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 |
|---|---|---|
| 92537 | HCPCS | Covered |
| 92538 | HCPCS | Covered |
| 92540 | HCPCS | Covered |
| 92541 | HCPCS | Covered |
| 92542 | HCPCS | Covered |
| 92544 | HCPCS | Covered |
| 92545 | HCPCS | Covered |
| 92546 | HCPCS | Covered |
| 92547 | HCPCS | Covered |
| 92550 | HCPCS | Covered |
| 92552 | HCPCS | Covered |
| 92553 | HCPCS | Covered |
| 92555 | HCPCS | Covered |
| 92556 | HCPCS | Covered |
| 92557 | HCPCS | Covered |
| 92562 | HCPCS | Covered |
| 92563 | HCPCS | Covered |
| 92565 | HCPCS | Covered |
| 92567 | HCPCS | Covered |
| 92568 | HCPCS | Covered |
| 92570 | HCPCS | Covered |
| 92571 | HCPCS | Covered |
| 92572 | HCPCS | Covered |
| 92575 | HCPCS | Covered |
| 92576 | HCPCS | Covered |
| 92577 | HCPCS | Covered |
| 92579 | HCPCS | Covered |
| 92582 | HCPCS | Covered |
| 92583 | HCPCS | Covered |
| 92584 | HCPCS | Covered |
| 92587 | HCPCS | Covered |
| 92588 | HCPCS | Covered |
| 92620 | HCPCS | Covered |
| 92621 | HCPCS | Covered |
| 92651 | HCPCS | Covered |
| 92652 | HCPCS | Covered |
| 92653 | HCPCS | Covered |
| C71.6 | ICD10CM | Covered |
| D33.1 | ICD10CM | Covered |
| D33.3 | ICD10CM | Covered |
| D43.1 | ICD10CM | Covered |
| F44.4 | ICD10CM | Covered |
| F44.6 | ICD10CM | Covered |
| F44.7 | ICD10CM | Covered |
| F44.9 | ICD10CM | Covered |
| F70 | ICD10CM | Covered |
| F71 | ICD10CM | Covered |
| F72 | ICD10CM | Covered |
| F73 | ICD10CM | Covered |
| F78.A9 | ICD10CM | Covered |
| F79 | ICD10CM | Covered |
| G10 | ICD10CM | Covered |
| G21.0 | ICD10CM | Covered |
| G23.0 | ICD10CM | Covered |
| G23.1 | ICD10CM | Covered |
| G23.2 | ICD10CM | Covered |
| G23.8 | ICD10CM | Covered |
| G23.9 | ICD10CM | Covered |
| G24.01 | 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 |
| G24.9 | ICD10CM | Covered |
| G25.0 | ICD10CM | Covered |
| G25.1 | ICD10CM | Covered |
| G25.2 | ICD10CM | Covered |
| G25.3 | ICD10CM | Covered |
| G25.4 | ICD10CM | Covered |
| G25.5 | ICD10CM | Covered |
| G25.61 | ICD10CM | Covered |
| G25.69 | ICD10CM | Covered |
| G25.70 | ICD10CM | Covered |
| G25.71 | ICD10CM | Covered |
| G25.79 | ICD10CM | Covered |
| G25.81 | ICD10CM | Covered |
| G25.82 | ICD10CM | Covered |
| G25.83 | ICD10CM | Covered |
| G25.89 | ICD10CM | Covered |
| G26 | 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 |
| G36.0 | ICD10CM | Covered |
| G36.1 | ICD10CM | Covered |
| G36.8 | ICD10CM | Covered |
| G37.0 | ICD10CM | Covered |
| G37.1 | ICD10CM | Covered |
| G37.2 | ICD10CM | Covered |
| G37.3 | ICD10CM | Covered |
| G37.4 | ICD10CM | Covered |
| G37.5 | ICD10CM | Covered |
| G37.89 | ICD10CM | Covered |
| G37.9 | ICD10CM | Covered |
| G80.3 | ICD10CM | Covered |
| G90.3 | ICD10CM | Covered |
| H46.00 | ICD10CM | Covered |
| H46.01 | ICD10CM | Covered |
| H46.02 | ICD10CM | Covered |
| H46.03 | ICD10CM | Covered |
| H46.10 | ICD10CM | Covered |
| H46.11 | ICD10CM | Covered |
| H46.12 | ICD10CM | Covered |
| H46.13 | ICD10CM | Covered |
| H46.2 | ICD10CM | Covered |
| H46.3 | ICD10CM | Covered |
| H46.8 | ICD10CM | Covered |
