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 |
|---|---|---|
| 81162 | HCPCS | Covered |
| 81163 | HCPCS | Covered |
| 81164 | HCPCS | Covered |
| 81165 | HCPCS | Covered |
| 81166 | HCPCS | Covered |
| 81167 | HCPCS | Covered |
| 81212 | HCPCS | Covered |
| 81215 | HCPCS | Covered |
| 81216 | HCPCS | Covered |
| 81217 | HCPCS | Covered |
| 81432 | HCPCS | Covered |
| 81479 | HCPCS | Covered |
| C25.0 | ICD10CM | Covered |
| C25.1 | ICD10CM | Covered |
| C25.2 | ICD10CM | Covered |
| C25.3 | ICD10CM | Covered |
| C25.4 | ICD10CM | Covered |
| C25.7 | ICD10CM | Covered |
| C25.8 | ICD10CM | Covered |
| C25.9 | ICD10CM | Covered |
| C50.011 | ICD10CM | Covered |
| C50.012 | ICD10CM | Covered |
| C50.019 | ICD10CM | Covered |
| C50.021 | ICD10CM | Covered |
| C50.022 | ICD10CM | Covered |
| C50.029 | ICD10CM | Covered |
| C50.111 | ICD10CM | Covered |
| C50.112 | ICD10CM | Covered |
| C50.119 | ICD10CM | Covered |
| C50.121 | ICD10CM | Covered |
| C50.122 | ICD10CM | Covered |
| C50.129 | ICD10CM | Covered |
| C50.211 | ICD10CM | Covered |
| C50.212 | ICD10CM | Covered |
| C50.219 | ICD10CM | Covered |
| C50.221 | ICD10CM | Covered |
| C50.222 | ICD10CM | Covered |
| C50.229 | ICD10CM | Covered |
| C50.311 | ICD10CM | Covered |
| C50.312 | ICD10CM | Covered |
| C50.319 | ICD10CM | Covered |
| C50.321 | ICD10CM | Covered |
| C50.322 | ICD10CM | Covered |
| C50.329 | ICD10CM | Covered |
| C50.411 | ICD10CM | Covered |
| C50.412 | ICD10CM | Covered |
| C50.419 | ICD10CM | Covered |
| C50.421 | ICD10CM | Covered |
| C50.422 | ICD10CM | Covered |
| C50.429 | ICD10CM | Covered |
| C50.511 | ICD10CM | Covered |
| C50.512 | ICD10CM | Covered |
| C50.519 | ICD10CM | Covered |
| C50.521 | ICD10CM | Covered |
| C50.522 | ICD10CM | Covered |
| C50.529 | ICD10CM | Covered |
| C50.611 | ICD10CM | Covered |
| C50.612 | ICD10CM | Covered |
| C50.619 | ICD10CM | Covered |
| C50.621 | ICD10CM | Covered |
| C50.622 | ICD10CM | Covered |
| C50.629 | ICD10CM | Covered |
| C50.811 | ICD10CM | Covered |
| C50.812 | ICD10CM | Covered |
| C50.819 | ICD10CM | Covered |
| C50.821 | ICD10CM | Covered |
| C50.822 | ICD10CM | Covered |
| C50.829 | ICD10CM | Covered |
| C50.911 | ICD10CM | Covered |
| C50.912 | ICD10CM | Covered |
| C50.919 | ICD10CM | Covered |
| C50.921 | ICD10CM | Covered |
| C50.922 | ICD10CM | Covered |
| C50.929 | ICD10CM | Covered |
| C50.A0 | ICD10CM | Covered |
| C50.A1 | ICD10CM | Covered |
| C50.A2 | ICD10CM | Covered |
| C56.1 | ICD10CM | Covered |
| C56.2 | ICD10CM | Covered |
| C56.3 | ICD10CM | Covered |
| C56.9 | ICD10CM | Covered |
| C57.00 | ICD10CM | Covered |
| C57.01 | ICD10CM | Covered |
| C57.02 | ICD10CM | Covered |
| C61 | ICD10CM | Covered |
| D05.00 | ICD10CM | Covered |
| D05.01 | ICD10CM | Covered |
| D05.02 | ICD10CM | Covered |
| D05.10 | ICD10CM | Covered |
| D05.11 | ICD10CM | Covered |
| D05.12 | ICD10CM | Covered |
| D05.80 | ICD10CM | Covered |
| D05.81 | ICD10CM | Covered |
| D05.82 | ICD10CM | Covered |
| D05.90 | ICD10CM | Covered |
| D05.91 | ICD10CM | Covered |
| D05.92 | ICD10CM | Covered |
| Z85.07 | ICD10CM | Covered |
| Z85.3 | ICD10CM | Covered |
| Z85.43 | ICD10CM | Covered |
| Z85.46 | ICD10CM | Covered |
| Z85.4A | ICD10CM | Covered |
| Z86.00A | ICD10CM | Covered |