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 |
|---|---|---|
| 63650 | HCPCS | Covered |
| 63655 | HCPCS | Covered |
| 63663 | HCPCS | Covered |
| 63664 | HCPCS | Covered |
| 63685 | HCPCS | Covered |
| A18.01 | ICD10CM | Covered |
| B02.23 | ICD10CM | Covered |
| B02.29 | ICD10CM | Covered |
| E08.41 | ICD10CM | Covered |
| E09.41 | ICD10CM | Covered |
| E10.41 | ICD10CM | Covered |
| E10.42 | ICD10CM | Covered |
| E11.41 | ICD10CM | Covered |
| E11.42 | ICD10CM | Covered |
| E13.41 | ICD10CM | Covered |
| G54.6 | ICD10CM | Covered |
| G54.8 | ICD10CM | Covered |
| G57.70 | ICD10CM | Covered |
| G57.71 | ICD10CM | Covered |
| G57.72 | ICD10CM | Covered |
| G57.73 | ICD10CM | Covered |
| G58.8 | ICD10CM | Covered |
| G58.9 | ICD10CM | Covered |
| G59 | ICD10CM | Covered |
| G89.0 | ICD10CM | Covered |
| G89.21 | ICD10CM | Covered |
| G89.22 | ICD10CM | Covered |
| G89.3 | ICD10CM | Covered |
| G89.4 | ICD10CM | Covered |
| G90.50 | ICD10CM | Covered |
| G90.511 | ICD10CM | Covered |
| G90.512 | ICD10CM | Covered |
| G90.513 | ICD10CM | Covered |
| G90.519 | ICD10CM | Covered |
| G90.521 | ICD10CM | Covered |
| G90.522 | ICD10CM | Covered |
| G90.523 | ICD10CM | Covered |
| G90.529 | ICD10CM | Covered |
| G90.59 | ICD10CM | Covered |
| G95.20 | ICD10CM | Covered |
| G95.29 | ICD10CM | Covered |
| G95.81 | ICD10CM | Covered |
| G95.89 | ICD10CM | Covered |
| G95.9 | ICD10CM | Covered |
| G99.2 | ICD10CM | Covered |
| M08.1 | ICD10CM | Covered |
| M25.511 | ICD10CM | Covered |
| M25.512 | ICD10CM | Covered |
| M25.551 | ICD10CM | Covered |
| M25.552 | ICD10CM | Covered |
| M43.6 | ICD10CM | Covered |
| M45.0 | ICD10CM | Covered |
| M45.1 | ICD10CM | Covered |
| M45.2 | ICD10CM | Covered |
| M45.3 | ICD10CM | Covered |
| M45.4 | ICD10CM | Covered |
| M45.5 | ICD10CM | Covered |
| M45.6 | ICD10CM | Covered |
| M45.7 | ICD10CM | Covered |
| M45.8 | ICD10CM | Covered |
| M45.9 | ICD10CM | Covered |
| M46.1 | ICD10CM | Covered |
| M46.50 | ICD10CM | Covered |
| M46.51 | ICD10CM | Covered |
| M46.52 | ICD10CM | Covered |
| M46.53 | ICD10CM | Covered |
| M46.54 | ICD10CM | Covered |
| M46.55 | ICD10CM | Covered |
| M46.56 | ICD10CM | Covered |
| M46.57 | ICD10CM | Covered |
| M46.58 | ICD10CM | Covered |
| M46.59 | ICD10CM | Covered |
| M46.80 | ICD10CM | Covered |
| M46.81 | ICD10CM | Covered |
| M46.82 | ICD10CM | Covered |
| M46.83 | ICD10CM | Covered |
| M46.84 | ICD10CM | Covered |
| M46.85 | ICD10CM | Covered |
| M46.86 | ICD10CM | Covered |
| M46.87 | ICD10CM | Covered |
| M46.88 | ICD10CM | Covered |
| M46.89 | ICD10CM | Covered |
| M47.011 | ICD10CM | Covered |
| M47.012 | ICD10CM | Covered |
| M47.013 | ICD10CM | Covered |
| M47.014 | ICD10CM | Covered |
| M47.015 | ICD10CM | Covered |
| M47.016 | ICD10CM | Covered |
| M47.019 | ICD10CM | Covered |
| M47.021 | ICD10CM | Covered |
