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 |
|---|---|---|
| 11600 | HCPCS | Covered |
| 11601 | HCPCS | Covered |
| 11602 | HCPCS | Covered |
| 11603 | HCPCS | Covered |
| 11604 | HCPCS | Covered |
| 11606 | HCPCS | Covered |
| 11620 | HCPCS | Covered |
| 11621 | HCPCS | Covered |
| 11622 | HCPCS | Covered |
| 11623 | HCPCS | Covered |
| 11624 | HCPCS | Covered |
| 11626 | HCPCS | Covered |
| 11640 | HCPCS | Covered |
| 11641 | HCPCS | Covered |
| 11642 | HCPCS | Covered |
| 11643 | HCPCS | Covered |
| 11644 | HCPCS | Covered |
| 11646 | HCPCS | Covered |
| C00.0 | ICD10CM | Covered |
| C00.1 | ICD10CM | Covered |
| C00.2 | ICD10CM | Covered |
| C00.3 | ICD10CM | Covered |
| C00.4 | ICD10CM | Covered |
| C00.5 | ICD10CM | Covered |
| C00.6 | ICD10CM | Covered |
| C00.8 | ICD10CM | Covered |
| C00.9 | ICD10CM | Covered |
| C01 | ICD10CM | Covered |
| C02.0 | ICD10CM | Covered |
| C02.1 | ICD10CM | Covered |
| C02.2 | ICD10CM | Covered |
| C02.3 | ICD10CM | Covered |
| C02.4 | ICD10CM | Covered |
| C02.8 | ICD10CM | Covered |
| C02.9 | ICD10CM | Covered |
| C03.0 | ICD10CM | Covered |
| C03.1 | ICD10CM | Covered |
| C03.9 | ICD10CM | Covered |
| C04.0 | ICD10CM | Covered |
| C04.1 | ICD10CM | Covered |
| C04.8 | ICD10CM | Covered |
| C04.9 | ICD10CM | Covered |
| C05.0 | ICD10CM | Covered |
| C05.1 | ICD10CM | Covered |
| C05.2 | ICD10CM | Covered |
| C05.8 | ICD10CM | Covered |
| C05.9 | ICD10CM | Covered |
| C06.0 | ICD10CM | Covered |
| C06.1 | ICD10CM | Covered |
| C06.2 | ICD10CM | Covered |
| C06.80 | ICD10CM | Covered |
| C06.89 | ICD10CM | Covered |
| C06.9 | ICD10CM | Covered |
| C07 | ICD10CM | Covered |
| C08.0 | ICD10CM | Covered |
| C08.1 | ICD10CM | Covered |
| C08.9 | ICD10CM | Covered |
| C09.0 | ICD10CM | Covered |
| C09.1 | ICD10CM | Covered |
| C09.8 | ICD10CM | Covered |
| C09.9 | ICD10CM | Covered |
| C10.0 | ICD10CM | Covered |
| C10.1 | ICD10CM | Covered |
| C10.2 | ICD10CM | Covered |
| C10.3 | ICD10CM | Covered |
| C10.4 | ICD10CM | Covered |
| C10.8 | ICD10CM | Covered |
| C10.9 | ICD10CM | Covered |
| C11.0 | ICD10CM | Covered |
| C11.1 | ICD10CM | Covered |
| C11.2 | ICD10CM | Covered |
| C11.3 | ICD10CM | Covered |
| C11.8 | ICD10CM | Covered |
| C11.9 | ICD10CM | Covered |
| C12 | ICD10CM | Covered |
| C13.0 | ICD10CM | Covered |
| C13.1 | ICD10CM | Covered |
| C13.2 | ICD10CM | Covered |
| C13.8 | ICD10CM | Covered |
| C13.9 | ICD10CM | Covered |
| C14.0 | ICD10CM | Covered |
| C14.2 | ICD10CM | Covered |
| C14.8 | ICD10CM | Covered |
| C43.0 | ICD10CM | Covered |
| C43.10 | ICD10CM | Covered |
| C43.111 | ICD10CM | Covered |
| C43.112 | ICD10CM | Covered |
| C43.121 | ICD10CM | Covered |
| C43.122 | ICD10CM | Covered |
| C43.20 | ICD10CM | Covered |
| C43.21 | ICD10CM | Covered |
| C43.22 | ICD10CM | Covered |
| C43.30 | ICD10CM | Covered |
| C43.31 | ICD10CM | Covered |
| C43.39 | ICD10CM | Covered |
| C43.4 | ICD10CM | Covered |
| C43.51 | ICD10CM | Covered |
| C43.52 | ICD10CM | Covered |
| C43.59 | ICD10CM | Covered |
| C43.60 | ICD10CM | Covered |
| C43.61 | ICD10CM | Covered |
| C43.62 | ICD10CM | Covered |
| C43.70 | ICD10CM | Covered |
| C43.71 | ICD10CM | Covered |
| C43.72 | ICD10CM | Covered |
| C43.8 | ICD10CM | Covered |
| C44.00 | ICD10CM | Covered |
