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 |
|---|---|---|
| 11200 | HCPCS | Covered |
| 11201 | HCPCS | Covered |
| 11300 | HCPCS | Covered |
| 11301 | HCPCS | Covered |
| 11302 | HCPCS | Covered |
| 11303 | HCPCS | Covered |
| 11305 | HCPCS | Covered |
| 11306 | HCPCS | Covered |
| 11307 | HCPCS | Covered |
| 11308 | HCPCS | Covered |
| 11310 | HCPCS | Covered |
| 11311 | HCPCS | Covered |
| 11312 | HCPCS | Covered |
| 11313 | HCPCS | Covered |
| 11400 | HCPCS | Covered |
| 11401 | HCPCS | Covered |
| 11402 | HCPCS | Covered |
| 11403 | HCPCS | Covered |
| 11404 | HCPCS | Covered |
| 11406 | HCPCS | Covered |
| 11420 | HCPCS | Covered |
| 11421 | HCPCS | Covered |
| 11422 | HCPCS | Covered |
| 11423 | HCPCS | Covered |
| 11424 | HCPCS | Covered |
| 11426 | HCPCS | Covered |
| 11440 | HCPCS | Covered |
| 11441 | HCPCS | Covered |
| 11442 | HCPCS | Covered |
| 11443 | HCPCS | Covered |
| 11444 | HCPCS | Covered |
| 11446 | HCPCS | Covered |
| 17106 | HCPCS | Covered |
| 17107 | HCPCS | Covered |
| 17108 | HCPCS | Covered |
| 17110 | HCPCS | Covered |
| 17111 | HCPCS | Covered |
| A63.0 | ICD10CM | Covered |
| B07.0 | ICD10CM | Covered |
| B07.8 | ICD10CM | Covered |
| B07.9 | ICD10CM | Covered |
| B08.1 | ICD10CM | Covered |
| D10.0 | ICD10CM | Covered |
| D10.39 | ICD10CM | Covered |
| D17.0 | ICD10CM | Covered |
| D17.1 | ICD10CM | Covered |
| D17.21 | ICD10CM | Covered |
| D17.22 | ICD10CM | Covered |
| D17.23 | ICD10CM | Covered |
| D17.24 | ICD10CM | Covered |
| D17.39 | ICD10CM | Covered |
| D18.01 | ICD10CM | Covered |
| D22.0 | ICD10CM | Covered |
| D22.111 | ICD10CM | Covered |
| D22.112 | ICD10CM | Covered |
| D22.121 | ICD10CM | Covered |
| D22.122 | ICD10CM | Covered |
| D22.21 | ICD10CM | Covered |
| D22.22 | ICD10CM | Covered |
| D22.39 | ICD10CM | Covered |
| D22.4 | ICD10CM | Covered |
| D22.5 | ICD10CM | Covered |
| D22.61 | ICD10CM | Covered |
| D22.62 | ICD10CM | Covered |
| D22.71 | ICD10CM | Covered |
| D22.72 | ICD10CM | Covered |
| D23.0 | ICD10CM | Covered |
| D23.111 | ICD10CM | Covered |
| D23.112 | ICD10CM | Covered |
| D23.121 | ICD10CM | Covered |
| D23.122 | ICD10CM | Covered |
| D23.21 | ICD10CM | Covered |
| D23.22 | ICD10CM | Covered |
| D23.39 | ICD10CM | Covered |
| D23.4 | ICD10CM | Covered |
| D23.5 | ICD10CM | Covered |
| D23.61 | ICD10CM | Covered |
| D23.62 | ICD10CM | Covered |
| D23.71 | ICD10CM | Covered |
| D23.72 | ICD10CM | Covered |
| D23.9 | ICD10CM | Covered |
| D28.0 | ICD10CM | Covered |
| D28.1 | ICD10CM | Covered |
| D29.0 | ICD10CM | Covered |
| D29.4 | ICD10CM | Covered |
| D37.01 | ICD10CM | Covered |
| D37.02 | ICD10CM | Covered |
| D37.04 | ICD10CM | Covered |
