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 |
|---|---|---|
| 11730 | HCPCS | Covered |
| 11732 | HCPCS | Covered |
| 11750 | HCPCS | Covered |
| 11765 | HCPCS | Covered |
| B35.1 | ICD10CM | Covered |
| I96 | ICD10CM | Covered |
| L03.011 | ICD10CM | Covered |
| L03.012 | ICD10CM | Covered |
| L03.031 | ICD10CM | Covered |
| L03.032 | ICD10CM | Covered |
| L40.0 | ICD10CM | Covered |
| L40.1 | ICD10CM | Covered |
| L40.2 | ICD10CM | Covered |
| L40.3 | ICD10CM | Covered |
| L40.4 | ICD10CM | Covered |
| L40.8 | ICD10CM | Covered |
| L43.0 | ICD10CM | Covered |
| L43.3 | ICD10CM | Covered |
| L43.8 | ICD10CM | Covered |
| L60.0 | ICD10CM | Covered |
| L60.1 | ICD10CM | Covered |
| L60.2 | ICD10CM | Covered |
| L60.3 | ICD10CM | Covered |
| L60.4 | ICD10CM | Covered |
| L60.5 | ICD10CM | Covered |
| L60.8 | ICD10CM | Covered |
| Q84.3 | ICD10CM | Covered |
| Q84.4 | ICD10CM | Covered |
| Q84.5 | ICD10CM | Covered |
| Q84.6 | ICD10CM | Covered |
| S60.111A | ICD10CM | Covered |
| S60.111D | ICD10CM | Covered |
| S60.111S | ICD10CM | Covered |
| S60.112A | ICD10CM | Covered |
| S60.112D | ICD10CM | Covered |
| S60.112S | ICD10CM | Covered |
| S60.121A | ICD10CM | Covered |
| S60.121D | ICD10CM | Covered |
| S60.121S | ICD10CM | Covered |
| S60.122A | ICD10CM | Covered |
| S60.122D | ICD10CM | Covered |
| S60.122S | ICD10CM | Covered |
| S60.131A | ICD10CM | Covered |
| S60.131D | ICD10CM | Covered |
| S60.131S | ICD10CM | Covered |
| S60.132A | ICD10CM | Covered |
| S60.132D | ICD10CM | Covered |
| S60.132S | ICD10CM | Covered |
| S60.141A | ICD10CM | Covered |
| S60.141D | ICD10CM | Covered |
| S60.141S | ICD10CM | Covered |
| S60.142A | ICD10CM | Covered |
| S60.142D | ICD10CM | Covered |
| S60.142S | ICD10CM | Covered |
| S60.151A | ICD10CM | Covered |
| S60.151D | ICD10CM | Covered |
| S60.151S | ICD10CM | Covered |
| S60.152A | ICD10CM | Covered |
| S60.152D | ICD10CM | Covered |
| S60.152S | ICD10CM | Covered |
| S61.111A | ICD10CM | Covered |
| S61.111D | ICD10CM | Covered |
| S61.111S | ICD10CM | Covered |
| S61.112A | ICD10CM | Covered |
| S61.112D | ICD10CM | Covered |
| S61.112S | ICD10CM | Covered |
| S61.121A | ICD10CM | Covered |
| S61.121D | ICD10CM | Covered |
| S61.121S | ICD10CM | Covered |
| S61.122A | ICD10CM | Covered |
| S61.122D | ICD10CM | Covered |
| S61.122S | ICD10CM | Covered |
| S61.131A | ICD10CM | Covered |
| S61.131D | ICD10CM | Covered |
| S61.131S | ICD10CM | Covered |
| S61.132A | ICD10CM | Covered |
| S61.132D | ICD10CM | Covered |
| S61.132S | ICD10CM | Covered |
| S61.141A | ICD10CM | Covered |
| S61.141D | ICD10CM | Covered |
| S61.141S | ICD10CM | Covered |
| S61.142A | ICD10CM | Covered |
| S61.142D | ICD10CM | Covered |
| S61.142S | ICD10CM | Covered |
| S61.151A | ICD10CM | Covered |
| S61.151D | ICD10CM | Covered |
| S61.151S | ICD10CM | Covered |
| S61.152A | ICD10CM | Covered |
| S61.152D | ICD10CM | Covered |
| S61.152S | ICD10CM | Covered |
| S61.310A | ICD10CM | Covered |
| S61.310D | ICD10CM | Covered |
| S61.310S | ICD10CM | Covered |
| S61.311A | ICD10CM | Covered |
| S61.311D | ICD10CM | Covered |
| S61.311S | ICD10CM | Covered |
| S61.312A | ICD10CM | Covered |
| S61.312D | ICD10CM | Covered |
| S61.312S | ICD10CM | Covered |
