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 |
|---|---|---|
| 44388 | HCPCS | Covered |
| 44389 | HCPCS | Covered |
| 44390 | HCPCS | Covered |
| 44391 | HCPCS | Covered |
| 44392 | HCPCS | Covered |
| 44394 | HCPCS | Covered |
| 44401 | HCPCS | Covered |
| 44402 | HCPCS | Covered |
| 44404 | HCPCS | Covered |
| 44405 | HCPCS | Covered |
| 44406 | HCPCS | Covered |
| 44407 | HCPCS | Covered |
| 45378 | HCPCS | Covered |
| 45379 | HCPCS | Covered |
| 45380 | HCPCS | Covered |
| 45381 | HCPCS | Covered |
| 45382 | HCPCS | Covered |
| 45384 | HCPCS | Covered |
| 45385 | HCPCS | Covered |
| 45386 | HCPCS | Covered |
| 45388 | HCPCS | Covered |
| 45389 | HCPCS | Covered |
| 45390 | HCPCS | Covered |
| 45391 | HCPCS | Covered |
| 45392 | HCPCS | Covered |
| 45393 | HCPCS | Covered |
| A04.3 | ICD10CM | Covered |
| A04.5 | ICD10CM | Covered |
| A04.71 | ICD10CM | Covered |
| A04.72 | ICD10CM | Covered |
| A06.0 | ICD10CM | Covered |
| A06.1 | ICD10CM | Covered |
| A06.2 | ICD10CM | Covered |
| A06.9 | ICD10CM | Covered |
| A18.31 | ICD10CM | Covered |
| A18.32 | ICD10CM | Covered |
| A41.01 | ICD10CM | Covered |
| A41.02 | ICD10CM | Covered |
| A41.4 | ICD10CM | Covered |
| A41.50 | ICD10CM | Covered |
| A41.51 | ICD10CM | Covered |
| A41.52 | ICD10CM | Covered |
| A41.53 | ICD10CM | Covered |
| A41.54 | ICD10CM | Covered |
| A41.59 | ICD10CM | Covered |
| A41.81 | ICD10CM | Covered |
| A41.89 | ICD10CM | Covered |
| A42.7 | ICD10CM | Covered |
| C18.0 | ICD10CM | Covered |
| C18.1 | ICD10CM | Covered |
| C18.2 | ICD10CM | Covered |
| C18.3 | ICD10CM | Covered |
| C18.4 | ICD10CM | Covered |
| C18.5 | ICD10CM | Covered |
| C18.6 | ICD10CM | Covered |
| C18.7 | ICD10CM | Covered |
| C18.8 | ICD10CM | Covered |
| C19 | ICD10CM | Covered |
| C20 | ICD10CM | Covered |
| C21.0 | ICD10CM | Covered |
| C21.1 | ICD10CM | Covered |
| C21.2 | ICD10CM | Covered |
| C21.8 | ICD10CM | Covered |
| C45.1 | ICD10CM | Covered |
| C46.4 | ICD10CM | Covered |
| C48.1 | ICD10CM | Covered |
| C48.2 | ICD10CM | Covered |
| C48.8 | ICD10CM | Covered |
| C49.4 | ICD10CM | Covered |
| C49.A4 | ICD10CM | Covered |
| C49.A9 | ICD10CM | Covered |
| C76.2 | ICD10CM | Covered |
| C76.3 | ICD10CM | Covered |
| C78.5 | ICD10CM | Covered |
| C78.6 | ICD10CM | Covered |
| C78.7 | ICD10CM | Covered |
| C7A.020 | ICD10CM | Covered |
| C7A.021 | ICD10CM | Covered |
| C7A.022 | ICD10CM | Covered |
| C7A.023 | ICD10CM | Covered |
| C7A.024 | ICD10CM | Covered |
| C7A.025 | ICD10CM | Covered |
| C7A.026 | ICD10CM | Covered |
| C7A.029 | ICD10CM | Covered |
| C80.2 | ICD10CM | Covered |
| D01.0 | ICD10CM | Covered |
| D01.1 | ICD10CM | Covered |
| D01.2 | ICD10CM | Covered |
| D01.3 | ICD10CM | Covered |
| D12.0 | ICD10CM | Covered |
| D12.1 | ICD10CM | Covered |
| D12.2 | ICD10CM | Covered |
| D12.3 | ICD10CM | Covered |
| D12.4 | ICD10CM | Covered |
| D12.5 | ICD10CM | Covered |
| D12.6 | ICD10CM | Covered |
| D12.7 | ICD10CM | Covered |
| D12.8 | ICD10CM | Covered |
| D12.9 | ICD10CM | Covered |
| D37.3 | ICD10CM | Covered |
| D37.4 | ICD10CM | Covered |
