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 |
|---|---|---|
| 11055 | HCPCS | Covered |
| 11056 | HCPCS | Covered |
| 11057 | HCPCS | Covered |
| 11719 | HCPCS | Covered |
| 11720 | HCPCS | Covered |
| 11721 | HCPCS | Covered |
| G0127 | HCPCS | Covered |
| A30.0 | ICD10CM | Covered |
| A30.1 | ICD10CM | Covered |
| A30.2 | ICD10CM | Covered |
| A30.3 | ICD10CM | Covered |
| A30.4 | ICD10CM | Covered |
| A30.5 | ICD10CM | Covered |
| A30.8 | ICD10CM | Covered |
| A50.41 | ICD10CM | Covered |
| A50.42 | ICD10CM | Covered |
| A50.43 | ICD10CM | Covered |
| A50.45 | ICD10CM | Covered |
| A52.11 | ICD10CM | Covered |
| A52.13 | ICD10CM | Covered |
| A52.14 | ICD10CM | Covered |
| A52.15 | ICD10CM | Covered |
| A52.16 | ICD10CM | Covered |
| A52.17 | ICD10CM | Covered |
| A52.19 | ICD10CM | Covered |
| B35.1 | ICD10CM | Covered |
| D51.0 | ICD10CM | Covered |
| D81.818 | ICD10CM | Covered |
| E08.41 | ICD10CM | Covered |
| E08.42 | ICD10CM | Covered |
| E08.43 | ICD10CM | Covered |
| E08.44 | ICD10CM | Covered |
| E08.49 | ICD10CM | Covered |
| E08.51 | ICD10CM | Covered |
| E08.52 | ICD10CM | Covered |
| E08.59 | ICD10CM | Covered |
| E08.610 | ICD10CM | Covered |
| E09.42 | ICD10CM | Covered |
| E09.49 | ICD10CM | Covered |
| E09.51 | ICD10CM | Covered |
| E09.52 | ICD10CM | Covered |
| E09.59 | ICD10CM | Covered |
| E09.610 | ICD10CM | Covered |
| E10.22 | ICD10CM | Covered |
| E10.41 | ICD10CM | Covered |
| E10.42 | ICD10CM | Covered |
| E10.43 | ICD10CM | Covered |
| E10.44 | ICD10CM | Covered |
| E10.49 | ICD10CM | Covered |
| E10.51 | ICD10CM | Covered |
| E10.52 | ICD10CM | Covered |
| E10.59 | ICD10CM | Covered |
| E10.610 | ICD10CM | Covered |
| E11.22 | ICD10CM | Covered |
| E11.41 | ICD10CM | Covered |
| E11.42 | ICD10CM | Covered |
| E11.43 | ICD10CM | Covered |
| E11.44 | ICD10CM | Covered |
| E11.49 | ICD10CM | Covered |
| E11.51 | ICD10CM | Covered |
| E11.52 | ICD10CM | Covered |
| E11.59 | ICD10CM | Covered |
| E11.610 | ICD10CM | Covered |
| E13.42 | ICD10CM | Covered |
| E13.49 | ICD10CM | Covered |
| E13.51 | ICD10CM | Covered |
| E13.52 | ICD10CM | Covered |
| E13.59 | ICD10CM | Covered |
| E13.610 | ICD10CM | Covered |
| E51.11 | ICD10CM | Covered |
| E51.12 | ICD10CM | Covered |
| E52 | ICD10CM | Covered |
| E53.1 | ICD10CM | Covered |
| E53.8 | ICD10CM | Covered |
| E64.0 | ICD10CM | Covered |
| E75.21 | ICD10CM | Covered |
| E75.22 | ICD10CM | Covered |
| E75.240 | ICD10CM | Covered |
| E75.241 | ICD10CM | Covered |
| E75.242 | ICD10CM | Covered |
| E75.243 | ICD10CM | Covered |
| E75.244 | ICD10CM | Covered |
| E75.248 | ICD10CM | Covered |
| E77.0 | ICD10CM | Covered |
| E77.1 | ICD10CM | Covered |
| E77.8 | ICD10CM | Covered |
| E85.1 | ICD10CM | Covered |
| E85.3 | ICD10CM | Covered |
| E85.4 | ICD10CM | Covered |
| E85.81 | ICD10CM | Covered |
| E85.82 | ICD10CM | Covered |
| E85.89 | ICD10CM | Covered |
| G04.1 | ICD10CM | Covered |
| G11.10 | ICD10CM | Covered |
| G11.11 | ICD10CM | Covered |
| G11.19 | ICD10CM | Covered |
| G12.21 | ICD10CM | Covered |
| G13.0 | ICD10CM | Covered |
| G13.1 | 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 |
| G61.0 | ICD10CM | Covered |
| G61.1 | ICD10CM | Covered |
| G61.81 | ICD10CM | Covered |
| G61.89 | 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 |
| G63 | ICD10CM | Covered |
| G64 | ICD10CM | Covered |
| G65.0 | ICD10CM | Covered |
| G65.1 | ICD10CM | Covered |
| G65.2 | ICD10CM | Covered |
| G70.1 | ICD10CM | Covered |
| G70.81 | ICD10CM | Covered |
| G73.1 | ICD10CM | Covered |
| G73.3 | ICD10CM | Covered |
| G82.21 | ICD10CM | Covered |
| G82.22 | ICD10CM | Covered |
| G82.51 | ICD10CM | Covered |
