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 |
|---|---|---|
| 17311 | HCPCS | Covered |
| 17312 | HCPCS | Covered |
| 17313 | HCPCS | Covered |
| 17314 | HCPCS | Covered |
| 17315 | 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 |
| C21.1 | ICD10CM | Covered |
| C30.0 | ICD10CM | Covered |
| C31.0 | ICD10CM | Covered |
| C31.2 | 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 |
| C44.01 | ICD10CM | Covered |
| C44.02 | ICD10CM | Covered |
| C44.09 | 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 |
| C44.211 | 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 |
| C44.310 | 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 |
| C44.41 | ICD10CM | Covered |
| C44.42 | ICD10CM | Covered |
| C44.49 | 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 |
| C44.611 | 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 |
| C44.711 | 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 |
| C44.81 | 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 |
| C50.011 | ICD10CM | Covered |
| C50.012 | ICD10CM | Covered |
| C50.019 | ICD10CM | Covered |
| C50.021 | ICD10CM | Covered |
| C50.022 | ICD10CM | Covered |
| C50.029 | ICD10CM | Covered |
| C51.0 | ICD10CM | Covered |
| C51.1 | ICD10CM | Covered |
| C52 | ICD10CM | Covered |
| C60.1 | ICD10CM | Covered |
| C60.2 | ICD10CM | Covered |
| C63.2 | ICD10CM | Covered |
| D00.01 | 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 |
| D07.4 | ICD10CM | Covered |