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 |
|---|---|---|
| 0111U | HCPCS | Covered |
| 0129U | HCPCS | Covered |
| 0130U | HCPCS | Covered |
| 0153U | HCPCS | Covered |
| 0154U | HCPCS | Covered |
| 0155U | HCPCS | Covered |
| 0156U | HCPCS | Covered |
| 0157U | HCPCS | Covered |
| 0158U | HCPCS | Covered |
| 0159U | HCPCS | Covered |
| 0160U | HCPCS | Covered |
| 0161U | HCPCS | Covered |
| 0162U | HCPCS | Covered |
| 81105 | HCPCS | Covered |
| 81106 | HCPCS | Covered |
| 81107 | HCPCS | Covered |
| 81108 | HCPCS | Covered |
| 81109 | HCPCS | Covered |
| 81110 | HCPCS | Covered |
| 81111 | HCPCS | Covered |
| 81112 | HCPCS | Covered |
| 81120 | HCPCS | Covered |
| 81121 | HCPCS | Covered |
| 81162 | HCPCS | Covered |
| 81163 | HCPCS | Covered |
| 81164 | HCPCS | Covered |
| 81165 | HCPCS | Covered |
| 81166 | HCPCS | Covered |
| 81167 | HCPCS | Covered |
| 81170 | HCPCS | Covered |
| 81171 | HCPCS | Covered |
| 81172 | HCPCS | Covered |
| 81173 | HCPCS | Covered |
| 81174 | HCPCS | Covered |
| 81175 | HCPCS | Covered |
| 81176 | HCPCS | Covered |
| 81177 | HCPCS | Covered |
| 81178 | HCPCS | Covered |
| 81179 | HCPCS | Covered |
| 81180 | HCPCS | Covered |
| 81181 | HCPCS | Covered |
| 81182 | HCPCS | Covered |
| 81183 | HCPCS | Covered |
| 81184 | HCPCS | Covered |
| 81185 | HCPCS | Covered |
| 81186 | HCPCS | Covered |
| 81187 | HCPCS | Covered |
| 81188 | HCPCS | Covered |
| 81189 | HCPCS | Covered |
| 81190 | HCPCS | Covered |
| 81200 | HCPCS | Covered |
| 81201 | HCPCS | Covered |
| 81202 | HCPCS | Covered |
| 81203 | HCPCS | Covered |
| 81204 | HCPCS | Covered |
| 81205 | HCPCS | Covered |
| 81206 | HCPCS | Covered |
| 81207 | HCPCS | Covered |
| 81208 | HCPCS | Covered |
| 81209 | HCPCS | Covered |
| 81210 | HCPCS | Covered |
| 81212 | HCPCS | Covered |
| 81215 | HCPCS | Covered |
| 81216 | HCPCS | Covered |
| 81217 | HCPCS | Covered |
| 81218 | HCPCS | Covered |
| 81219 | HCPCS | Covered |
| 81221 | HCPCS | Covered |
| 81222 | HCPCS | Covered |
| 81223 | HCPCS | Covered |
| 81224 | HCPCS | Covered |
| 81228 | HCPCS | Covered |
| 81229 | HCPCS | Covered |
| 81233 | HCPCS | Covered |
| 81234 | HCPCS | Covered |
| 81235 | HCPCS | Covered |
| 81236 | HCPCS | Covered |
| 81237 | HCPCS | Covered |
| 81238 | HCPCS | Covered |
| 81239 | HCPCS | Covered |
| 81240 | HCPCS | Covered |
| 81241 | HCPCS | Covered |
| 81242 | HCPCS | Covered |
| 81243 | HCPCS | Covered |
| 81244 | HCPCS | Covered |
| 81245 | HCPCS | Covered |
| 81246 | HCPCS | Covered |
| 81248 | HCPCS | Covered |
| 81249 | HCPCS | Covered |
| 81250 | HCPCS | Covered |
| 81251 | HCPCS | Covered |
| 81252 | HCPCS | Covered |
| 81253 | HCPCS | Covered |