| G82.52 | ICD10CM | Covered |
| G82.53 | ICD10CM | Covered |
| G82.54 | ICD10CM | Covered |
| G95.0 | ICD10CM | Covered |
| I70.201 | ICD10CM | Covered |
| I70.202 | ICD10CM | Covered |
| I70.203 | ICD10CM | Covered |
| I70.211 | ICD10CM | Covered |
| I70.212 | ICD10CM | Covered |
| I70.213 | ICD10CM | Covered |
| I70.221 | ICD10CM | Covered |
| I70.222 | ICD10CM | Covered |
| I70.223 | ICD10CM | Covered |
| I70.233 | ICD10CM | Covered |
| I70.234 | ICD10CM | Covered |
| I70.235 | ICD10CM | Covered |
| I70.241 | ICD10CM | Covered |
| I70.243 | ICD10CM | Covered |
| I70.244 | ICD10CM | Covered |
| I70.245 | ICD10CM | Covered |
| I70.25 | ICD10CM | Covered |
| I70.261 | ICD10CM | Covered |
| I70.262 | ICD10CM | Covered |
| I70.263 | ICD10CM | Covered |
| I70.291 | ICD10CM | Covered |
| I70.292 | ICD10CM | Covered |
| I70.293 | ICD10CM | Covered |
| I70.90 | ICD10CM | Covered |
| I70.91 | ICD10CM | Covered |
| I73.00 | ICD10CM | Covered |
| I73.01 | ICD10CM | Covered |
| I73.1 | ICD10CM | Covered |
| I73.81 | ICD10CM | Covered |
| I73.89 | ICD10CM | Covered |
| I79.1 | ICD10CM | Covered |
| I79.8 | ICD10CM | Covered |
| I80.01 | ICD10CM | Covered |
| I80.02 | ICD10CM | Covered |
| I80.03 | ICD10CM | Covered |
| I80.11 | ICD10CM | Covered |
| I80.12 | ICD10CM | Covered |
| I80.13 | ICD10CM | Covered |
| I80.211 | ICD10CM | Covered |
| I80.212 | ICD10CM | Covered |
| I80.213 | ICD10CM | Covered |
| I80.221 | ICD10CM | Covered |
| I80.222 | ICD10CM | Covered |
| I80.223 | ICD10CM | Covered |
| I80.231 | ICD10CM | Covered |
| I80.232 | ICD10CM | Covered |
| I80.233 | ICD10CM | Covered |
| I80.241 | ICD10CM | Covered |
| I80.242 | ICD10CM | Covered |
| I80.243 | ICD10CM | Covered |
| I80.251 | ICD10CM | Covered |
| I80.252 | ICD10CM | Covered |
| I80.253 | ICD10CM | Covered |
| I80.291 | ICD10CM | Covered |
| I80.292 | ICD10CM | Covered |
| I80.293 | ICD10CM | Covered |
| I82.541 | ICD10CM | Covered |
| I82.542 | ICD10CM | Covered |
| I82.543 | ICD10CM | Covered |
| I82.811 | ICD10CM | Covered |
| I82.812 | ICD10CM | Covered |
| I82.813 | ICD10CM | Covered |
| I82.891 | ICD10CM | Covered |
| I89.0 | ICD10CM | Covered |
| K90.0 | ICD10CM | Covered |
| K90.1 | ICD10CM | Covered |
| K90.2 | ICD10CM | Covered |
| K90.3 | ICD10CM | Covered |
| K91.2 | ICD10CM | Covered |
| L02.611 | ICD10CM | Covered |
| L02.612 | ICD10CM | Covered |
| L03.031 | ICD10CM | Covered |
| L03.032 | ICD10CM | Covered |
| L03.041 | ICD10CM | Covered |
| L03.042 | ICD10CM | Covered |
| L60.0 | ICD10CM | Covered |
| L60.2 | ICD10CM | Covered |
| L60.3 | ICD10CM | Covered |
| M05.471 | ICD10CM | Covered |
| M05.472 | ICD10CM | Covered |
| M05.571 | ICD10CM | Covered |
| M05.572 | ICD10CM | Covered |
| M05.771 | ICD10CM | Covered |
| M05.772 | ICD10CM | Covered |
| M05.871 | ICD10CM | Covered |
| M05.872 | ICD10CM | Covered |
| M06.071 | ICD10CM | Covered |
| M06.072 | ICD10CM | Covered |
| M06.871 | ICD10CM | Covered |
| M06.872 | ICD10CM | Covered |
| M30.0 | ICD10CM | Covered |
| M30.2 | ICD10CM | Covered |
| M30.8 | ICD10CM | Covered |
| M31.4 | ICD10CM | Covered |
| M31.7 | ICD10CM | Covered |
| M34.83 | ICD10CM | Covered |
| M79.671 | ICD10CM | Covered |
| M79.672 | ICD10CM | Covered |
| M79.674 | ICD10CM | Covered |
| M79.675 | ICD10CM | Covered |
| N18.1 | ICD10CM | Covered |
| N18.2 | ICD10CM | Covered |
| N18.30 | ICD10CM | Covered |
| N18.31 | ICD10CM | Covered |
| N18.32 | ICD10CM | Covered |
| N18.4 | ICD10CM | Covered |
| N18.5 | ICD10CM | Covered |
| N18.6 | ICD10CM | Covered |
| R26.0 | ICD10CM | Covered |
| R26.1 | ICD10CM | Covered |
| R26.2 | ICD10CM | Covered |
| R26.81 | ICD10CM | Covered |
| R26.89 | ICD10CM | Covered |