| C44.01 | ICD10CM | Covered |
| C44.02 | ICD10CM | Covered |
| C44.09 | ICD10CM | Covered |
| C44.101 | ICD10CM | Covered |
| C44.1021 | ICD10CM | Covered |
| C44.1022 | ICD10CM | Covered |
| C44.1091 | ICD10CM | Covered |
| C44.1092 | ICD10CM | Covered |
| C44.111 | ICD10CM | Covered |
| C44.1121 | ICD10CM | Covered |
| C44.1122 | ICD10CM | Covered |
| C44.1191 | ICD10CM | Covered |
| C44.1192 | ICD10CM | Covered |
| C44.121 | ICD10CM | Covered |
| C44.1221 | ICD10CM | Covered |
| C44.1222 | ICD10CM | Covered |
| C44.1291 | ICD10CM | Covered |
| C44.1292 | ICD10CM | Covered |
| C44.131 | ICD10CM | Covered |
| C44.1321 | ICD10CM | Covered |
| C44.1322 | ICD10CM | Covered |
| C44.1391 | ICD10CM | Covered |
| C44.1392 | ICD10CM | Covered |
| C44.191 | ICD10CM | Covered |
| C44.1921 | ICD10CM | Covered |
| C44.1922 | ICD10CM | Covered |
| C44.1991 | ICD10CM | Covered |
| C44.1992 | ICD10CM | Covered |
| C44.201 | ICD10CM | Covered |
| C44.202 | ICD10CM | Covered |
| C44.209 | ICD10CM | Covered |
| C44.211 | ICD10CM | Covered |
| C44.212 | ICD10CM | Covered |
| C44.219 | ICD10CM | Covered |
| C44.221 | ICD10CM | Covered |
| C44.222 | ICD10CM | Covered |
| C44.229 | ICD10CM | Covered |
| C44.291 | ICD10CM | Covered |
| C44.292 | ICD10CM | Covered |
| C44.299 | ICD10CM | Covered |
| C44.300 | ICD10CM | Covered |
| C44.301 | ICD10CM | Covered |
| C44.309 | ICD10CM | Covered |
| C44.310 | ICD10CM | Covered |
| C44.311 | ICD10CM | Covered |
| C44.319 | ICD10CM | Covered |
| C44.320 | ICD10CM | Covered |
| C44.321 | ICD10CM | Covered |
| C44.329 | ICD10CM | Covered |
| C44.390 | ICD10CM | Covered |
| C44.391 | ICD10CM | Covered |
| C44.399 | ICD10CM | Covered |
| C44.40 | ICD10CM | Covered |
| C44.41 | ICD10CM | Covered |
| C44.42 | ICD10CM | Covered |
| C44.49 | ICD10CM | Covered |
| C44.500 | ICD10CM | Covered |
| C44.501 | ICD10CM | Covered |
| C44.509 | ICD10CM | Covered |
| C44.510 | ICD10CM | Covered |
| C44.511 | ICD10CM | Covered |
| C44.519 | ICD10CM | Covered |
| C44.520 | ICD10CM | Covered |
| C44.521 | ICD10CM | Covered |
| C44.529 | ICD10CM | Covered |
| C44.590 | ICD10CM | Covered |
| C44.591 | ICD10CM | Covered |
| C44.599 | ICD10CM | Covered |
| C44.601 | ICD10CM | Covered |
| C44.602 | ICD10CM | Covered |
| C44.609 | ICD10CM | Covered |
| C44.611 | ICD10CM | Covered |
| C44.612 | ICD10CM | Covered |
| C44.619 | ICD10CM | Covered |
| C44.621 | ICD10CM | Covered |
| C44.622 | ICD10CM | Covered |
| C44.629 | ICD10CM | Covered |
| C44.691 | ICD10CM | Covered |
| C44.692 | ICD10CM | Covered |
| C44.699 | ICD10CM | Covered |
| C44.701 | ICD10CM | Covered |
| C44.702 | ICD10CM | Covered |
| C44.709 | ICD10CM | Covered |
| C44.711 | ICD10CM | Covered |
| C44.712 | ICD10CM | Covered |
| C44.719 | ICD10CM | Covered |
| C44.721 | ICD10CM | Covered |
| C44.722 | ICD10CM | Covered |
| C44.729 | ICD10CM | Covered |
| C44.791 | ICD10CM | Covered |
| C44.792 | ICD10CM | Covered |
| C44.799 | ICD10CM | Covered |
| C44.80 | ICD10CM | Covered |
| C44.81 | ICD10CM | Covered |
| C44.82 | ICD10CM | Covered |
| C44.89 | ICD10CM | Covered |
| C4A.0 | ICD10CM | Covered |
| C4A.10 | ICD10CM | Covered |
| C4A.111 | ICD10CM | Covered |
| C4A.112 | ICD10CM | Covered |
| C4A.121 | ICD10CM | Covered |
| C4A.122 | ICD10CM | Covered |
