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 |
|---|---|---|
| 0446T | HCPCS | Covered |
| 0447T | HCPCS | Covered |
| 0448T | HCPCS | Covered |
| E08.00 | ICD10CM | Covered |
| E08.01 | ICD10CM | Covered |
| E08.10 | ICD10CM | Covered |
| E08.11 | ICD10CM | Covered |
| E08.21 | ICD10CM | Covered |
| E08.22 | ICD10CM | Covered |
| E08.29 | ICD10CM | Covered |
| E08.311 | ICD10CM | Covered |
| E08.319 | ICD10CM | Covered |
| E08.3211 | ICD10CM | Covered |
| E08.3212 | ICD10CM | Covered |
| E08.3213 | ICD10CM | Covered |
| E08.3291 | ICD10CM | Covered |
| E08.3292 | ICD10CM | Covered |
| E08.3293 | ICD10CM | Covered |
| E08.3311 | ICD10CM | Covered |
| E08.3312 | ICD10CM | Covered |
| E08.3313 | ICD10CM | Covered |
| E08.3391 | ICD10CM | Covered |
| E08.3392 | ICD10CM | Covered |
| E08.3393 | ICD10CM | Covered |
| E08.3411 | ICD10CM | Covered |
| E08.3412 | ICD10CM | Covered |
| E08.3413 | ICD10CM | Covered |
| E08.3491 | ICD10CM | Covered |
| E08.3492 | ICD10CM | Covered |
| E08.3493 | ICD10CM | Covered |
| E08.3511 | ICD10CM | Covered |
| E08.3512 | ICD10CM | Covered |
| E08.3513 | ICD10CM | Covered |
| E08.3521 | ICD10CM | Covered |
| E08.3522 | ICD10CM | Covered |
| E08.3523 | ICD10CM | Covered |
| E08.3531 | ICD10CM | Covered |
| E08.3532 | ICD10CM | Covered |
| E08.3533 | ICD10CM | Covered |
| E08.3541 | ICD10CM | Covered |
| E08.3542 | ICD10CM | Covered |
| E08.3543 | ICD10CM | Covered |
| E08.3551 | ICD10CM | Covered |
| E08.3552 | ICD10CM | Covered |
| E08.3553 | ICD10CM | Covered |
| E08.3591 | ICD10CM | Covered |
| E08.3592 | ICD10CM | Covered |
| E08.3593 | ICD10CM | Covered |
| E08.36 | ICD10CM | Covered |
| E08.37X1 | ICD10CM | Covered |
| E08.37X2 | ICD10CM | Covered |
| E08.37X3 | ICD10CM | Covered |
| E08.39 | ICD10CM | Covered |
| E08.40 | 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 |
| E08.618 | ICD10CM | Covered |
| E08.620 | ICD10CM | Covered |
| E08.621 | ICD10CM | Covered |
| E08.622 | ICD10CM | Covered |
| E08.628 | ICD10CM | Covered |
| E08.630 | ICD10CM | Covered |
| E08.638 | ICD10CM | Covered |
| E08.641 | ICD10CM | Covered |
| E08.649 | ICD10CM | Covered |
| E08.65 | ICD10CM | Covered |
| E08.69 | ICD10CM | Covered |
| E08.9 | ICD10CM | Covered |
| E09.00 | ICD10CM | Covered |
| E09.01 | ICD10CM | Covered |
| E09.10 | ICD10CM | Covered |
| E09.11 | ICD10CM | Covered |
| E09.21 | ICD10CM | Covered |
| E09.22 | ICD10CM | Covered |
| E09.29 | ICD10CM | Covered |
| E09.311 | ICD10CM | Covered |
| E09.319 | ICD10CM | Covered |
| E09.3211 | ICD10CM | Covered |
| E09.3212 | ICD10CM | Covered |
| E09.3213 | ICD10CM | Covered |
| E09.3291 | ICD10CM | Covered |
| E09.3292 | ICD10CM | Covered |
| E09.3293 | ICD10CM | Covered |
| E09.3311 | ICD10CM | Covered |
| E09.3312 | ICD10CM | Covered |
| E09.3313 | ICD10CM | Covered |
| E09.3391 | ICD10CM | Covered |
| E09.3392 | ICD10CM | Covered |