| 81254 | HCPCS | Covered |
| 81255 | HCPCS | Covered |
| 81256 | HCPCS | Covered |
| 81257 | HCPCS | Covered |
| 81258 | HCPCS | Covered |
| 81259 | HCPCS | Covered |
| 81260 | HCPCS | Covered |
| 81261 | HCPCS | Covered |
| 81262 | HCPCS | Covered |
| 81263 | HCPCS | Covered |
| 81264 | HCPCS | Covered |
| 81265 | HCPCS | Covered |
| 81266 | HCPCS | Covered |
| 81267 | HCPCS | Covered |
| 81268 | HCPCS | Covered |
| 81269 | HCPCS | Covered |
| 81270 | HCPCS | Covered |
| 81271 | HCPCS | Covered |
| 81272 | HCPCS | Covered |
| 81273 | HCPCS | Covered |
| 81274 | HCPCS | Covered |
| 81275 | HCPCS | Covered |
| 81276 | HCPCS | Covered |
| 81277 | HCPCS | Covered |
| 81284 | HCPCS | Covered |
| 81285 | HCPCS | Covered |
| 81286 | HCPCS | Covered |
| 81287 | HCPCS | Covered |
| 81288 | HCPCS | Covered |
| 81289 | HCPCS | Covered |
| 81290 | HCPCS | Covered |
| 81291 | HCPCS | Covered |
| 81292 | HCPCS | Covered |
| 81293 | HCPCS | Covered |
| 81294 | HCPCS | Covered |
| 81295 | HCPCS | Covered |
| 81296 | HCPCS | Covered |
| 81297 | HCPCS | Covered |
| 81298 | HCPCS | Covered |
| 81299 | HCPCS | Covered |
| 81300 | HCPCS | Covered |
| 81301 | HCPCS | Covered |
| 81302 | HCPCS | Covered |
| 81303 | HCPCS | Covered |
| 81304 | HCPCS | Covered |
| 81305 | HCPCS | Covered |
| 81307 | HCPCS | Covered |
| 81308 | HCPCS | Covered |
| 81309 | HCPCS | Covered |
| 81310 | HCPCS | Covered |
| 81311 | HCPCS | Covered |
| 81312 | HCPCS | Covered |
| 81313 | HCPCS | Covered |
| 81314 | HCPCS | Covered |
| 81315 | HCPCS | Covered |
| 81316 | HCPCS | Covered |
| 81317 | HCPCS | Covered |
| 81318 | HCPCS | Covered |
| 81319 | HCPCS | Covered |
| 81320 | HCPCS | Covered |
| 81321 | HCPCS | Covered |
| 81322 | HCPCS | Covered |
| 81323 | HCPCS | Covered |
| 81324 | HCPCS | Covered |
| 81325 | HCPCS | Covered |
| 81326 | HCPCS | Covered |
| 81327 | HCPCS | Covered |
| 81329 | HCPCS | Covered |
| 81330 | HCPCS | Covered |
| 81331 | HCPCS | Covered |
| 81332 | HCPCS | Covered |
| 81333 | HCPCS | Covered |
| 81334 | HCPCS | Covered |
| 81336 | HCPCS | Covered |
| 81337 | HCPCS | Covered |
| 81340 | HCPCS | Covered |
| 81341 | HCPCS | Covered |
| 81342 | HCPCS | Covered |
| 81343 | HCPCS | Covered |
| 81344 | HCPCS | Covered |
| 81345 | HCPCS | Covered |
| 81349 | HCPCS | Covered |
| 81361 | HCPCS | Covered |
| 81362 | HCPCS | Covered |
| 81363 | HCPCS | Covered |
| 81364 | HCPCS | Covered |
| 81400 | HCPCS | Covered |
| 81401 | HCPCS | Covered |
| 81402 | HCPCS | Covered |
| 81403 | HCPCS | Covered |
| 81404 | HCPCS | Covered |
| 81405 | HCPCS | Covered |
| 81443 | HCPCS | Covered |
| 81479 | HCPCS | Covered |
| 81523 | HCPCS | Covered |