| D37.05 | ICD10CM | Covered |
| D37.09 | ICD10CM | Covered |
| D40.8 | ICD10CM | Covered |
| D48.5 | ICD10CM | Covered |
| H00.11 | ICD10CM | Covered |
| H00.12 | ICD10CM | Covered |
| H00.14 | ICD10CM | Covered |
| H00.15 | ICD10CM | Covered |
| H02.61 | ICD10CM | Covered |
| H02.62 | ICD10CM | Covered |
| H02.64 | ICD10CM | Covered |
| H02.65 | ICD10CM | Covered |
| H02.821 | ICD10CM | Covered |
| H02.822 | ICD10CM | Covered |
| H02.824 | ICD10CM | Covered |
| H02.825 | ICD10CM | Covered |
| H61.011 | ICD10CM | Covered |
| H61.012 | ICD10CM | Covered |
| H61.013 | ICD10CM | Covered |
| H61.021 | ICD10CM | Covered |
| H61.022 | ICD10CM | Covered |
| H61.023 | ICD10CM | Covered |
| H61.031 | ICD10CM | Covered |
| H61.032 | ICD10CM | Covered |
| H61.033 | ICD10CM | Covered |
| I78.1 | ICD10CM | Covered |
| K13.21 | ICD10CM | Covered |
| K13.3 | ICD10CM | Covered |
| K13.5 | ICD10CM | Covered |
| K62.82 | ICD10CM | Covered |
| K64.4 | ICD10CM | Covered |
| L11.0 | ICD10CM | Covered |
| L11.8 | ICD10CM | Covered |
| L28.1 | ICD10CM | Covered |
| L56.5 | ICD10CM | Covered |
| L66.4 | ICD10CM | Covered |
| L72.0 | ICD10CM | Covered |
| L72.11 | ICD10CM | Covered |
| L72.12 | ICD10CM | Covered |
| L72.2 | ICD10CM | Covered |
| L72.3 | ICD10CM | Covered |
| L72.8 | ICD10CM | Covered |
| L82.0 | ICD10CM | Covered |
| L82.1 | ICD10CM | Covered |
| L85.0 | ICD10CM | Covered |
| L85.1 | ICD10CM | Covered |
| L85.2 | ICD10CM | Covered |
| L85.8 | ICD10CM | Covered |
| L87.0 | ICD10CM | Covered |
| L87.1 | ICD10CM | Covered |
| L87.2 | ICD10CM | Covered |
| L87.8 | ICD10CM | Covered |
| L90.3 | ICD10CM | Covered |
| L90.4 | ICD10CM | Covered |
| L90.5 | ICD10CM | Covered |
| L90.8 | ICD10CM | Covered |
| L91.0 | ICD10CM | Covered |
| L91.8 | ICD10CM | Covered |
| L91.9 | ICD10CM | Covered |
| L92.2 | ICD10CM | Covered |
| L92.3 | ICD10CM | Covered |
| L92.8 | ICD10CM | Covered |
| L98.0 | ICD10CM | Covered |
| L98.5 | ICD10CM | Covered |
| L98.6 | ICD10CM | Covered |
| L99 | ICD10CM | Covered |
| N75.0 | ICD10CM | Covered |
| N84.3 | ICD10CM | Covered |
| N90.0 | ICD10CM | Covered |
| N90.1 | ICD10CM | Covered |
| Q18.1 | ICD10CM | Covered |
| Q82.1 | ICD10CM | Covered |
| Q82.3 | ICD10CM | Covered |
| Q82.5 | ICD10CM | Covered |
| Q82.8 | ICD10CM | Covered |
| Q85.01 | ICD10CM | Covered |
| Q85.03 | ICD10CM | Covered |
| Q85.09 | ICD10CM | Covered |
| R22.0 | ICD10CM | Covered |
| R22.1 | ICD10CM | Covered |
| R22.2 | ICD10CM | Covered |
| R22.31 | ICD10CM | Covered |
| R22.32 | ICD10CM | Covered |
| R22.33 | ICD10CM | Covered |
| R22.41 | ICD10CM | Covered |
| R22.42 | ICD10CM | Covered |
| R22.43 | ICD10CM | Covered |
| Z41.1 | ICD10CM | Not covered |