM | Covered |
| G25.0 | ICD10CM | Covered |
| G25.1 | ICD10CM | Covered |
| G25.2 | ICD10CM | Covered |
| G25.61 | ICD10CM | Covered |
| G25.69 | ICD10CM | Covered |
| G25.89 | ICD10CM | Covered |
| G35.A | ICD10CM | Covered |
| G35.B0 | ICD10CM | Covered |
| G35.B1 | ICD10CM | Covered |
| G35.B2 | ICD10CM | Covered |
| G35.C0 | ICD10CM | Covered |
| G35.C1 | ICD10CM | Covered |
| G35.C2 | ICD10CM | Covered |
| G35.D | ICD10CM | Covered |
| G43.001 | ICD10CM | Covered |
| G43.009 | ICD10CM | Covered |
| G43.011 | ICD10CM | Covered |
| G43.019 | ICD10CM | Covered |
| G43.101 | ICD10CM | Covered |
| G43.109 | ICD10CM | Covered |
| G43.111 | ICD10CM | Covered |
| G43.119 | ICD10CM | Covered |
| G43.401 | ICD10CM | Covered |
| G43.409 | ICD10CM | Covered |
| G43.411 | ICD10CM | Covered |
| G43.419 | ICD10CM | Covered |
| G43.501 | ICD10CM | Covered |
| G43.509 | ICD10CM | Covered |
| G43.511 | ICD10CM | Covered |
| G43.519 | ICD10CM | Covered |
| G43.601 | ICD10CM | Covered |
| G43.609 | ICD10CM | Covered |
| G43.611 | ICD10CM | Covered |
| G43.619 | ICD10CM | Covered |
| G43.701 | ICD10CM | Covered |
| G43.709 | ICD10CM | Covered |
| G43.711 | ICD10CM | Covered |
| G43.719 | ICD10CM | Covered |
| G43.801 | ICD10CM | Covered |
| G43.809 | ICD10CM | Covered |
| G43.811 | ICD10CM | Covered |
| G43.819 | ICD10CM | Covered |
| G43.901 | ICD10CM | Covered |
| G43.909 | ICD10CM | Covered |
| G43.911 | ICD10CM | Covered |
| G43.919 | ICD10CM | Covered |
| G43.A0 | ICD10CM | Covered |
| G43.A1 | ICD10CM | Covered |
| G43.B0 | ICD10CM | Covered |
| G43.B1 | ICD10CM | Covered |
| G43.C0 | ICD10CM | Covered |
| G43.C1 | ICD10CM | Covered |
| G43.D0 | ICD10CM | Covered |
| G43.D1 | ICD10CM | Covered |
| G43.E01 | ICD10CM | Covered |
| G43.E09 | ICD10CM | Covered |
| G43.E11 | ICD10CM | Covered |
| G43.E19 | ICD10CM | Covered |
| G51.2 | ICD10CM | Covered |
| G51.31 | ICD10CM | Covered |
| G51.32 | ICD10CM | Covered |
| G51.33 | ICD10CM | Covered |
| G51.4 | ICD10CM | Covered |
| G51.8 | ICD10CM | Covered |
| G80.0 | ICD10CM | Covered |
| G80.1 | ICD10CM | Covered |
| G80.2 | ICD10CM | Covered |
| G80.3 | ICD10CM | Covered |
| G80.4 | ICD10CM | Covered |
| G80.8 | ICD10CM | Covered |
| G81.11 | ICD10CM | Covered |
| G81.12 | ICD10CM | Covered |
| G81.13 | ICD10CM | Covered |
| G81.14 | ICD10CM | Covered |
| G82.21 | ICD10CM | Covered |
| G82.22 | ICD10CM | Covered |
| G82.51 | ICD10CM | Covered |
| G82.52 | ICD10CM | Covered |
| G82.53 | ICD10CM | Covered |
| G82.54 | ICD10CM | Covered |
| G83.0 | ICD10CM | Covered |
| G83.11 | ICD10CM | Covered |
| G83.12 | ICD10CM | Covered |