| E09.3393 | ICD10CM | Covered |
| E09.3411 | ICD10CM | Covered |
| E09.3412 | ICD10CM | Covered |
| E09.3413 | ICD10CM | Covered |
| E09.3491 | ICD10CM | Covered |
| E09.3492 | ICD10CM | Covered |
| E09.3493 | ICD10CM | Covered |
| E09.3511 | ICD10CM | Covered |
| E09.3512 | ICD10CM | Covered |
| E09.3513 | ICD10CM | Covered |
| E09.3521 | ICD10CM | Covered |
| E09.3522 | ICD10CM | Covered |
| E09.3523 | ICD10CM | Covered |
| E09.3531 | ICD10CM | Covered |
| E09.3532 | ICD10CM | Covered |
| E09.3533 | ICD10CM | Covered |
| E09.3541 | ICD10CM | Covered |
| E09.3542 | ICD10CM | Covered |
| E09.3543 | ICD10CM | Covered |
| E09.3551 | ICD10CM | Covered |
| E09.3552 | ICD10CM | Covered |
| E09.3553 | ICD10CM | Covered |
| E09.3591 | ICD10CM | Covered |
| E09.3592 | ICD10CM | Covered |
| E09.3593 | ICD10CM | Covered |
| E09.36 | ICD10CM | Covered |
| E09.37X1 | ICD10CM | Covered |
| E09.37X2 | ICD10CM | Covered |
| E09.37X3 | ICD10CM | Covered |
| E09.39 | ICD10CM | Covered |
| E09.40 | ICD10CM | Covered |
| E09.41 | ICD10CM | Covered |
| E09.42 | ICD10CM | Covered |
| E09.43 | ICD10CM | Covered |
| E09.44 | ICD10CM | Covered |
| E09.49 | ICD10CM | Covered |
| E09.51 | ICD10CM | Covered |
| E09.52 | ICD10CM | Covered |
| E09.59 | ICD10CM | Covered |
| E09.610 | ICD10CM | Covered |
| E09.618 | ICD10CM | Covered |
| E09.620 | ICD10CM | Covered |
| E09.621 | ICD10CM | Covered |
| E09.622 | ICD10CM | Covered |
| E09.628 | ICD10CM | Covered |
| E09.630 | ICD10CM | Covered |
| E09.638 | ICD10CM | Covered |
| E09.641 | ICD10CM | Covered |
| E09.649 | ICD10CM | Covered |
| E09.65 | ICD10CM | Covered |
| E09.69 | ICD10CM | Covered |
| E09.9 | ICD10CM | Covered |
| E10.10 | ICD10CM | Covered |
| E10.11 | ICD10CM | Covered |
| E10.21 | ICD10CM | Covered |
| E10.22 | ICD10CM | Covered |
| E10.29 | ICD10CM | Covered |
| E10.311 | ICD10CM | Covered |
| E10.319 | ICD10CM | Covered |
| E10.3211 | ICD10CM | Covered |
| E10.3212 | ICD10CM | Covered |
| E10.3213 | ICD10CM | Covered |
| E10.3291 | ICD10CM | Covered |
| E10.3292 | ICD10CM | Covered |
| E10.3293 | ICD10CM | Covered |
| E10.3311 | ICD10CM | Covered |
| E10.3312 | ICD10CM | Covered |
| E10.3313 | ICD10CM | Covered |
| E10.3391 | ICD10CM | Covered |
| E10.3392 | ICD10CM | Covered |
| E10.3393 | ICD10CM | Covered |
| E10.3411 | ICD10CM | Covered |
| E10.3412 | ICD10CM | Covered |
| E10.3413 | ICD10CM | Covered |
| E10.3491 | ICD10CM | Covered |
| E10.3492 | ICD10CM | Covered |
| E10.3493 | ICD10CM | Covered |
| E10.3511 | ICD10CM | Covered |
| E10.3512 | ICD10CM | Covered |
| E10.3513 | ICD10CM | Covered |
| E10.3521 | ICD10CM | Covered |
| E10.3522 | ICD10CM | Covered |
| E10.3523 | ICD10CM | Covered |
| E10.3531 | ICD10CM | Covered |
| E10.3532 | ICD10CM | Covered |
| E10.3533 | ICD10CM | Covered |
| E10.3541 | ICD10CM | Covered |
| E10.3542 | ICD10CM | Covered |
