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 |
|---|---|---|
| 93224 | HCPCS | Covered |
| 93225 | HCPCS | Covered |
| 93226 | HCPCS | Covered |
| 93227 | HCPCS | Covered |
| 93228 | HCPCS | Covered |
| 93229 | HCPCS | Covered |
| 93241 | HCPCS | Covered |
| 93242 | HCPCS | Covered |
| 93243 | HCPCS | Covered |
| 93244 | HCPCS | Covered |
| 93245 | HCPCS | Covered |
| 93246 | HCPCS | Covered |
| 93247 | HCPCS | Covered |
| 93248 | HCPCS | Covered |
| 93268 | HCPCS | Covered |
| 93270 | HCPCS | Covered |
| 93271 | HCPCS | Covered |
| 93272 | HCPCS | Covered |
| G45.0 | ICD10CM | Covered |
| G45.1 | ICD10CM | Covered |
| G45.2 | ICD10CM | Covered |
| G45.3 | ICD10CM | Covered |
| G45.4 | ICD10CM | Covered |
| G45.8 | ICD10CM | Covered |
| G45.9 | ICD10CM | Covered |
| I20.0 | ICD10CM | Covered |
| I20.1 | ICD10CM | Covered |
| I20.81 | ICD10CM | Covered |
| I20.89 | ICD10CM | Covered |
| I21.01 | ICD10CM | Covered |
| I21.02 | ICD10CM | Covered |
| I21.09 | ICD10CM | Covered |
| I21.11 | ICD10CM | Covered |
| I21.19 | ICD10CM | Covered |
| I21.21 | ICD10CM | Covered |
| I21.29 | ICD10CM | Covered |
| I21.4 | ICD10CM | Covered |
| I21.9 | ICD10CM | Covered |
| I21.A1 | ICD10CM | Covered |
| I21.A9 | ICD10CM | Covered |
| I22.0 | ICD10CM | Covered |
| I22.1 | ICD10CM | Covered |
| I22.2 | ICD10CM | Covered |
| I22.8 | ICD10CM | Covered |
| I24.0 | ICD10CM | Covered |
| I24.1 | ICD10CM | Covered |
| I24.81 | ICD10CM | Covered |
| I24.89 | ICD10CM | Covered |
| I25.110 | ICD10CM | Covered |
| I25.111 | ICD10CM | Covered |
| I25.112 | ICD10CM | Covered |
| I25.118 | ICD10CM | Covered |
| I25.2 | ICD10CM | Covered |
| I25.700 | ICD10CM | Covered |
| I25.701 | ICD10CM | Covered |
| I25.702 | ICD10CM | Covered |
| I25.708 | ICD10CM | Covered |
| I25.710 | ICD10CM | Covered |
| I25.711 | ICD10CM | Covered |
| I25.712 | ICD10CM | Covered |
| I25.718 | ICD10CM | Covered |
| I25.720 | ICD10CM | Covered |
| I25.721 | ICD10CM | Covered |
| I25.722 | ICD10CM | Covered |
| I25.728 | ICD10CM | Covered |
| I25.730 | ICD10CM | Covered |
| I25.731 | ICD10CM | Covered |
| I25.732 | ICD10CM | Covered |
| I25.738 | ICD10CM | Covered |
| I25.750 | ICD10CM | Covered |
| I25.751 | ICD10CM | Covered |
| I25.752 | ICD10CM | Covered |
| I25.758 | ICD10CM | Covered |
| I25.760 | ICD10CM | Covered |
| I25.761 | ICD10CM | Covered |
| I25.762 | ICD10CM | Covered |
| I25.768 | ICD10CM | Covered |
| I25.790 | ICD10CM | Covered |
| I25.791 | ICD10CM | Covered |
| I25.792 | ICD10CM | Covered |
| I25.798 | ICD10CM | Covered |
| I44.0 | ICD10CM | Covered |
| I44.1 | ICD10CM | Covered |
| I44.2 | ICD10CM | Covered |
| I44.39 | ICD10CM | Covered |
| I44.4 | ICD10CM | Covered |
| I44.5 | ICD10CM | Covered |