| D37.5 | ICD10CM | Covered |
| D37.8 | ICD10CM | Covered |
| D3A.020 | ICD10CM | Covered |
| D3A.021 | ICD10CM | Covered |
| D3A.022 | ICD10CM | Covered |
| D3A.023 | ICD10CM | Covered |
| D3A.024 | ICD10CM | Covered |
| D3A.025 | ICD10CM | Covered |
| D3A.026 | ICD10CM | Covered |
| D3A.029 | ICD10CM | Covered |
| D50.0 | ICD10CM | Covered |
| D50.9 | ICD10CM | Covered |
| E34.00 | ICD10CM | Covered |
| E34.01 | ICD10CM | Covered |
| E34.09 | ICD10CM | Covered |
| E44.0 | ICD10CM | Covered |
| I33.0 | ICD10CM | Covered |
| I78.0 | ICD10CM | Covered |
| K50.00 | ICD10CM | Covered |
| K50.011 | ICD10CM | Covered |
| K50.012 | ICD10CM | Covered |
| K50.013 | ICD10CM | Covered |
| K50.014 | ICD10CM | Covered |
| K50.018 | ICD10CM | Covered |
| K50.10 | ICD10CM | Covered |
| K50.111 | ICD10CM | Covered |
| K50.112 | ICD10CM | Covered |
| K50.113 | ICD10CM | Covered |
| K50.114 | ICD10CM | Covered |
| K50.118 | ICD10CM | Covered |
| K50.80 | ICD10CM | Covered |
| K50.811 | ICD10CM | Covered |
| K50.812 | ICD10CM | Covered |
| K50.813 | ICD10CM | Covered |
| K50.814 | ICD10CM | Covered |
| K50.818 | ICD10CM | Covered |
| K51.00 | ICD10CM | Covered |
| K51.011 | ICD10CM | Covered |
| K51.012 | ICD10CM | Covered |
| K51.013 | ICD10CM | Covered |
| K51.014 | ICD10CM | Covered |
| K51.018 | ICD10CM | Covered |
| K51.20 | ICD10CM | Covered |
| K51.211 | ICD10CM | Covered |
| K51.212 | ICD10CM | Covered |
| K51.213 | ICD10CM | Covered |
| K51.214 | ICD10CM | Covered |
| K51.218 | ICD10CM | Covered |
| K51.30 | ICD10CM | Covered |
| K51.311 | ICD10CM | Covered |
| K51.312 | ICD10CM | Covered |
| K51.313 | ICD10CM | Covered |
| K51.314 | ICD10CM | Covered |
| K51.318 | ICD10CM | Covered |
| K51.40 | ICD10CM | Covered |
| K51.411 | ICD10CM | Covered |
| K51.412 | ICD10CM | Covered |
| K51.413 | ICD10CM | Covered |
| K51.414 | ICD10CM | Covered |
| K51.418 | ICD10CM | Covered |
| K51.50 | ICD10CM | Covered |
| K51.511 | ICD10CM | Covered |
| K51.512 | ICD10CM | Covered |
| K51.513 | ICD10CM | Covered |
| K51.514 | ICD10CM | Covered |
| K51.518 | ICD10CM | Covered |
| K51.80 | ICD10CM | Covered |
| K51.811 | ICD10CM | Covered |
| K51.812 | ICD10CM | Covered |
| K51.813 | ICD10CM | Covered |
| K51.814 | ICD10CM | Covered |
| K51.818 | ICD10CM | Covered |
| K52.0 | ICD10CM | Covered |
| K52.1 | ICD10CM | Covered |
| K52.21 | ICD10CM | Covered |
| K52.22 | ICD10CM | Covered |
| K52.29 | ICD10CM | Covered |
| K52.3 | ICD10CM | Covered |
| K52.81 | ICD10CM | Covered |
| K52.82 | ICD10CM | Covered |
| K52.831 | ICD10CM | Covered |
| K52.832 | ICD10CM | Covered |
| K52.838 | ICD10CM | Covered |
| K52.89 | ICD10CM | Covered |
| K55.031 | ICD10CM | Covered |
| K55.032 | ICD10CM | Covered |
| K55.039 | ICD10CM | Covered |
| K55.041 | ICD10CM | Covered |
| K55.1 | ICD10CM | Covered |
| K55.20 | ICD10CM | Covered |
| K55.21 | ICD10CM | Covered |
| K55.8 | ICD10CM | Covered |
| K56.0 | ICD10CM | Covered |
| K56.1 | ICD10CM | Covered |
| K56.2 | ICD10CM | Covered |
| K56.3 | ICD10CM | Covered |
| K56.41 | ICD10CM | Covered |
| K56.49 | ICD10CM | Covered |