| E10.3543 | ICD10CM | Covered |
| E10.3551 | ICD10CM | Covered |
| E10.3552 | ICD10CM | Covered |
| E10.3553 | ICD10CM | Covered |
| E10.3591 | ICD10CM | Covered |
| E10.3592 | ICD10CM | Covered |
| E10.3593 | ICD10CM | Covered |
| E10.36 | ICD10CM | Covered |
| E10.37X1 | ICD10CM | Covered |
| E10.37X2 | ICD10CM | Covered |
| E10.37X3 | ICD10CM | Covered |
| E10.39 | ICD10CM | Covered |
| E10.40 | 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 |
| E10.618 | ICD10CM | Covered |
| E10.620 | ICD10CM | Covered |
| E10.621 | ICD10CM | Covered |
| E10.622 | ICD10CM | Covered |
| E10.628 | ICD10CM | Covered |
| E10.630 | ICD10CM | Covered |
| E10.638 | ICD10CM | Covered |
| E10.641 | ICD10CM | Covered |
| E10.649 | ICD10CM | Covered |
| E10.65 | ICD10CM | Covered |
| E10.69 | ICD10CM | Covered |
| E10.9 | ICD10CM | Covered |
| E11.00 | ICD10CM | Covered |
| E11.01 | ICD10CM | Covered |
| E11.10 | ICD10CM | Covered |
| E11.11 | ICD10CM | Covered |
| E11.21 | ICD10CM | Covered |
| E11.22 | ICD10CM | Covered |
| E11.29 | ICD10CM | Covered |
| E11.311 | ICD10CM | Covered |
| E11.319 | ICD10CM | Covered |
| E11.3211 | ICD10CM | Covered |
| E11.3212 | ICD10CM | Covered |
| E11.3213 | ICD10CM | Covered |
| E11.3291 | ICD10CM | Covered |
| E11.3292 | ICD10CM | Covered |
| E11.3293 | ICD10CM | Covered |
| E11.3311 | ICD10CM | Covered |
| E11.3312 | ICD10CM | Covered |
| E11.3313 | ICD10CM | Covered |
| E11.3391 | ICD10CM | Covered |
| E11.3392 | ICD10CM | Covered |
| E11.3393 | ICD10CM | Covered |
| E11.3411 | ICD10CM | Covered |
| E11.3412 | ICD10CM | Covered |
| E11.3413 | ICD10CM | Covered |
| E11.3491 | ICD10CM | Covered |
| E11.3492 | ICD10CM | Covered |
| E11.3493 | ICD10CM | Covered |
| E11.3511 | ICD10CM | Covered |
| E11.3512 | ICD10CM | Covered |
| E11.3513 | ICD10CM | Covered |
| E11.3521 | ICD10CM | Covered |
| E11.3522 | ICD10CM | Covered |
| E11.3523 | ICD10CM | Covered |
| E11.3531 | ICD10CM | Covered |
| E11.3532 | ICD10CM | Covered |
| E11.3533 | ICD10CM | Covered |
| E11.3541 | ICD10CM | Covered |
| E11.3542 | ICD10CM | Covered |
| E11.3543 | ICD10CM | Covered |
| E11.3551 | ICD10CM | Covered |
| E11.3552 | ICD10CM | Covered |
| E11.3553 | ICD10CM | Covered |
| E11.3591 | ICD10CM | Covered |
| E11.3592 | ICD10CM | Covered |
| E11.3593 | ICD10CM | Covered |
| E11.36 | ICD10CM | Covered |
| E11.37X1 | ICD10CM | Covered |
| E11.37X2 | ICD10CM | Covered |
| E11.37X3 | ICD10CM | Covered |
| E11.39 | ICD10CM | Covered |
| E11.40 | 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 |
| E11.618 | ICD10CM | Covered |
| E11.620 | ICD10CM | Covered |
| E11.621 | ICD10CM | Covered |
| E11.622 | ICD10CM | Covered |
| E11.628 | ICD10CM | Covered |
| E11.630 | ICD10CM | Covered |
| E11.638 | ICD10CM | Covered |
| E11.641 | ICD10CM | Covered |
| E11.649 | ICD10CM | Covered |
| E11.65 | ICD10CM | Covered |