| S61.313A | ICD10CM | Covered |
| S61.313D | ICD10CM | Covered |
| S61.313S | ICD10CM | Covered |
| S61.314A | ICD10CM | Covered |
| S61.314D | ICD10CM | Covered |
| S61.314S | ICD10CM | Covered |
| S61.315A | ICD10CM | Covered |
| S61.315D | ICD10CM | Covered |
| S61.315S | ICD10CM | Covered |
| S61.316A | ICD10CM | Covered |
| S61.316D | ICD10CM | Covered |
| S61.316S | ICD10CM | Covered |
| S61.317A | ICD10CM | Covered |
| S61.317D | ICD10CM | Covered |
| S61.317S | ICD10CM | Covered |
| S61.320A | ICD10CM | Covered |
| S61.320D | ICD10CM | Covered |
| S61.320S | ICD10CM | Covered |
| S61.321A | ICD10CM | Covered |
| S61.321D | ICD10CM | Covered |
| S61.321S | ICD10CM | Covered |
| S61.322A | ICD10CM | Covered |
| S61.322D | ICD10CM | Covered |
| S61.322S | ICD10CM | Covered |
| S61.323A | ICD10CM | Covered |
| S61.323D | ICD10CM | Covered |
| S61.323S | ICD10CM | Covered |
| S61.324A | ICD10CM | Covered |
| S61.324D | ICD10CM | Covered |
| S61.324S | ICD10CM | Covered |
| S61.325A | ICD10CM | Covered |
| S61.325D | ICD10CM | Covered |
| S61.325S | ICD10CM | Covered |
| S61.326A | ICD10CM | Covered |
| S61.326D | ICD10CM | Covered |
| S61.326S | ICD10CM | Covered |
| S61.327A | ICD10CM | Covered |
| S61.327D | ICD10CM | Covered |
| S61.327S | ICD10CM | Covered |
| S61.330A | ICD10CM | Covered |
| S61.330D | ICD10CM | Covered |
| S61.330S | ICD10CM | Covered |
| S61.331A | ICD10CM | Covered |
| S61.331D | ICD10CM | Covered |
| S61.331S | ICD10CM | Covered |
| S61.332A | ICD10CM | Covered |
| S61.332D | ICD10CM | Covered |
| S61.332S | ICD10CM | Covered |
| S61.333A | ICD10CM | Covered |
| S61.333D | ICD10CM | Covered |
| S61.333S | ICD10CM | Covered |
| S61.334A | ICD10CM | Covered |
| S61.334D | ICD10CM | Covered |
| S61.334S | ICD10CM | Covered |
| S61.335A | ICD10CM | Covered |
| S61.335D | ICD10CM | Covered |
| S61.335S | ICD10CM | Covered |
| S61.336A | ICD10CM | Covered |
| S61.336D | ICD10CM | Covered |
| S61.336S | ICD10CM | Covered |
| S61.337A | ICD10CM | Covered |
| S61.337D | ICD10CM | Covered |
| S61.337S | ICD10CM | Covered |
| S61.340A | ICD10CM | Covered |
| S61.340D | ICD10CM | Covered |
| S61.340S | ICD10CM | Covered |
| S61.341A | ICD10CM | Covered |
| S61.341D | ICD10CM | Covered |
| S61.341S | ICD10CM | Covered |
| S61.342A | ICD10CM | Covered |
| S61.342D | ICD10CM | Covered |
| S61.342S | ICD10CM | Covered |
| S61.343A | ICD10CM | Covered |
| S61.343D | ICD10CM | Covered |
| S61.343S | ICD10CM | Covered |
| S61.344A | ICD10CM | Covered |
| S61.344D | ICD10CM | Covered |
| S61.344S | ICD10CM | Covered |
| S61.345A | ICD10CM | Covered |
| S61.345D | ICD10CM | Covered |
| S61.345S | ICD10CM | Covered |
| S61.346A | ICD10CM | Covered |
| S61.346D | ICD10CM | Covered |
| S61.346S | ICD10CM | Covered |
| S61.347A | ICD10CM | Covered |
| S61.347D | ICD10CM | Covered |
| S61.347S | ICD10CM | Covered |
| S61.350A | ICD10CM | Covered |
| S61.350D | ICD10CM | Covered |
| S61.350S | ICD10CM | Covered |
| S61.351A | ICD10CM | Covered |
| S61.351D | ICD10CM | Covered |
| S61.351S | ICD10CM | Covered |
| S61.352A | ICD10CM | Covered |
| S61.352D | ICD10CM | Covered |
| S61.352S | ICD10CM | Covered |
| S61.353A | ICD10CM | Covered |
| S61.353D | ICD10CM | Covered |
| S61.353S | ICD10CM | Covered |