| G83.13 | ICD10CM | Covered |
| G83.14 | ICD10CM | Covered |
| G83.21 | ICD10CM | Covered |
| G83.22 | ICD10CM | Covered |
| G83.23 | ICD10CM | Covered |
| G83.24 | ICD10CM | Covered |
| H02.041 | ICD10CM | Covered |
| H02.042 | ICD10CM | Covered |
| H02.044 | ICD10CM | Covered |
| H02.045 | ICD10CM | Covered |
| H02.141 | ICD10CM | Covered |
| H02.142 | ICD10CM | Covered |
| H02.144 | ICD10CM | Covered |
| H02.145 | ICD10CM | Covered |
| H49.01 | ICD10CM | Covered |
| H49.02 | ICD10CM | Covered |
| H49.03 | ICD10CM | Covered |
| H49.11 | ICD10CM | Covered |
| H49.12 | ICD10CM | Covered |
| H49.13 | ICD10CM | Covered |
| H49.21 | ICD10CM | Covered |
| H49.22 | ICD10CM | Covered |
| H49.23 | ICD10CM | Covered |
| H49.31 | ICD10CM | Covered |
| H49.32 | ICD10CM | Covered |
| H49.33 | ICD10CM | Covered |
| H49.41 | ICD10CM | Covered |
| H49.42 | ICD10CM | Covered |
| H49.43 | ICD10CM | Covered |
| H49.881 | ICD10CM | Covered |
| H49.882 | ICD10CM | Covered |
| H49.883 | ICD10CM | Covered |
| H49.9 | ICD10CM | Covered |
| H50.00 | ICD10CM | Covered |
| H50.011 | ICD10CM | Covered |
| H50.012 | ICD10CM | Covered |
| H50.021 | ICD10CM | Covered |
| H50.022 | ICD10CM | Covered |
| H50.031 | ICD10CM | Covered |
| H50.032 | ICD10CM | Covered |
| H50.041 | ICD10CM | Covered |
| H50.042 | ICD10CM | Covered |
| H50.05 | ICD10CM | Covered |
| H50.06 | ICD10CM | Covered |
| H50.07 | ICD10CM | Covered |
| H50.08 | ICD10CM | Covered |
| H50.10 | ICD10CM | Covered |
| H50.111 | ICD10CM | Covered |
| H50.112 | ICD10CM | Covered |
| H50.121 | ICD10CM | Covered |
| H50.122 | ICD10CM | Covered |
| H50.131 | ICD10CM | Covered |
| H50.132 | ICD10CM | Covered |
| H50.141 | ICD10CM | Covered |
| H50.142 | ICD10CM | Covered |
| H50.15 | ICD10CM | Covered |
| H50.16 | ICD10CM | Covered |
| H50.17 | ICD10CM | Covered |
| H50.18 | ICD10CM | Covered |
| H50.21 | ICD10CM | Covered |
| H50.22 | ICD10CM | Covered |
| H50.30 | ICD10CM | Covered |
| H50.311 | ICD10CM | Covered |
| H50.312 | ICD10CM | Covered |
| H50.32 | ICD10CM | Covered |
| H50.331 | ICD10CM | Covered |
| H50.332 | ICD10CM | Covered |
| H50.34 | ICD10CM | Covered |
| H50.40 | ICD10CM | Covered |
| H50.411 | ICD10CM | Covered |
| H50.412 | ICD10CM | Covered |
| H50.42 | ICD10CM | Covered |
| H50.43 | ICD10CM | Covered |
| H50.50 | ICD10CM | Covered |
| H50.51 | ICD10CM | Covered |
| H50.52 | ICD10CM | Covered |
| H50.53 | ICD10CM | Covered |
| H50.54 | ICD10CM | Covered |
| H50.55 | ICD10CM | Covered |
| H50.60 | ICD10CM | Covered |
| H50.611 | ICD10CM | Covered |
| H50.612 | ICD10CM | Covered |
| H50.621 | ICD10CM | Covered |