| M47.022 | ICD10CM | Covered |
| M47.029 | ICD10CM | Covered |
| M47.10 | ICD10CM | Covered |
| M47.11 | ICD10CM | Covered |
| M47.12 | ICD10CM | Covered |
| M47.13 | ICD10CM | Covered |
| M47.14 | ICD10CM | Covered |
| M47.15 | ICD10CM | Covered |
| M47.16 | ICD10CM | Covered |
| M48.00 | ICD10CM | Covered |
| M48.01 | ICD10CM | Covered |
| M48.02 | ICD10CM | Covered |
| M48.03 | ICD10CM | Covered |
| M48.04 | ICD10CM | Covered |
| M48.05 | ICD10CM | Covered |
| M48.061 | ICD10CM | Covered |
| M48.062 | ICD10CM | Covered |
| M48.07 | ICD10CM | Covered |
| M48.08 | ICD10CM | Covered |
| M48.10 | ICD10CM | Covered |
| M48.11 | ICD10CM | Covered |
| M48.12 | ICD10CM | Covered |
| M48.13 | ICD10CM | Covered |
| M48.14 | ICD10CM | Covered |
| M48.15 | ICD10CM | Covered |
| M48.16 | ICD10CM | Covered |
| M48.17 | ICD10CM | Covered |
| M48.18 | ICD10CM | Covered |
| M48.19 | ICD10CM | Covered |
| M48.20 | ICD10CM | Covered |
| M48.21 | ICD10CM | Covered |
| M48.22 | ICD10CM | Covered |
| M48.23 | ICD10CM | Covered |
| M48.24 | ICD10CM | Covered |
| M48.25 | ICD10CM | Covered |
| M48.26 | ICD10CM | Covered |
| M48.27 | ICD10CM | Covered |
| M48.30 | ICD10CM | Covered |
| M48.31 | ICD10CM | Covered |
| M48.32 | ICD10CM | Covered |
| M48.33 | ICD10CM | Covered |
| M48.34 | ICD10CM | Covered |
| M48.35 | ICD10CM | Covered |
| M48.36 | ICD10CM | Covered |
| M48.37 | ICD10CM | Covered |
| M48.38 | ICD10CM | Covered |
| M48.8X1 | ICD10CM | Covered |
| M48.8X2 | ICD10CM | Covered |
| M48.8X3 | ICD10CM | Covered |
| M48.8X4 | ICD10CM | Covered |
| M48.8X5 | ICD10CM | Covered |
| M48.8X6 | ICD10CM | Covered |
| M48.8X7 | ICD10CM | Covered |
| M48.8X8 | ICD10CM | Covered |
| M48.8X9 | ICD10CM | Covered |
| M49.80 | ICD10CM | Covered |
| M49.81 | ICD10CM | Covered |
| M49.82 | ICD10CM | Covered |
| M49.83 | ICD10CM | Covered |
| M49.84 | ICD10CM | Covered |
| M49.85 | ICD10CM | Covered |
| M49.86 | ICD10CM | Covered |
| M49.87 | ICD10CM | Covered |
| M49.88 | ICD10CM | Covered |
| M49.89 | ICD10CM | Covered |
| M51.04 | ICD10CM | Covered |
| M51.05 | ICD10CM | Covered |
| M51.06 | ICD10CM | Covered |
| M51.14 | ICD10CM | Covered |
| M51.15 | ICD10CM | Covered |
| M51.16 | ICD10CM | Covered |
| M51.17 | ICD10CM | Covered |
| M51.24 | ICD10CM | Covered |
| M51.25 | ICD10CM | Covered |
| M51.26 | ICD10CM | Covered |
| M51.27 | ICD10CM | Covered |
| M53.0 | ICD10CM | Covered |
| M53.1 | ICD10CM | Covered |
| M53.81 | ICD10CM | Covered |
| M53.82 | ICD10CM | Covered |
| M53.83 | ICD10CM | Covered |
| M54.00 | ICD10CM | Covered |
| M54.01 | ICD10CM | Covered |
| M54.02 | ICD10CM | Covered |
| M54.11 | ICD10CM | Covered |
| M54.12 | ICD10CM | Covered |
| M54.13 | ICD10CM | Covered |
| M54.14 | ICD10CM | Covered |
| M54.15 | ICD10CM | Covered |
| M54.16 | ICD10CM | Covered |
| M54.17 | ICD10CM | Covered |
| M54.18 | ICD10CM | Covered |