| E11.69 | ICD10CM | Covered |
| E11.9 | ICD10CM | Covered |
| E13.00 | ICD10CM | Covered |
| E13.01 | ICD10CM | Covered |
| E13.10 | ICD10CM | Covered |
| E13.11 | ICD10CM | Covered |
| E13.21 | ICD10CM | Covered |
| E13.22 | ICD10CM | Covered |
| E13.29 | ICD10CM | Covered |
| E13.311 | ICD10CM | Covered |
| E13.319 | ICD10CM | Covered |
| E13.3211 | ICD10CM | Covered |
| E13.3212 | ICD10CM | Covered |
| E13.3213 | ICD10CM | Covered |
| E13.3291 | ICD10CM | Covered |
| E13.3292 | ICD10CM | Covered |
| E13.3293 | ICD10CM | Covered |
| E13.3311 | ICD10CM | Covered |
| E13.3312 | ICD10CM | Covered |
| E13.3313 | ICD10CM | Covered |
| E13.3391 | ICD10CM | Covered |
| E13.3392 | ICD10CM | Covered |
| E13.3393 | ICD10CM | Covered |
| E13.3411 | ICD10CM | Covered |
| E13.3412 | ICD10CM | Covered |
| E13.3413 | ICD10CM | Covered |
| E13.3491 | ICD10CM | Covered |
| E13.3492 | ICD10CM | Covered |
| E13.3493 | ICD10CM | Covered |
| E13.3511 | ICD10CM | Covered |
| E13.3512 | ICD10CM | Covered |
| E13.3513 | ICD10CM | Covered |
| E13.3521 | ICD10CM | Covered |
| E13.3522 | ICD10CM | Covered |
| E13.3523 | ICD10CM | Covered |
| E13.3531 | ICD10CM | Covered |
| E13.3532 | ICD10CM | Covered |
| E13.3533 | ICD10CM | Covered |
| E13.3541 | ICD10CM | Covered |
| E13.3542 | ICD10CM | Covered |
| E13.3543 | ICD10CM | Covered |
| E13.3551 | ICD10CM | Covered |
| E13.3552 | ICD10CM | Covered |
| E13.3553 | ICD10CM | Covered |
| E13.3591 | ICD10CM | Covered |
| E13.3592 | ICD10CM | Covered |
| E13.3593 | ICD10CM | Covered |
| E13.36 | ICD10CM | Covered |
| E13.37X1 | ICD10CM | Covered |
| E13.37X2 | ICD10CM | Covered |
| E13.37X3 | ICD10CM | Covered |
| E13.39 | ICD10CM | Covered |
| E13.40 | ICD10CM | Covered |
| E13.41 | ICD10CM | Covered |
| E13.42 | ICD10CM | Covered |
| E13.43 | ICD10CM | Covered |
| E13.44 | ICD10CM | Covered |
| E13.49 | ICD10CM | Covered |
| E13.51 | ICD10CM | Covered |
| E13.52 | ICD10CM | Covered |
| E13.59 | ICD10CM | Covered |
| E13.610 | ICD10CM | Covered |
| E13.618 | ICD10CM | Covered |
| E13.620 | ICD10CM | Covered |
| E13.621 | ICD10CM | Covered |
| E13.622 | ICD10CM | Covered |
| E13.628 | ICD10CM | Covered |
| E13.630 | ICD10CM | Covered |
| E13.638 | ICD10CM | Covered |
| E13.641 | ICD10CM | Covered |
| E13.649 | ICD10CM | Covered |
| E13.65 | ICD10CM | Covered |
| E13.69 | ICD10CM | Covered |
| E13.9 | ICD10CM | Covered |
| O24.011 | ICD10CM | Covered |
| O24.012 | ICD10CM | Covered |
| O24.013 | ICD10CM | Covered |
| O24.02 | ICD10CM | Covered |
| O24.03 | ICD10CM | Covered |
| O24.111 | ICD10CM | Covered |
| O24.112 | ICD10CM | Covered |
| O24.113 | ICD10CM | Covered |
| O24.12 | ICD10CM | Covered |
| O24.13 | ICD10CM | Covered |
| O24.811 | ICD10CM | Covered |
| O24.812 | ICD10CM | Covered |
| O24.813 | ICD10CM | Covered |
| O24.82 | ICD10CM | Covered |
| O24.83 | ICD10CM | Covered |