| H50.622 | ICD10CM | Covered |
| H50.631 | ICD10CM | Covered |
| H50.632 | ICD10CM | Covered |
| H50.641 | ICD10CM | Covered |
| H50.642 | ICD10CM | Covered |
| H50.651 | ICD10CM | Covered |
| H50.652 | ICD10CM | Covered |
| H50.661 | ICD10CM | Covered |
| H50.662 | ICD10CM | Covered |
| H50.671 | ICD10CM | Covered |
| H50.672 | ICD10CM | Covered |
| H50.681 | ICD10CM | Covered |
| H50.682 | ICD10CM | Covered |
| H50.69 | ICD10CM | Covered |
| H50.811 | ICD10CM | Covered |
| H50.812 | ICD10CM | Covered |
| H50.89 | ICD10CM | Covered |
| H50.9 | ICD10CM | Covered |
| H51.0 | ICD10CM | Covered |
| H51.11 | ICD10CM | Covered |
| H51.12 | ICD10CM | Covered |
| H51.21 | ICD10CM | Covered |
| H51.22 | ICD10CM | Covered |
| H51.23 | ICD10CM | Covered |
| H51.8 | ICD10CM | Covered |
| I69.031 | ICD10CM | Covered |
| I69.032 | ICD10CM | Covered |
| I69.033 | ICD10CM | Covered |
| I69.034 | ICD10CM | Covered |
| I69.041 | ICD10CM | Covered |
| I69.042 | ICD10CM | Covered |
| I69.043 | ICD10CM | Covered |
| I69.044 | ICD10CM | Covered |
| I69.051 | ICD10CM | Covered |
| I69.052 | ICD10CM | Covered |
| I69.053 | ICD10CM | Covered |
| I69.054 | ICD10CM | Covered |
| I69.131 | ICD10CM | Covered |
| I69.132 | ICD10CM | Covered |
| I69.133 | ICD10CM | Covered |
| I69.134 | ICD10CM | Covered |
| I69.141 | ICD10CM | Covered |
| I69.142 | ICD10CM | Covered |
| I69.143 | ICD10CM | Covered |
| I69.144 | ICD10CM | Covered |
| I69.151 | ICD10CM | Covered |
| I69.152 | ICD10CM | Covered |
| I69.153 | ICD10CM | Covered |
| I69.154 | ICD10CM | Covered |
| I69.231 | ICD10CM | Covered |
| I69.232 | ICD10CM | Covered |
| I69.233 | ICD10CM | Covered |
| I69.234 | ICD10CM | Covered |
| I69.241 | ICD10CM | Covered |
| I69.242 | ICD10CM | Covered |
| I69.243 | ICD10CM | Covered |
| I69.244 | ICD10CM | Covered |
| I69.251 | ICD10CM | Covered |
| I69.252 | ICD10CM | Covered |
| I69.253 | ICD10CM | Covered |
| I69.254 | ICD10CM | Covered |
| I69.331 | ICD10CM | Covered |
| I69.332 | ICD10CM | Covered |
| I69.333 | ICD10CM | Covered |
| I69.334 | ICD10CM | Covered |
| I69.341 | ICD10CM | Covered |
| I69.342 | ICD10CM | Covered |
| I69.343 | ICD10CM | Covered |
| I69.344 | ICD10CM | Covered |
| I69.351 | ICD10CM | Covered |
| I69.352 | ICD10CM | Covered |
| I69.353 | ICD10CM | Covered |
| I69.354 | ICD10CM | Covered |
| I69.831 | ICD10CM | Covered |
| I69.832 | ICD10CM | Covered |
| I69.833 | ICD10CM | Covered |
| I69.834 | ICD10CM | Covered |
| I69.841 | ICD10CM | Covered |
| I69.842 | ICD10CM | Covered |
| I69.843 | ICD10CM | Covered |
| I69.844 | ICD10CM | Covered |
| I69.851 | ICD10CM | Covered |