| C4A.20 | ICD10CM | Covered |
| C4A.21 | ICD10CM | Covered |
| C4A.22 | ICD10CM | Covered |
| C4A.30 | ICD10CM | Covered |
| C4A.31 | ICD10CM | Covered |
| C4A.39 | ICD10CM | Covered |
| C4A.4 | ICD10CM | Covered |
| C4A.51 | ICD10CM | Covered |
| C4A.52 | ICD10CM | Covered |
| C4A.59 | ICD10CM | Covered |
| C4A.60 | ICD10CM | Covered |
| C4A.61 | ICD10CM | Covered |
| C4A.62 | ICD10CM | Covered |
| C4A.70 | ICD10CM | Covered |
| C4A.71 | ICD10CM | Covered |
| C4A.72 | ICD10CM | Covered |
| C4A.8 | ICD10CM | Covered |
| C4A.9 | ICD10CM | Covered |
| C51.0 | ICD10CM | Covered |
| C51.1 | ICD10CM | Covered |
| C51.2 | ICD10CM | Covered |
| C51.8 | ICD10CM | Covered |
| C51.9 | ICD10CM | Covered |
| C52 | ICD10CM | Covered |
| C57.7 | ICD10CM | Covered |
| C57.8 | ICD10CM | Covered |
| C60.0 | ICD10CM | Covered |
| C60.1 | ICD10CM | Covered |
| C60.2 | ICD10CM | Covered |
| C60.8 | ICD10CM | Covered |
| C60.9 | ICD10CM | Covered |
| C63.2 | ICD10CM | Covered |
| C76.0 | ICD10CM | Covered |
| C76.1 | ICD10CM | Covered |
| C76.2 | ICD10CM | Covered |
| C76.3 | ICD10CM | Covered |
| C76.40 | ICD10CM | Covered |
| C76.41 | ICD10CM | Covered |
| C76.42 | ICD10CM | Covered |
| C76.50 | ICD10CM | Covered |
| C76.51 | ICD10CM | Covered |
| C76.52 | ICD10CM | Covered |
| C76.8 | ICD10CM | Covered |
| C79.2 | ICD10CM | Covered |
| C79.81 | ICD10CM | Covered |
| C79.82 | ICD10CM | Covered |
| D00.00 | ICD10CM | Covered |
| D00.01 | ICD10CM | Covered |
| D00.02 | ICD10CM | Covered |
| D00.03 | ICD10CM | Covered |
| D00.04 | ICD10CM | Covered |
| D00.05 | ICD10CM | Covered |
| D00.06 | ICD10CM | Covered |
| D00.07 | ICD10CM | Covered |
| D00.08 | ICD10CM | Covered |
| D03.0 | ICD10CM | Covered |
| D03.10 | ICD10CM | Covered |
| D03.111 | ICD10CM | Covered |
| D03.112 | ICD10CM | Covered |
| D03.121 | ICD10CM | Covered |
| D03.122 | ICD10CM | Covered |
| D03.20 | ICD10CM | Covered |
| D03.21 | ICD10CM | Covered |
| D03.22 | ICD10CM | Covered |
| D03.30 | ICD10CM | Covered |
| D03.39 | ICD10CM | Covered |
| D03.4 | ICD10CM | Covered |
| D03.51 | ICD10CM | Covered |
| D03.52 | ICD10CM | Covered |
| D03.59 | ICD10CM | Covered |
| D03.60 | ICD10CM | Covered |
| D03.61 | ICD10CM | Covered |
| D03.62 | ICD10CM | Covered |
| D03.70 | ICD10CM | Covered |
| D03.71 | ICD10CM | Covered |
| D03.72 | ICD10CM | Covered |
| D03.8 | ICD10CM | Covered |
| D04.0 | ICD10CM | Covered |
| D04.10 | ICD10CM | Covered |
| D04.111 | ICD10CM | Covered |
| D04.112 | ICD10CM | Covered |
| D04.121 | ICD10CM | Covered |
| D04.122 | ICD10CM | Covered |
| D04.20 | ICD10CM | Covered |
| D04.21 | ICD10CM | Covered |
| D04.22 | ICD10CM | Covered |
| D04.30 | ICD10CM | Covered |
| D04.39 | ICD10CM | Covered |
| D04.4 | ICD10CM | Covered |
| D04.5 | ICD10CM | Covered |
| D04.60 | ICD10CM | Covered |
| D04.61 | ICD10CM | Covered |
| D04.62 | ICD10CM | Covered |
| D04.70 | ICD10CM | Covered |
| D04.71 | ICD10CM | Covered |
| D04.72 | ICD10CM | Covered |
| D04.8 | ICD10CM | Covered |
| D07.1 | ICD10CM | Covered |
| D07.2 | ICD10CM | Covered |
| D07.30 | ICD10CM | Covered |
| D07.39 | ICD10CM | Covered |
| D07.4 | ICD10CM | Covered |
| D07.60 | ICD10CM | Covered |
| D07.61 | ICD10CM | Covered |
| D07.69 | ICD10CM | Covered |
| D48.5 | ICD10CM | Covered |