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 |
|---|---|---|
| 95925 | HCPCS | Covered |
| 95926 | HCPCS | Covered |
| 95927 | HCPCS | Covered |
| 95938 | HCPCS | Covered |
| A52.15 | ICD10CM | Covered |
| C72.0 | ICD10CM | Covered |
| C72.1 | ICD10CM | Covered |
| C79.31 | ICD10CM | Covered |
| D32.0 | ICD10CM | Covered |
| D32.1 | ICD10CM | Covered |
| D33.4 | ICD10CM | Covered |
| D43.0 | ICD10CM | Covered |
| D43.1 | ICD10CM | Covered |
| D43.2 | ICD10CM | Covered |
| D43.4 | ICD10CM | Covered |
| E03.5 | ICD10CM | Covered |
| E08.40 | ICD10CM | Covered |
| E08.42 | ICD10CM | Covered |
| E09.40 | ICD10CM | Covered |
| E09.42 | ICD10CM | Covered |
| E10.40 | ICD10CM | Covered |
| E10.41 | ICD10CM | Covered |
| E10.42 | ICD10CM | Covered |
| E10.43 | ICD10CM | Covered |
| E10.44 | ICD10CM | Covered |
| E10.49 | ICD10CM | Covered |
| E10.610 | ICD10CM | Covered |
| E11.42 | ICD10CM | Covered |
| E13.40 | ICD10CM | Covered |
| E13.42 | ICD10CM | Covered |
| G11.0 | ICD10CM | Covered |
| G11.11 | ICD10CM | Covered |
| G11.19 | ICD10CM | Covered |
| G11.2 | ICD10CM | Covered |
| G11.4 | ICD10CM | Covered |
| G13.0 | ICD10CM | Covered |
| G13.1 | ICD10CM | Covered |
| G25.3 | 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 |
| G60.0 | ICD10CM | Covered |
| G60.1 | ICD10CM | Covered |
| G60.2 | ICD10CM | Covered |
| G60.3 | ICD10CM | Covered |
| G60.8 | ICD10CM | Covered |
| G60.9 | ICD10CM | Covered |
| G61.0 | ICD10CM | Covered |
| G61.1 | ICD10CM | Covered |
| G61.81 | ICD10CM | Covered |
| G61.82 | ICD10CM | Covered |
| G61.89 | ICD10CM | Covered |
| G61.9 | ICD10CM | Covered |
| G62.0 | ICD10CM | Covered |
| G62.1 | ICD10CM | Covered |
| G62.2 | ICD10CM | Covered |
| G62.81 | ICD10CM | Covered |
| G62.82 | ICD10CM | Covered |
| G62.89 | ICD10CM | Covered |
| G62.9 | ICD10CM | Covered |
| G63 | ICD10CM | Covered |
| G64 | ICD10CM | Covered |
| G65.0 | ICD10CM | Covered |
| G65.1 | ICD10CM | Covered |
| G65.2 | ICD10CM | Covered |
| G95.0 | ICD10CM | Covered |
| G95.20 | ICD10CM | Covered |
| G95.29 | ICD10CM | Covered |
| G95.9 | ICD10CM | Covered |
| I65.01 | ICD10CM | Covered |
| I65.02 | ICD10CM | Covered |
| I65.03 | ICD10CM | Covered |
| I65.21 | ICD10CM | Covered |
| I65.22 | ICD10CM | Covered |
| I65.23 | ICD10CM | Covered |
| I67.1 | ICD10CM | Covered |
| M05.50 | ICD10CM | Covered |
| M05.511 | ICD10CM | Covered |
| M05.512 | ICD10CM | Covered |
| M05.519 | ICD10CM | Covered |
| M05.521 | ICD10CM | Covered |
| M05.522 | ICD10CM | Covered |
| M05.529 | ICD10CM | Covered |
| M05.531 | ICD10CM | Covered |
| M05.532 | ICD10CM | Covered |
| M05.539 | ICD10CM | Covered |
| M05.541 | ICD10CM | Covered |
| M05.542 | ICD10CM | Covered |
| M05.549 | ICD10CM | Covered |
| M05.551 | ICD10CM | Covered |
| M05.552 | ICD10CM | Covered |
| M05.559 | ICD10CM | Covered |
| M05.561 | ICD10CM | Covered |
| M05.562 | ICD10CM | Covered |
| M05.569 | ICD10CM | Covered |
| M05.571 | ICD10CM | Covered |
| M05.572 | ICD10CM | Covered |
| M05.579 | ICD10CM | Covered |
