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 |
|---|---|---|
| J0585 | HCPCS | Covered |
| J0586 | HCPCS | Covered |
| J0587 | HCPCS | Covered |
| J0588 | HCPCS | Covered |
| J0589 | HCPCS | Covered |
| F95.1 | ICD10CM | Covered |
| F95.2 | ICD10CM | Covered |
| G11.4 | ICD10CM | Covered |
| G24.3 | ICD10CM | Covered |
| G24.4 | ICD10CM | Covered |
| G24.5 | ICD10CM | Covered |
| G24.8 | ICD10CM | Covered |
| G25.0 | ICD10CM | Covered |
| G43.701 | ICD10CM | Covered |
| G43.709 | ICD10CM | Covered |
| G43.711 | ICD10CM | Covered |
| G43.719 | ICD10CM | Covered |
| G43.E01 | ICD10CM | Covered |
| G43.E09 | ICD10CM | Covered |
| G43.E11 | ICD10CM | Covered |
| G43.E19 | ICD10CM | Covered |
| G51.31 | ICD10CM | Covered |
| G51.32 | ICD10CM | Covered |
| G51.33 | ICD10CM | Covered |
| G80.0 | ICD10CM | Covered |
| G80.1 | ICD10CM | Covered |
| G80.2 | ICD10CM | Covered |
| G80.8 | ICD10CM | Covered |
| G81.11 | ICD10CM | Covered |
| G81.12 | ICD10CM | Covered |
| G81.13 | ICD10CM | Covered |
| G81.14 | ICD10CM | Covered |
| G83.0 | ICD10CM | Covered |
| H49.01 | ICD10CM | Covered |
| H49.02 | ICD10CM | Covered |
| H49.03 | ICD10CM | Covered |
| H49.11 | ICD10CM | Covered |
| H49.12 | ICD10CM | Covered |
| H49.13 | ICD10CM | Covered |
| H49.21 | ICD10CM | Covered |
| H49.22 | ICD10CM | Covered |
| H49.23 | ICD10CM | Covered |
| H49.31 | ICD10CM | Covered |
| H49.32 | ICD10CM | Covered |
| H49.33 | ICD10CM | Covered |
| H49.41 | ICD10CM | Covered |
| H49.42 | ICD10CM | Covered |
| H49.43 | ICD10CM | Covered |
| H49.881 | ICD10CM | Covered |
| H49.882 | ICD10CM | Covered |
| H49.883 | ICD10CM | Covered |
| H50.011 | ICD10CM | Covered |
| H50.012 | ICD10CM | Covered |
| H50.021 | ICD10CM | Covered |
| H50.022 | ICD10CM | Covered |
| H50.031 | ICD10CM | Covered |
| H50.032 | ICD10CM | Covered |
| H50.041 | ICD10CM | Covered |
| H50.042 | ICD10CM | Covered |
| H50.05 | ICD10CM | Covered |
| H50.06 | ICD10CM | Covered |
| H50.07 | ICD10CM | Covered |
| H50.08 | ICD10CM | Covered |
| H50.111 | ICD10CM | Covered |
| H50.112 | ICD10CM | Covered |
| H50.121 | ICD10CM | Covered |
| H50.122 | ICD10CM | Covered |
| H50.131 | ICD10CM | Covered |
| H50.132 | ICD10CM | Covered |
| H50.141 | ICD10CM | Covered |
| H50.142 | ICD10CM | Covered |
| H50.15 | ICD10CM | Covered |
| H50.16 | ICD10CM | Covered |
| H50.17 | ICD10CM | Covered |
| H50.18 | ICD10CM | Covered |
| H50.21 | ICD10CM | Covered |
| H50.22 | ICD10CM | Covered |
| H50.311 | ICD10CM | Covered |
| H50.312 | ICD10CM | Covered |
| H50.32 | ICD10CM | Covered |
| H50.331 | ICD10CM | Covered |
| H50.332 | ICD10CM | Covered |
| H50.34 | ICD10CM | Covered |
| H50.411 | ICD10CM | Covered |
| H50.412 | ICD10CM | Covered |
| H50.42 | ICD10CM | Covered |
| H50.43 | ICD10CM | Covered |
| H50.51 | ICD10CM | Covered |
| H50.52 | ICD10CM | Covered |
| H50.53 | ICD10CM | Covered |
| H50.54 | ICD10CM | Covered |
| H50.55 | ICD10CM | Covered |
| H50.611 | ICD10CM | Covered |
| H50.612 | ICD10CM | Covered |
| H50.69 | ICD10CM | Covered |
| H50.811 | ICD10CM | Covered |
| H50.812 | ICD10CM | Covered |
| H50.89 | ICD10CM | Covered |
| H51.11 | ICD10CM | Covered |
| H51.8 | ICD10CM | Covered |
| J38.5 | ICD10CM | Covered |
| K11.7 | ICD10CM | Covered |
| K22.0 | ICD10CM | Covered |
| K60.1 | ICD10CM | Covered |
| L74.510 | ICD10CM | Covered |
| M62.838 | ICD10CM | Covered |
| N31.9 | ICD10CM | Covered |
| N32.81 | ICD10CM | Covered |