| H46.9 | ICD10CM | Covered |
| H65.01 | ICD10CM | Covered |
| H65.02 | ICD10CM | Covered |
| H65.03 | ICD10CM | Covered |
| H65.04 | ICD10CM | Covered |
| H65.05 | ICD10CM | Covered |
| H65.06 | ICD10CM | Covered |
| H65.111 | ICD10CM | Covered |
| H65.112 | ICD10CM | Covered |
| H65.113 | ICD10CM | Covered |
| H65.114 | ICD10CM | Covered |
| H65.115 | ICD10CM | Covered |
| H65.116 | ICD10CM | Covered |
| H65.191 | ICD10CM | Covered |
| H65.192 | ICD10CM | Covered |
| H65.193 | ICD10CM | Covered |
| H65.194 | ICD10CM | Covered |
| H65.195 | ICD10CM | Covered |
| H65.196 | ICD10CM | Covered |
| H65.21 | ICD10CM | Covered |
| H65.22 | ICD10CM | Covered |
| H65.23 | ICD10CM | Covered |
| H65.31 | ICD10CM | Covered |
| H65.32 | ICD10CM | Covered |
| H65.33 | ICD10CM | Covered |
| H65.411 | ICD10CM | Covered |
| H65.412 | ICD10CM | Covered |
| H65.413 | ICD10CM | Covered |
| H65.491 | ICD10CM | Covered |
| H65.492 | ICD10CM | Covered |
| H65.493 | ICD10CM | Covered |
| H65.91 | ICD10CM | Covered |
| H65.92 | ICD10CM | Covered |
| H65.93 | ICD10CM | Covered |
| H66.001 | ICD10CM | Covered |
| H66.002 | ICD10CM | Covered |
| H66.003 | ICD10CM | Covered |
| H66.004 | ICD10CM | Covered |
| H66.005 | ICD10CM | Covered |
| H66.006 | ICD10CM | Covered |
| H66.007 | ICD10CM | Covered |
| H66.011 | ICD10CM | Covered |
| H66.012 | ICD10CM | Covered |
| H66.013 | ICD10CM | Covered |
| H66.014 | ICD10CM | Covered |
| H66.015 | ICD10CM | Covered |
| H66.016 | ICD10CM | Covered |
| H66.11 | ICD10CM | Covered |
| H66.12 | ICD10CM | Covered |
| H66.13 | ICD10CM | Covered |
| H66.21 | ICD10CM | Covered |
| H66.22 | ICD10CM | Covered |
| H66.23 | ICD10CM | Covered |
| H66.3X1 | ICD10CM | Covered |
| H66.3X2 | ICD10CM | Covered |
| H66.3X3 | ICD10CM | Covered |
| H66.41 | ICD10CM | Covered |
| H66.42 | ICD10CM | Covered |
| H66.43 | ICD10CM | Covered |
| H66.91 | ICD10CM | Covered |
| H66.92 | ICD10CM | Covered |
| H66.93 | ICD10CM | Covered |
| H67.1 | ICD10CM | Covered |
| H67.2 | ICD10CM | Covered |
| H67.3 | ICD10CM | Covered |
| H68.001 | ICD10CM | Covered |
| H68.002 | ICD10CM | Covered |
| H68.003 | ICD10CM | Covered |
| H68.011 | ICD10CM | Covered |
| H68.012 | ICD10CM | Covered |
| H68.013 | ICD10CM | Covered |
| H68.021 | ICD10CM | Covered |
| H68.022 | ICD10CM | Covered |
| H68.023 | ICD10CM | Covered |
| H68.101 | ICD10CM | Covered |
| H68.102 | ICD10CM | Covered |
| H68.103 | ICD10CM | Covered |
| H68.111 | ICD10CM | Covered |
| H68.112 | ICD10CM | Covered |
| H68.113 | ICD10CM | Covered |
| H68.121 | ICD10CM | Covered |
| H68.122 | ICD10CM | Covered |
| H68.123 | ICD10CM | Covered |
| H68.131 | ICD10CM | Covered |
| H68.132 | ICD10CM | Covered |
| H68.133 | ICD10CM | Covered |
| H69.01 | ICD10CM | Covered |
| H69.02 | ICD10CM | Covered |
| H69.03 | ICD10CM | Covered |
| H69.81 | ICD10CM | Covered |
| H69.82 | ICD10CM | Covered |
| H69.83 | ICD10CM | Covered |
| H69.91 | ICD10CM | Covered |
| H69.92 | ICD10CM | Covered |
| H69.93 | ICD10CM | Covered |
| H71.01 | ICD10CM | Covered |
| H71.02 | ICD10CM | Covered |