| M05.59 | ICD10CM | Covered |
| M34.83 | ICD10CM | Covered |
| M47.011 | ICD10CM | Covered |
| M47.012 | ICD10CM | Covered |
| M47.013 | ICD10CM | Covered |
| M47.014 | ICD10CM | Covered |
| M47.015 | ICD10CM | Covered |
| M47.016 | ICD10CM | Covered |
| M47.019 | ICD10CM | Covered |
| M47.021 | ICD10CM | Covered |
| M47.022 | ICD10CM | Covered |
| M47.029 | ICD10CM | Covered |
| M47.11 | ICD10CM | Covered |
| M47.12 | ICD10CM | Covered |
| M47.13 | ICD10CM | Covered |
| M47.15 | ICD10CM | Covered |
| M47.22 | ICD10CM | Covered |
| M47.812 | ICD10CM | Covered |
| M47.816 | ICD10CM | Covered |
| M48.01 | ICD10CM | Covered |
| M48.02 | ICD10CM | Covered |
| M48.03 | ICD10CM | Covered |
| M48.061 | ICD10CM | Covered |
| M48.062 | ICD10CM | Covered |
| M48.07 | ICD10CM | Covered |
| M99.20 | ICD10CM | Covered |
| M99.21 | ICD10CM | Covered |
| M99.23 | ICD10CM | Covered |
| M99.30 | ICD10CM | Covered |
| M99.31 | ICD10CM | Covered |
| M99.33 | ICD10CM | Covered |
| M99.40 | ICD10CM | Covered |
| M99.41 | ICD10CM | Covered |
| M99.43 | ICD10CM | Covered |
| M99.50 | ICD10CM | Covered |
| M99.51 | ICD10CM | Covered |
| M99.53 | ICD10CM | Covered |
| M99.60 | ICD10CM | Covered |
| M99.61 | ICD10CM | Covered |
| M99.63 | ICD10CM | Covered |
| M99.70 | ICD10CM | Covered |
| M99.71 | ICD10CM | Covered |
| M99.73 | ICD10CM | Covered |
| R40.20 | ICD10CM | Covered |
| R40.2110 | ICD10CM | Covered |
| R40.2111 | ICD10CM | Covered |
| R40.2112 | ICD10CM | Covered |
| R40.2113 | ICD10CM | Covered |
| R40.2114 | ICD10CM | Covered |
| R40.2120 | ICD10CM | Covered |
| R40.2121 | ICD10CM | Covered |
| R40.2122 | ICD10CM | Covered |
| R40.2123 | ICD10CM | Covered |
| R40.2124 | ICD10CM | Covered |
| R40.2210 | ICD10CM | Covered |
| R40.2211 | ICD10CM | Covered |
| R40.2212 | ICD10CM | Covered |
| R40.2213 | ICD10CM | Covered |
| R40.2214 | ICD10CM | Covered |
| R40.2220 | ICD10CM | Covered |
| R40.2221 | ICD10CM | Covered |
| R40.2222 | ICD10CM | Covered |
| R40.2223 | ICD10CM | Covered |
| R40.2224 | ICD10CM | Covered |
| R40.2310 | ICD10CM | Covered |
| R40.2311 | ICD10CM | Covered |
| R40.2312 | ICD10CM | Covered |
| R40.2313 | ICD10CM | Covered |
| R40.2314 | ICD10CM | Covered |
| R40.2320 | ICD10CM | Covered |
| R40.2321 | ICD10CM | Covered |
| R40.2322 | ICD10CM | Covered |
| R40.2323 | ICD10CM | Covered |
| R40.2324 | ICD10CM | Covered |
| R40.2340 | ICD10CM | Covered |
| R40.2341 | ICD10CM | Covered |
| R40.2342 | ICD10CM | Covered |
| R40.2343 | ICD10CM | Covered |
| R40.2344 | ICD10CM | Covered |
| R40.2A | ICD10CM | Covered |
| S12.000A | ICD10CM | Covered |
| S12.000B | ICD10CM | Covered |
| S12.000D | ICD10CM | Covered |
| S12.000G | ICD10CM | Covered |
| S12.000K | ICD10CM | Covered |
| S12.000S | ICD10CM | Covered |
| S12.001A | ICD10CM | Covered |
| S12.001B | ICD10CM | Covered |
| S12.001D | ICD10CM | Covered |
| S12.001G | ICD10CM | Covered |
| S12.001K | ICD10CM | Covered |
| S12.001S | ICD10CM | Covered |
| S14.101A | ICD10CM | Covered |
| S14.101D | ICD10CM | Covered |