| I69.852 | ICD10CM | Covered |
| I69.853 | ICD10CM | Covered |
| I69.854 | ICD10CM | Covered |
| I69.931 | ICD10CM | Covered |
| I69.932 | ICD10CM | Covered |
| I69.933 | ICD10CM | Covered |
| I69.934 | ICD10CM | Covered |
| I69.941 | ICD10CM | Covered |
| I69.942 | ICD10CM | Covered |
| I69.943 | ICD10CM | Covered |
| I69.944 | ICD10CM | Covered |
| I69.951 | ICD10CM | Covered |
| I69.952 | ICD10CM | Covered |
| I69.953 | ICD10CM | Covered |
| I69.954 | ICD10CM | Covered |
| J38.01 | ICD10CM | Covered |
| J38.02 | ICD10CM | Covered |
| J38.5 | ICD10CM | Covered |
| K11.7 | ICD10CM | Covered |
| K22.0 | ICD10CM | Covered |
| K60.0 | ICD10CM | Covered |
| K60.1 | ICD10CM | Covered |
| K60.2 | ICD10CM | Covered |
| K60.30 | ICD10CM | Covered |
| K60.311 | ICD10CM | Covered |
| K60.312 | ICD10CM | Covered |
| K60.313 | ICD10CM | Covered |
| K60.319 | ICD10CM | Covered |
| K60.321 | ICD10CM | Covered |
| K60.322 | ICD10CM | Covered |
| K60.323 | ICD10CM | Covered |
| K60.329 | ICD10CM | Covered |
| K60.40 | ICD10CM | Covered |
| K60.411 | ICD10CM | Covered |
| K60.412 | ICD10CM | Covered |
| K60.413 | ICD10CM | Covered |
| K60.419 | ICD10CM | Covered |
| K60.421 | ICD10CM | Covered |
| K60.422 | ICD10CM | Covered |
| K60.423 | ICD10CM | Covered |
| K60.429 | ICD10CM | Covered |
| K60.50 | ICD10CM | Covered |
| K60.511 | ICD10CM | Covered |
| K60.512 | ICD10CM | Covered |
| K60.513 | ICD10CM | Covered |
| K60.519 | ICD10CM | Covered |
| K60.521 | ICD10CM | Covered |
| K60.522 | ICD10CM | Covered |
| K60.523 | ICD10CM | Covered |
| K60.529 | ICD10CM | Covered |
| L74.510 | ICD10CM | Covered |
| L74.511 | ICD10CM | Covered |
| L74.512 | ICD10CM | Covered |
| L74.513 | ICD10CM | Covered |
| L74.519 | ICD10CM | Covered |
| L74.52 | ICD10CM | Covered |
| L74.8 | ICD10CM | Covered |
| L74.9 | ICD10CM | Covered |
| M43.6 | ICD10CM | Covered |
| M47.812 | ICD10CM | Covered |
| M47.892 | ICD10CM | Covered |
| M54.2 | ICD10CM | Covered |
| N30.10 | ICD10CM | Covered |
| N30.11 | ICD10CM | Covered |
| N31.1 | ICD10CM | Covered |
| N31.2 | ICD10CM | Covered |
| N31.8 | ICD10CM | Covered |
| N31.9 | ICD10CM | Covered |
| N32.81 | ICD10CM | Covered |
| N39.41 | ICD10CM | Covered |
| N39.42 | ICD10CM | Covered |
| N39.43 | ICD10CM | Covered |
| N39.44 | ICD10CM | Covered |
| N39.45 | ICD10CM | Covered |
| N39.46 | ICD10CM | Covered |
| N39.490 | ICD10CM | Covered |
| N39.491 | ICD10CM | Covered |
| N39.492 | ICD10CM | Covered |
| N39.498 | ICD10CM | Covered |
| Q68.0 | ICD10CM | Covered |
| R39.89 | ICD10CM | Covered |
| R49.0 | ICD10CM | Covered |
| R49.8 | ICD10CM | Covered |