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 |
|---|---|---|
| 22510 | HCPCS | Covered |
| 22511 | HCPCS | Covered |
| 22512 | HCPCS | Covered |
| 22513 | HCPCS | Covered |
| 22514 | HCPCS | Covered |
| 22515 | HCPCS | Covered |
| C41.2 | ICD10CM | Covered |
| C79.51 | ICD10CM | Covered |
| C79.52 | ICD10CM | Covered |
| C90.00 | ICD10CM | Covered |
| C90.01 | ICD10CM | Covered |
| C90.02 | ICD10CM | Covered |
| C96.5 | ICD10CM | Covered |
| C96.6 | ICD10CM | Covered |
| C96.A | ICD10CM | Covered |
| D16.6 | ICD10CM | Covered |
| D47.1 | ICD10CM | Covered |
| E24.0 | ICD10CM | Covered |
| E24.1 | ICD10CM | Covered |
| E24.2 | ICD10CM | Covered |
| E24.3 | ICD10CM | Covered |
| E24.4 | ICD10CM | Covered |
| E24.8 | ICD10CM | Covered |
| E24.9 | ICD10CM | Covered |
| M48.33 | ICD10CM | Covered |
| M48.34 | ICD10CM | Covered |
| M48.35 | ICD10CM | Covered |
| M48.36 | ICD10CM | Covered |
| M48.37 | ICD10CM | Covered |
| M80.08XA | ICD10CM | Covered |
| M80.08XS | ICD10CM | Covered |
| M80.88XA | ICD10CM | Covered |
| M80.88XS | ICD10CM | Covered |
| M81.6 | ICD10CM | Covered |
| M84.58XA | ICD10CM | Covered |
| M84.58XD | ICD10CM | Covered |
| M84.58XG | ICD10CM | Covered |
| M84.58XK | ICD10CM | Covered |
| M84.58XP | ICD10CM | Covered |
| M84.58XS | ICD10CM | Covered |
| S12.690A | ICD10CM | Covered |
| S12.691A | ICD10CM | Covered |
| S22.010A | ICD10CM | Covered |
| S22.011A | ICD10CM | Covered |
| S22.012A | ICD10CM | Covered |
| S22.018A | ICD10CM | Covered |
| S22.020A | ICD10CM | Covered |
| S22.021A | ICD10CM | Covered |
| S22.022A | ICD10CM | Covered |
| S22.028A | ICD10CM | Covered |
| S22.030A | ICD10CM | Covered |
| S22.031A | ICD10CM | Covered |
| S22.032A | ICD10CM | Covered |
| S22.038A | ICD10CM | Covered |
| S22.040A | ICD10CM | Covered |
| S22.041A | ICD10CM | Covered |
| S22.042A | ICD10CM | Covered |
| S22.048A | ICD10CM | Covered |
| S22.050A | ICD10CM | Covered |
| S22.051A | ICD10CM | Covered |
| S22.052A | ICD10CM | Covered |
| S22.058A | ICD10CM | Covered |
| S22.060A | ICD10CM | Covered |
| S22.061A | ICD10CM | Covered |
| S22.062A | ICD10CM | Covered |
| S22.068A | ICD10CM | Covered |
| S22.070A | ICD10CM | Covered |
| S22.071A | ICD10CM | Covered |
| S22.072A | ICD10CM | Covered |
| S22.078A | ICD10CM | Covered |
| S22.080A | ICD10CM | Covered |
| S22.081A | ICD10CM | Covered |
| S22.082A | ICD10CM | Covered |
| S22.088A | ICD10CM | Covered |
| S32.010A | ICD10CM | Covered |
| S32.011A | ICD10CM | Covered |
| S32.012A | ICD10CM | Covered |
| S32.018A | ICD10CM | Covered |
| S32.020A | ICD10CM | Covered |
| S32.021A | ICD10CM | Covered |
| S32.022A | ICD10CM | Covered |
| S32.028A | ICD10CM | Covered |
| S32.030A | ICD10CM | Covered |
| S32.031A | ICD10CM | Covered |
| S32.032A | ICD10CM | Covered |
| S32.038A | ICD10CM | Covered |
| S32.040A | ICD10CM | Covered |
| S32.041A | ICD10CM | Covered |
| S32.042A | ICD10CM | Covered |
| S32.048A | ICD10CM | Covered |
| S32.050A | ICD10CM | Covered |
| S32.051A | ICD10CM | Covered |
| S32.052A | ICD10CM | Covered |
| S32.058A | ICD10CM | Covered |
| T38.0X5A | ICD10CM | Covered |
| T38.0X5D | ICD10CM | Covered |
| T38.0X5S | ICD10CM | Covered |