| I44.69 | ICD10CM | Covered |
| I44.7 | ICD10CM | Covered |
| I45.0 | ICD10CM | Covered |
| I45.19 | ICD10CM | Covered |
| I45.2 | ICD10CM | Covered |
| I45.3 | ICD10CM | Covered |
| I45.4 | ICD10CM | Covered |
| I45.5 | ICD10CM | Covered |
| I45.6 | ICD10CM | Covered |
| I45.81 | ICD10CM | Covered |
| I45.89 | ICD10CM | Covered |
| I47.0 | ICD10CM | Covered |
| I47.10 | ICD10CM | Covered |
| I47.11 | ICD10CM | Covered |
| I47.19 | ICD10CM | Covered |
| I47.20 | ICD10CM | Covered |
| I47.29 | ICD10CM | Covered |
| I47.9 | ICD10CM | Covered |
| I48.0 | ICD10CM | Covered |
| I48.11 | ICD10CM | Covered |
| I48.19 | ICD10CM | Covered |
| I48.20 | ICD10CM | Covered |
| I48.21 | ICD10CM | Covered |
| I48.3 | ICD10CM | Covered |
| I48.4 | ICD10CM | Covered |
| I48.91 | ICD10CM | Covered |
| I48.92 | ICD10CM | Covered |
| I49.01 | ICD10CM | Covered |
| I49.02 | ICD10CM | Covered |
| I49.1 | ICD10CM | Covered |
| I49.2 | ICD10CM | Covered |
| I49.3 | ICD10CM | Covered |
| I49.5 | ICD10CM | Covered |
| I49.8 | ICD10CM | Covered |
| I63.10 | ICD10CM | Covered |
| I63.111 | ICD10CM | Covered |
| I63.112 | ICD10CM | Covered |
| I63.113 | ICD10CM | Covered |
| I63.119 | ICD10CM | Covered |
| I63.12 | ICD10CM | Covered |
| I63.131 | ICD10CM | Covered |
| I63.132 | ICD10CM | Covered |
| I63.133 | ICD10CM | Covered |
| I63.139 | ICD10CM | Covered |
| I63.19 | ICD10CM | Covered |
| I63.40 | ICD10CM | Covered |
| I63.411 | ICD10CM | Covered |
| I63.412 | ICD10CM | Covered |
| I63.413 | ICD10CM | Covered |
| I63.419 | ICD10CM | Covered |
| I63.421 | ICD10CM | Covered |
| I63.422 | ICD10CM | Covered |
| I63.423 | ICD10CM | Covered |
| I63.429 | ICD10CM | Covered |
| I63.431 | ICD10CM | Covered |
| I63.432 | ICD10CM | Covered |
| I63.433 | ICD10CM | Covered |
| I63.439 | ICD10CM | Covered |
| I63.441 | ICD10CM | Covered |
| I63.442 | ICD10CM | Covered |
| I63.443 | ICD10CM | Covered |
| I63.449 | ICD10CM | Covered |
| I63.49 | ICD10CM | Covered |
| R00.1 | ICD10CM | Covered |
| R00.2 | ICD10CM | Covered |
| R06.01 | ICD10CM | Covered |
| R06.02 | ICD10CM | Covered |
| R06.03 | ICD10CM | Covered |
| R06.09 | ICD10CM | Covered |
| R06.2 | ICD10CM | Covered |
| R06.3 | ICD10CM | Covered |
| R06.4 | ICD10CM | Covered |
| R06.81 | ICD10CM | Covered |
| R06.82 | ICD10CM | Covered |
| R06.83 | ICD10CM | Covered |
| R06.89 | ICD10CM | Covered |
| R07.2 | ICD10CM | Covered |
| R07.82 | ICD10CM | Covered |
| R07.89 | ICD10CM | Covered |
| R07.9 | ICD10CM | Covered |
| R29.5 | ICD10CM | Covered |
| R40.4 | ICD10CM | Covered |
| R42 | ICD10CM | Covered |
| R55 | ICD10CM | Covered |
| Z79.85 | ICD10CM | Covered |
| Z79.891 | ICD10CM | Covered |
| Z79.899 | ICD10CM | Covered |
| Z86.73 | ICD10CM | Covered |