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 |
|---|---|---|
| 76872 | HCPCS | Covered |
| 76873 | HCPCS | Covered |
| A18.14 | ICD10CM | Covered |
| C19 | ICD10CM | Covered |
| C20 | ICD10CM | Covered |
| C21.1 | ICD10CM | Covered |
| C21.2 | ICD10CM | Covered |
| C21.8 | ICD10CM | Covered |
| C45.1 | ICD10CM | Covered |
| C48.0 | ICD10CM | Covered |
| C48.1 | ICD10CM | Covered |
| C48.8 | ICD10CM | Covered |
| C61 | ICD10CM | Covered |
| C67.0 | ICD10CM | Covered |
| C67.1 | ICD10CM | Covered |
| C67.2 | ICD10CM | Covered |
| C67.3 | ICD10CM | Covered |
| C67.4 | ICD10CM | Covered |
| C67.5 | ICD10CM | Covered |
| C67.8 | ICD10CM | Covered |
| C78.5 | ICD10CM | Covered |
| C79.51 | ICD10CM | Covered |
| C79.52 | ICD10CM | Covered |
| C79.82 | ICD10CM | Covered |
| D01.1 | ICD10CM | Covered |
| D01.2 | ICD10CM | Covered |
| D01.3 | ICD10CM | Covered |
| D07.5 | ICD10CM | Covered |
| D12.7 | ICD10CM | Covered |
| D12.8 | ICD10CM | Covered |
| D12.9 | ICD10CM | Covered |
| D29.1 | ICD10CM | Covered |
| D37.1 | ICD10CM | Covered |
| D37.2 | ICD10CM | Covered |
| D37.3 | ICD10CM | Covered |
| D37.4 | ICD10CM | Covered |
| D37.5 | ICD10CM | Covered |
| D40.0 | ICD10CM | Covered |
| K50.014 | ICD10CM | Covered |
| K50.114 | ICD10CM | Covered |
| K50.814 | ICD10CM | Covered |
| K60.311 | ICD10CM | Covered |
| K60.312 | ICD10CM | Covered |
| K60.313 | ICD10CM | Covered |
| K60.321 | ICD10CM | Covered |
| K60.322 | ICD10CM | Covered |
| K60.323 | ICD10CM | Covered |
| K60.411 | ICD10CM | Covered |
| K60.412 | ICD10CM | Covered |
| K60.413 | ICD10CM | Covered |
| K60.421 | ICD10CM | Covered |
| K60.422 | ICD10CM | Covered |
| K60.423 | ICD10CM | Covered |
| K60.511 | ICD10CM | Covered |
| K60.512 | ICD10CM | Covered |
| K60.513 | ICD10CM | Covered |
| K60.521 | ICD10CM | Covered |
| K60.522 | ICD10CM | Covered |
| K60.523 | ICD10CM | Covered |
| K61.0 | ICD10CM | Covered |
| K61.1 | ICD10CM | Covered |
| K61.2 | ICD10CM | Covered |
| K61.31 | ICD10CM | Covered |
| K61.39 | ICD10CM | Covered |
| K61.4 | ICD10CM | Covered |
| K62.0 | ICD10CM | Covered |
| K62.1 | ICD10CM | Covered |
| K62.5 | ICD10CM | Covered |
| K62.7 | ICD10CM | Covered |
| K62.82 | ICD10CM | Covered |
| K62.89 | ICD10CM | Covered |
| N40.0 | ICD10CM | Covered |
| N40.1 | ICD10CM | Covered |
| N40.2 | ICD10CM | Covered |
| N40.3 | ICD10CM | Covered |
| N41.0 | ICD10CM | Covered |
| N41.1 | ICD10CM | Covered |
| N41.2 | ICD10CM | Covered |
| N41.3 | ICD10CM | Covered |
| N41.4 | ICD10CM | Covered |
| N41.8 | ICD10CM | Covered |
| N42.30 | ICD10CM | Covered |
| N42.31 | ICD10CM | Covered |
| N42.32 | ICD10CM | Covered |
| N42.39 | ICD10CM | Covered |
| N42.81 | ICD10CM | Covered |
| N42.82 | ICD10CM | Covered |
| N42.83 | ICD10CM | Covered |
| N42.89 | ICD10CM | Covered |
| N46.01 | ICD10CM | Covered |
| N46.021 | ICD10CM | Covered |
| N46.022 | ICD10CM | Covered |
| N46.023 | ICD10CM | Covered |
| N46.024 | ICD10CM | Covered |
| N46.025 | ICD10CM | Covered |
| N46.029 | ICD10CM | Covered |
| N46.11 | ICD10CM | Covered |
| N46.121 | ICD10CM | Covered |
| N46.122 | ICD10CM | Covered |
| N46.123 | ICD10CM | Covered |
| N46.124 | ICD10CM | Covered |
| N46.125 | ICD10CM | Covered |
| N46.129 | ICD10CM | Covered |
| N46.8 | ICD10CM | Covered |
| N50.1 | ICD10CM | Covered |
| N53.11 | ICD10CM | Covered |
| N53.13 | ICD10CM | Covered |
| N53.14 | ICD10CM | Covered |
| N53.19 | ICD10CM | Covered |
| R15.0 | ICD10CM | Covered |
| R15.1 | ICD10CM | Covered |
| R15.2 | ICD10CM | Covered |
| R15.9 | ICD10CM | Covered |
| R36.1 | ICD10CM | Covered |
| R97.20 | ICD10CM | Covered |
| R97.21 | ICD10CM | Covered |
| Z03.89 | ICD10CM | Covered |
| Z12.12 | ICD10CM | Covered |
| Z85.048 | ICD10CM | Covered |
| Z85.46 | ICD10CM | Covered |