| S14.101S | ICD10CM | Covered |
| S14.102A | ICD10CM | Covered |
| S14.102D | ICD10CM | Covered |
| S14.102S | ICD10CM | Covered |
| S14.103A | ICD10CM | Covered |
| S14.103D | ICD10CM | Covered |
| S14.103S | ICD10CM | Covered |
| S14.104A | ICD10CM | Covered |
| S14.104D | ICD10CM | Covered |
| S14.104S | ICD10CM | Covered |
| S14.105A | ICD10CM | Covered |
| S14.105D | ICD10CM | Covered |
| S14.105S | ICD10CM | Covered |
| S14.106A | ICD10CM | Covered |
| S14.106D | ICD10CM | Covered |
| S14.106S | ICD10CM | Covered |
| S14.107A | ICD10CM | Covered |
| S14.107D | ICD10CM | Covered |
| S14.107S | ICD10CM | Covered |
| S14.108A | ICD10CM | Covered |
| S14.108D | ICD10CM | Covered |
| S14.108S | ICD10CM | Covered |
| S14.109A | ICD10CM | Covered |
| S14.109D | ICD10CM | Covered |
| S14.109S | ICD10CM | Covered |
| S24.101A | ICD10CM | Covered |
| S24.101D | ICD10CM | Covered |
| S24.101S | ICD10CM | Covered |
| S24.102A | ICD10CM | Covered |
| S24.102D | ICD10CM | Covered |
| S24.102S | ICD10CM | Covered |
| S24.103A | ICD10CM | Covered |
| S24.103D | ICD10CM | Covered |
| S24.103S | ICD10CM | Covered |
| S24.104A | ICD10CM | Covered |
| S24.104D | ICD10CM | Covered |
| S24.104S | ICD10CM | Covered |
| S24.109A | ICD10CM | Covered |
| S24.109D | ICD10CM | Covered |
| S24.109S | ICD10CM | Covered |
| S24.131A | ICD10CM | Covered |
| S24.131D | ICD10CM | Covered |
| S24.131S | ICD10CM | Covered |
| S24.132A | ICD10CM | Covered |
| S24.132D | ICD10CM | Covered |
| S24.132S | ICD10CM | Covered |
| S24.133A | ICD10CM | Covered |
| S24.133D | ICD10CM | Covered |
| S24.133S | ICD10CM | Covered |
| S24.134A | ICD10CM | Covered |
| S24.134D | ICD10CM | Covered |
| S24.134S | ICD10CM | Covered |
| S24.139A | ICD10CM | Covered |
| S24.139D | ICD10CM | Covered |
| S24.139S | ICD10CM | Covered |
| S24.151A | ICD10CM | Covered |
| S24.151D | ICD10CM | Covered |
| S24.151S | ICD10CM | Covered |
| S24.152A | ICD10CM | Covered |
| S24.152D | ICD10CM | Covered |
| S24.152S | ICD10CM | Covered |
| S24.153A | ICD10CM | Covered |
| S24.153D | ICD10CM | Covered |
| S24.153S | ICD10CM | Covered |
| S24.154A | ICD10CM | Covered |
| S24.154D | ICD10CM | Covered |
| S24.154S | ICD10CM | Covered |
| S24.159A | ICD10CM | Covered |
| S24.159D | ICD10CM | Covered |
| S24.159S | ICD10CM | Covered |
| S34.101A | ICD10CM | Covered |
| S34.101D | ICD10CM | Covered |
| S34.101S | ICD10CM | Covered |
| S34.102A | ICD10CM | Covered |
| S34.102D | ICD10CM | Covered |
| S34.102S | ICD10CM | Covered |
| S34.103A | ICD10CM | Covered |
| S34.103D | ICD10CM | Covered |
| S34.103S | ICD10CM | Covered |
| S34.104A | ICD10CM | Covered |
| S34.104D | ICD10CM | Covered |
| S34.104S | ICD10CM | Covered |
| S34.105A | ICD10CM | Covered |
| S34.105D | ICD10CM | Covered |
| S34.105S | ICD10CM | Covered |
| S34.109A | ICD10CM | Covered |
| S34.109D | ICD10CM | Covered |
| S34.109S | ICD10CM | Covered |
| S34.139A | ICD10CM | Covered |
| S34.139D | ICD10CM | Covered |
| S34.139S | ICD10CM | Covered |