| M54.2 | ICD10CM | Covered |
| M54.31 | ICD10CM | Covered |
| M54.32 | ICD10CM | Covered |
| M54.41 | ICD10CM | Covered |
| M54.42 | ICD10CM | Covered |
| M54.81 | ICD10CM | Covered |
| M67.88 | ICD10CM | Covered |
| M79.601 | ICD10CM | Covered |
| M79.602 | ICD10CM | Covered |
| M79.604 | ICD10CM | Covered |
| M79.605 | ICD10CM | Covered |
| M96.1 | ICD10CM | Covered |
| M99.20 | ICD10CM | Covered |
| M99.21 | ICD10CM | Covered |
| M99.22 | ICD10CM | Covered |
| M99.23 | ICD10CM | Covered |
| M99.24 | ICD10CM | Covered |
| M99.25 | ICD10CM | Covered |
| M99.26 | ICD10CM | Covered |
| M99.27 | ICD10CM | Covered |
| M99.28 | ICD10CM | Covered |
| M99.29 | ICD10CM | Covered |
| M99.30 | ICD10CM | Covered |
| M99.31 | ICD10CM | Covered |
| M99.32 | ICD10CM | Covered |
| M99.33 | ICD10CM | Covered |
| M99.34 | ICD10CM | Covered |
| M99.35 | ICD10CM | Covered |
| M99.36 | ICD10CM | Covered |
| M99.37 | ICD10CM | Covered |
| M99.38 | ICD10CM | Covered |
| M99.39 | ICD10CM | Covered |
| M99.40 | ICD10CM | Covered |
| M99.41 | ICD10CM | Covered |
| M99.42 | ICD10CM | Covered |
| M99.43 | ICD10CM | Covered |
| M99.44 | ICD10CM | Covered |
| M99.45 | ICD10CM | Covered |
| M99.46 | ICD10CM | Covered |
| M99.47 | ICD10CM | Covered |
| M99.48 | ICD10CM | Covered |
| M99.49 | ICD10CM | Covered |
| M99.50 | ICD10CM | Covered |
| M99.51 | ICD10CM | Covered |
| M99.52 | ICD10CM | Covered |
| M99.53 | ICD10CM | Covered |
| M99.54 | ICD10CM | Covered |
| M99.55 | ICD10CM | Covered |
| M99.56 | ICD10CM | Covered |
| M99.57 | ICD10CM | Covered |
| M99.58 | ICD10CM | Covered |
| M99.59 | ICD10CM | Covered |
| M99.60 | ICD10CM | Covered |
| M99.61 | ICD10CM | Covered |
| M99.62 | ICD10CM | Covered |
| M99.63 | ICD10CM | Covered |
| M99.64 | ICD10CM | Covered |
| M99.65 | ICD10CM | Covered |
| M99.66 | ICD10CM | Covered |
| M99.67 | ICD10CM | Covered |
| M99.68 | ICD10CM | Covered |
| M99.69 | ICD10CM | Covered |
| M99.70 | ICD10CM | Covered |
| M99.71 | ICD10CM | Covered |
| M99.72 | ICD10CM | Covered |
| M99.73 | ICD10CM | Covered |
| M99.74 | ICD10CM | Covered |
| M99.75 | ICD10CM | Covered |
| M99.76 | ICD10CM | Covered |
| M99.77 | ICD10CM | Covered |
| M99.78 | ICD10CM | Covered |
| M99.79 | ICD10CM | Covered |
| T85.112A | ICD10CM | Covered |
| T85.112D | ICD10CM | Covered |
| T85.112S | ICD10CM | Covered |
| T85.113A | ICD10CM | Covered |
| T85.113D | ICD10CM | Covered |
| T85.113S | ICD10CM | Covered |
| T85.122A | ICD10CM | Covered |
| T85.122D | ICD10CM | Covered |
| T85.122S | ICD10CM | Covered |
| T85.123A | ICD10CM | Covered |
| T85.123D | ICD10CM | Covered |
| T85.123S | ICD10CM | Covered |
| T85.192A | ICD10CM | Covered |
| T85.192D | ICD10CM | Covered |
| T85.192S | ICD10CM | Covered |
| T85.193A | ICD10CM | Covered |
| T85.193D | ICD10CM | Covered |
| T85.193S | ICD10CM | Covered |
| Z45.42 | ICD10CM | Covered |