| S61.354A | ICD10CM | Covered |
| S61.354D | ICD10CM | Covered |
| S61.354S | ICD10CM | Covered |
| S61.355A | ICD10CM | Covered |
| S61.355D | ICD10CM | Covered |
| S61.355S | ICD10CM | Covered |
| S61.356A | ICD10CM | Covered |
| S61.356D | ICD10CM | Covered |
| S61.356S | ICD10CM | Covered |
| S61.357A | ICD10CM | Covered |
| S61.357D | ICD10CM | Covered |
| S61.357S | ICD10CM | Covered |
| S67.01XA | ICD10CM | Covered |
| S67.01XD | ICD10CM | Covered |
| S67.01XS | ICD10CM | Covered |
| S67.02XA | ICD10CM | Covered |
| S67.02XD | ICD10CM | Covered |
| S67.02XS | ICD10CM | Covered |
| S67.190A | ICD10CM | Covered |
| S67.190D | ICD10CM | Covered |
| S67.190S | ICD10CM | Covered |
| S67.191A | ICD10CM | Covered |
| S67.191D | ICD10CM | Covered |
| S67.191S | ICD10CM | Covered |
| S67.192A | ICD10CM | Covered |
| S67.192D | ICD10CM | Covered |
| S67.192S | ICD10CM | Covered |
| S67.193A | ICD10CM | Covered |
| S67.193D | ICD10CM | Covered |
| S67.193S | ICD10CM | Covered |
| S67.194A | ICD10CM | Covered |
| S67.194D | ICD10CM | Covered |
| S67.194S | ICD10CM | Covered |
| S67.195A | ICD10CM | Covered |
| S67.195D | ICD10CM | Covered |
| S67.195S | ICD10CM | Covered |
| S67.196A | ICD10CM | Covered |
| S67.196D | ICD10CM | Covered |
| S67.196S | ICD10CM | Covered |
| S67.197A | ICD10CM | Covered |
| S67.197D | ICD10CM | Covered |
| S67.197S | ICD10CM | Covered |
| S90.211A | ICD10CM | Covered |
| S90.211D | ICD10CM | Covered |
| S90.211S | ICD10CM | Covered |
| S90.212A | ICD10CM | Covered |
| S90.212D | ICD10CM | Covered |
| S90.212S | ICD10CM | Covered |
| S90.221A | ICD10CM | Covered |
| S90.221D | ICD10CM | Covered |
| S90.221S | ICD10CM | Covered |
| S90.222A | ICD10CM | Covered |
| S90.222D | ICD10CM | Covered |
| S90.222S | ICD10CM | Covered |
| S91.211A | ICD10CM | Covered |
| S91.211D | ICD10CM | Covered |
| S91.211S | ICD10CM | Covered |
| S91.212A | ICD10CM | Covered |
| S91.212D | ICD10CM | Covered |
| S91.212S | ICD10CM | Covered |
| S91.214A | ICD10CM | Covered |
| S91.214D | ICD10CM | Covered |
| S91.214S | ICD10CM | Covered |
| S91.215A | ICD10CM | Covered |
| S91.215D | ICD10CM | Covered |
| S91.215S | ICD10CM | Covered |
| S91.221A | ICD10CM | Covered |
| S91.221D | ICD10CM | Covered |
| S91.221S | ICD10CM | Covered |
| S91.222A | ICD10CM | Covered |
| S91.222D | ICD10CM | Covered |
| S91.222S | ICD10CM | Covered |
| S91.224A | ICD10CM | Covered |
| S91.224D | ICD10CM | Covered |
| S91.224S | ICD10CM | Covered |
| S91.225A | ICD10CM | Covered |
| S91.225D | ICD10CM | Covered |
| S91.225S | ICD10CM | Covered |
| S91.231A | ICD10CM | Covered |
| S91.231D | ICD10CM | Covered |
| S91.231S | ICD10CM | Covered |
| S91.232A | ICD10CM | Covered |
| S91.232D | ICD10CM | Covered |
| S91.232S | ICD10CM | Covered |
| S91.234A | ICD10CM | Covered |
| S91.234D | ICD10CM | Covered |
| S91.234S | ICD10CM | Covered |
| S91.235A | ICD10CM | Covered |
| S91.235D | ICD10CM | Covered |
| S91.235S | ICD10CM | Covered |
| S91.241A | ICD10CM | Covered |
| S91.241D | ICD10CM | Covered |
| S91.241S | ICD10CM | Covered |
| S91.242A | ICD10CM | Covered |
| S91.242D | ICD10CM | Covered |
| S91.242S | ICD10CM | Covered |
| S91.244A | ICD10CM | Covered |
| S91.244D | ICD10CM | Covered |
| S91.244S | ICD10CM | Covered |