| H71.03 | ICD10CM | Covered |
| H71.11 | ICD10CM | Covered |
| H71.12 | ICD10CM | Covered |
| H71.13 | ICD10CM | Covered |
| H71.21 | ICD10CM | Covered |
| H71.22 | ICD10CM | Covered |
| H71.23 | ICD10CM | Covered |
| H71.31 | ICD10CM | Covered |
| H71.32 | ICD10CM | Covered |
| H71.33 | ICD10CM | Covered |
| H71.91 | ICD10CM | Covered |
| H71.92 | ICD10CM | Covered |
| H71.93 | ICD10CM | Covered |
| H72.01 | ICD10CM | Covered |
| H72.02 | ICD10CM | Covered |
| H72.03 | ICD10CM | Covered |
| H72.11 | ICD10CM | Covered |
| H72.12 | ICD10CM | Covered |
| H72.13 | ICD10CM | Covered |
| H72.2X1 | ICD10CM | Covered |
| H72.2X2 | ICD10CM | Covered |
| H72.2X3 | ICD10CM | Covered |
| H72.811 | ICD10CM | Covered |
| H72.812 | ICD10CM | Covered |
| H72.813 | ICD10CM | Covered |
| H72.821 | ICD10CM | Covered |
| H72.822 | ICD10CM | Covered |
| H72.823 | ICD10CM | Covered |
| H72.91 | ICD10CM | Covered |
| H72.92 | ICD10CM | Covered |
| H72.93 | ICD10CM | Covered |
| H74.01 | ICD10CM | Covered |
| H74.02 | ICD10CM | Covered |
| H74.03 | ICD10CM | Covered |
| H74.11 | ICD10CM | Covered |
| H74.12 | ICD10CM | Covered |
| H74.13 | ICD10CM | Covered |
| H74.21 | ICD10CM | Covered |
| H74.22 | ICD10CM | Covered |
| H74.23 | ICD10CM | Covered |
| H74.311 | ICD10CM | Covered |
| H74.312 | ICD10CM | Covered |
| H74.313 | ICD10CM | Covered |
| H80.11 | ICD10CM | Covered |
| H80.12 | ICD10CM | Covered |
| H80.13 | ICD10CM | Covered |
| H81.01 | ICD10CM | Covered |
| H81.02 | ICD10CM | Covered |
| H81.03 | ICD10CM | Covered |
| H81.09 | ICD10CM | Covered |
| H81.10 | ICD10CM | Covered |
| H81.11 | ICD10CM | Covered |
| H81.12 | ICD10CM | Covered |
| H81.13 | ICD10CM | Covered |
| H81.20 | ICD10CM | Covered |
| H81.21 | ICD10CM | Covered |
| H81.22 | ICD10CM | Covered |
| H81.23 | ICD10CM | Covered |
| H81.311 | ICD10CM | Covered |
| H81.312 | ICD10CM | Covered |
| H81.313 | ICD10CM | Covered |
| H81.319 | ICD10CM | Covered |
| H81.391 | ICD10CM | Covered |
| H81.392 | ICD10CM | Covered |
| H81.393 | ICD10CM | Covered |
| H81.399 | ICD10CM | Covered |
| H81.4 | ICD10CM | Covered |
| H81.8X1 | ICD10CM | Covered |
| H81.8X2 | ICD10CM | Covered |
| H81.8X3 | ICD10CM | Covered |
| H81.8X9 | ICD10CM | Covered |
| H81.90 | ICD10CM | Covered |
| H81.91 | ICD10CM | Covered |
| H81.92 | ICD10CM | Covered |
| H81.93 | ICD10CM | Covered |
| H82.1 | ICD10CM | Covered |
| H82.2 | ICD10CM | Covered |
| H82.3 | ICD10CM | Covered |
| H82.9 | ICD10CM | Covered |
| H83.01 | ICD10CM | Covered |
| H83.02 | ICD10CM | Covered |
| H83.03 | ICD10CM | Covered |
| H83.09 | ICD10CM | Covered |
| H83.11 | ICD10CM | Covered |
| H83.12 | ICD10CM | Covered |
| H83.13 | ICD10CM | Covered |
| H83.19 | ICD10CM | Covered |
| H83.2X1 | ICD10CM | Covered |
| H83.2X2 | ICD10CM | Covered |
| H83.2X3 | ICD10CM | Covered |
| H83.2X9 | ICD10CM | Covered |
| H83.3X1 | ICD10CM | Covered |
| H83.3X2 | ICD10CM | Covered |
| H83.3X3 | ICD10CM | Covered |
| H83.3X9 | ICD10CM | Covered |
| H83.8X1 | ICD10CM | Covered |
| H83.8X2 | ICD10CM | Covered |
| H83.8X3 | ICD10CM | Covered |
| H83.8X9 | ICD10CM | Covered |