| K56.50 | ICD10CM | Covered |
| K56.51 | ICD10CM | Covered |
| K56.52 | ICD10CM | Covered |
| K56.690 | ICD10CM | Covered |
| K56.691 | ICD10CM | Covered |
| K56.699 | ICD10CM | Covered |
| K57.20 | ICD10CM | Covered |
| K57.21 | ICD10CM | Covered |
| K57.30 | ICD10CM | Covered |
| K57.31 | ICD10CM | Covered |
| K57.32 | ICD10CM | Covered |
| K57.33 | ICD10CM | Covered |
| K57.40 | ICD10CM | Covered |
| K57.41 | ICD10CM | Covered |
| K57.50 | ICD10CM | Covered |
| K57.51 | ICD10CM | Covered |
| K57.52 | ICD10CM | Covered |
| K57.53 | ICD10CM | Covered |
| K59.1 | ICD10CM | Covered |
| K59.2 | ICD10CM | Covered |
| K59.81 | ICD10CM | Covered |
| K59.89 | ICD10CM | Covered |
| K62.0 | ICD10CM | Covered |
| K62.1 | ICD10CM | Covered |
| K62.2 | ICD10CM | Covered |
| K62.3 | ICD10CM | Covered |
| K62.4 | ICD10CM | Covered |
| K62.5 | ICD10CM | Covered |
| K62.6 | ICD10CM | Covered |
| K62.7 | ICD10CM | Covered |
| K62.81 | ICD10CM | Covered |
| K62.89 | ICD10CM | Covered |
| K63.1 | ICD10CM | Covered |
| K63.2 | ICD10CM | Covered |
| K63.3 | ICD10CM | Covered |
| K63.4 | ICD10CM | Covered |
| K63.5 | ICD10CM | Covered |
| K63.81 | ICD10CM | Covered |
| K63.89 | ICD10CM | Covered |
| K64.0 | ICD10CM | Covered |
| K64.1 | ICD10CM | Covered |
| K64.2 | ICD10CM | Covered |
| K64.3 | ICD10CM | Covered |
| K64.4 | ICD10CM | Covered |
| K64.5 | ICD10CM | Covered |
| K64.8 | ICD10CM | Covered |
| K64.9 | ICD10CM | Covered |
| K90.1 | ICD10CM | Covered |
| K91.89 | ICD10CM | Covered |
| K92.1 | ICD10CM | Covered |
| K92.2 | ICD10CM | Covered |
| K92.89 | ICD10CM | Covered |
| L83 | ICD10CM | Covered |
| Q42.8 | ICD10CM | Covered |
| Q85.81 | ICD10CM | Covered |
| Q85.82 | ICD10CM | Covered |
| Q85.83 | ICD10CM | Covered |
| Q85.89 | ICD10CM | Covered |
| R10.0 | ICD10CM | Covered |
| R10.11 | ICD10CM | Covered |
| R10.12 | ICD10CM | Covered |
| R10.13 | ICD10CM | Covered |
| R10.20 | ICD10CM | Covered |
| R10.21 | ICD10CM | Covered |
| R10.22 | ICD10CM | Covered |
| R10.23 | ICD10CM | Covered |
| R10.24 | ICD10CM | Covered |
| R10.31 | ICD10CM | Covered |
| R10.32 | ICD10CM | Covered |
| R10.33 | ICD10CM | Covered |
| R10.84 | ICD10CM | Covered |
| R11.13 | ICD10CM | Covered |
| R19.4 | ICD10CM | Covered |
| R19.5 | ICD10CM | Covered |
| R19.7 | ICD10CM | Covered |
| R19.8 | ICD10CM | Covered |
| R71.0 | ICD10CM | Covered |
| R93.3 | ICD10CM | Covered |
| T18.3XXA | ICD10CM | Covered |
| T18.3XXD | ICD10CM | Covered |
| T18.3XXS | ICD10CM | Covered |
| T18.4XXA | ICD10CM | Covered |
| T18.4XXD | ICD10CM | Covered |
| T18.4XXS | ICD10CM | Covered |
| Z85.020 | ICD10CM | Covered |
| Z85.030 | ICD10CM | Covered |
| Z85.038 | ICD10CM | Covered |
| Z85.040 | ICD10CM | Covered |
| Z85.048 | ICD10CM | Covered |
| Z85.05 | ICD10CM | Covered |
| Z85.060 | ICD10CM | Covered |
| Z85.110 | ICD10CM | Covered |
| Z85.230 | ICD10CM | Covered |
| Z85.520 | ICD10CM | Covered |
| Z85.821 | ICD10CM | Covered |
| Z86.004 | ICD10CM | Covered |
| Z86.0101 | ICD10CM | Covered |
| Z86.0102 | ICD10CM | Covered |
| Z86.0109 | ICD10CM | Covered |
| Z87.19 | ICD10CM | Covered |