| S91.245A | ICD10CM | Covered |
| S91.245D | ICD10CM | Covered |
| S91.245S | ICD10CM | Covered |
| S91.251A | ICD10CM | Covered |
| S91.251D | ICD10CM | Covered |
| S91.251S | ICD10CM | Covered |
| S91.252A | ICD10CM | Covered |
| S91.252D | ICD10CM | Covered |
| S91.252S | ICD10CM | Covered |
| S91.254A | ICD10CM | Covered |
| S91.254D | ICD10CM | Covered |
| S91.254S | ICD10CM | Covered |
| S91.255A | ICD10CM | Covered |
| S91.255D | ICD10CM | Covered |
| S91.255S | ICD10CM | Covered |
| S97.111A | ICD10CM | Covered |
| S97.111D | ICD10CM | Covered |
| S97.111S | ICD10CM | Covered |
| S97.112A | ICD10CM | Covered |
| S97.112D | ICD10CM | Covered |
| S97.112S | ICD10CM | Covered |
| S97.121A | ICD10CM | Covered |
| S97.121D | ICD10CM | Covered |
| S97.121S | ICD10CM | Covered |
| S97.122A | ICD10CM | Covered |
| S97.122D | ICD10CM | Covered |
| S97.122S | ICD10CM | Covered |
| T23.311A | ICD10CM | Covered |
| T23.311D | ICD10CM | Covered |
| T23.311S | ICD10CM | Covered |
| T23.312A | ICD10CM | Covered |
| T23.312D | ICD10CM | Covered |
| T23.312S | ICD10CM | Covered |
| T23.321A | ICD10CM | Covered |
| T23.321D | ICD10CM | Covered |
| T23.321S | ICD10CM | Covered |
| T23.322A | ICD10CM | Covered |
| T23.322D | ICD10CM | Covered |
| T23.322S | ICD10CM | Covered |
| T23.331A | ICD10CM | Covered |
| T23.331D | ICD10CM | Covered |
| T23.331S | ICD10CM | Covered |
| T23.332A | ICD10CM | Covered |
| T23.332D | ICD10CM | Covered |
| T23.332S | ICD10CM | Covered |
| T23.341A | ICD10CM | Covered |
| T23.341D | ICD10CM | Covered |
| T23.341S | ICD10CM | Covered |
| T23.342A | ICD10CM | Covered |
| T23.342D | ICD10CM | Covered |
| T23.342S | ICD10CM | Covered |
| T23.711A | ICD10CM | Covered |
| T23.711D | ICD10CM | Covered |
| T23.711S | ICD10CM | Covered |
| T23.712A | ICD10CM | Covered |
| T23.712D | ICD10CM | Covered |
| T23.712S | ICD10CM | Covered |
| T23.721A | ICD10CM | Covered |
| T23.721D | ICD10CM | Covered |
| T23.721S | ICD10CM | Covered |
| T23.722A | ICD10CM | Covered |
| T23.722D | ICD10CM | Covered |
| T23.722S | ICD10CM | Covered |
| T23.731A | ICD10CM | Covered |
| T23.731D | ICD10CM | Covered |
| T23.731S | ICD10CM | Covered |
| T23.732A | ICD10CM | Covered |
| T23.732D | ICD10CM | Covered |
| T23.732S | ICD10CM | Covered |
| T23.741A | ICD10CM | Covered |
| T23.741D | ICD10CM | Covered |
| T23.741S | ICD10CM | Covered |
| T23.742A | ICD10CM | Covered |
| T23.742D | ICD10CM | Covered |
| T23.742S | ICD10CM | Covered |
| T25.331A | ICD10CM | Covered |
| T25.331D | ICD10CM | Covered |
| T25.331S | ICD10CM | Covered |
| T25.332A | ICD10CM | Covered |
| T25.332D | ICD10CM | Covered |
| T25.332S | ICD10CM | Covered |
| T25.731A | ICD10CM | Covered |
| T25.731D | ICD10CM | Covered |
| T25.731S | ICD10CM | Covered |
| T25.732A | ICD10CM | Covered |
| T25.732D | ICD10CM | Covered |
| T25.732S | ICD10CM | Covered |
| T33.531A | ICD10CM | Covered |
| T33.531D | ICD10CM | Covered |
| T33.531S | ICD10CM | Covered |
| T33.532A | ICD10CM | Covered |
| T33.532D | ICD10CM | Covered |
| T33.532S | ICD10CM | Covered |
| T33.831A | ICD10CM | Covered |
| T33.831D | ICD10CM | Covered |
| T33.831S | ICD10CM | Covered |
| T33.832A | ICD10CM | Covered |
| T33.832D | ICD10CM | Covered |
| T33.832S | ICD10CM | Covered |