| H83.90 | ICD10CM | Covered |
| H83.91 | ICD10CM | Covered |
| H83.92 | ICD10CM | Covered |
| H83.93 | ICD10CM | Covered |
| H90.0 | ICD10CM | Covered |
| H90.11 | ICD10CM | Covered |
| H90.12 | ICD10CM | Covered |
| H90.2 | ICD10CM | Covered |
| H90.3 | ICD10CM | Covered |
| H90.41 | ICD10CM | Covered |
| H90.42 | ICD10CM | Covered |
| H90.5 | ICD10CM | Covered |
| H90.6 | ICD10CM | Covered |
| H90.71 | ICD10CM | Covered |
| H90.72 | ICD10CM | Covered |
| H90.8 | ICD10CM | Covered |
| H90.A11 | ICD10CM | Covered |
| H90.A12 | ICD10CM | Covered |
| H90.A21 | ICD10CM | Covered |
| H90.A22 | ICD10CM | Covered |
| H90.A31 | ICD10CM | Covered |
| H90.A32 | ICD10CM | Covered |
| H91.01 | ICD10CM | Covered |
| H91.02 | ICD10CM | Covered |
| H91.03 | ICD10CM | Covered |
| H91.09 | ICD10CM | Covered |
| H91.10 | ICD10CM | Covered |
| H91.11 | ICD10CM | Covered |
| H91.12 | ICD10CM | Covered |
| H91.13 | ICD10CM | Covered |
| H91.20 | ICD10CM | Covered |
| H91.21 | ICD10CM | Covered |
| H91.22 | ICD10CM | Covered |
| H91.23 | ICD10CM | Covered |
| H91.3 | ICD10CM | Covered |
| H91.8X1 | ICD10CM | Covered |
| H91.8X2 | ICD10CM | Covered |
| H91.8X3 | ICD10CM | Covered |
| H91.8X9 | ICD10CM | Covered |
| H91.90 | ICD10CM | Covered |
| H91.91 | ICD10CM | Covered |
| H91.92 | ICD10CM | Covered |
| H91.93 | ICD10CM | Covered |
| H93.011 | ICD10CM | Covered |
| H93.012 | ICD10CM | Covered |
| H93.013 | ICD10CM | Covered |
| H93.019 | ICD10CM | Covered |
| H93.091 | ICD10CM | Covered |
| H93.092 | ICD10CM | Covered |
| H93.093 | ICD10CM | Covered |
| H93.099 | ICD10CM | Covered |
| H93.11 | ICD10CM | Covered |
| H93.12 | ICD10CM | Covered |
| H93.13 | ICD10CM | Covered |
| H93.19 | ICD10CM | Covered |
| H93.211 | ICD10CM | Covered |
| H93.212 | ICD10CM | Covered |
| H93.213 | ICD10CM | Covered |
| H93.219 | ICD10CM | Covered |
| H93.221 | ICD10CM | Covered |
| H93.222 | ICD10CM | Covered |
| H93.223 | ICD10CM | Covered |
| H93.229 | ICD10CM | Covered |
| H93.231 | ICD10CM | Covered |
| H93.232 | ICD10CM | Covered |
| H93.233 | ICD10CM | Covered |
| H93.239 | ICD10CM | Covered |
| H93.241 | ICD10CM | Covered |
| H93.242 | ICD10CM | Covered |
| H93.243 | ICD10CM | Covered |
| H93.249 | ICD10CM | Covered |
| H93.25 | ICD10CM | Covered |
| H93.291 | ICD10CM | Covered |
| H93.292 | ICD10CM | Covered |
| H93.293 | ICD10CM | Covered |
| H93.299 | ICD10CM | Covered |
| H93.3X1 | ICD10CM | Covered |
| H93.3X2 | ICD10CM | Covered |
| H93.3X3 | ICD10CM | Covered |
| H93.3X9 | ICD10CM | Covered |
| H93.90 | ICD10CM | Covered |
| H94.00 | ICD10CM | Covered |
| H94.01 | ICD10CM | Covered |
| H94.02 | ICD10CM | Covered |
| H94.03 | ICD10CM | Covered |
| R25.0 | ICD10CM | Covered |
| R25.1 | ICD10CM | Covered |
| R25.2 | ICD10CM | Covered |
| R25.3 | ICD10CM | Covered |
| R25.8 | ICD10CM | Covered |
| R25.9 | ICD10CM | Covered |
| R42 | ICD10CM | Covered |
| Z01.12 | ICD10CM | Covered |
| Z01.818 | ICD10CM | Covered |
| Z45.321 | ICD10CM | Covered |
| Z51.11 | ICD10CM | Covered |
| Z76.5 | ICD10CM | Covered |
| Z79.2 | ICD10CM | Covered |