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 |
|---|---|---|
| 0001U | HCPCS | Covered |
| 0004M | HCPCS | Covered |
| 0005U | HCPCS | Covered |
| 0006M | HCPCS | Covered |
| 0007M | HCPCS | Covered |
| 0007U | HCPCS | Covered |
| 0008U | HCPCS | Covered |
| 0009U | HCPCS | Covered |
| 0010U | HCPCS | Covered |
| 0011M | HCPCS | Covered |
| 0012M | HCPCS | Covered |
| 0013M | HCPCS | Covered |
| 0016M | HCPCS | Covered |
| 0016U | HCPCS | Covered |
| 0017M | HCPCS | Covered |
| 0017U | HCPCS | Covered |
| 0018U | HCPCS | Covered |
| 0019U | HCPCS | Covered |
| 0022U | HCPCS | Covered |
| 0023U | HCPCS | Covered |
| 0026U | HCPCS | Covered |
| 0027U | HCPCS | Covered |
| 0030U | HCPCS | Covered |
| 0032U | HCPCS | Covered |
| 0034U | HCPCS | Covered |
| 0036U | HCPCS | Covered |
| 0037U | HCPCS | Covered |
| 0040U | HCPCS | Covered |
| 0045U | HCPCS | Covered |
| 0046U | HCPCS | Covered |
| 0047U | HCPCS | Covered |
| 0048U | HCPCS | Covered |
| 0049U | HCPCS | Covered |
| 0050U | HCPCS | Covered |
| 0055U | HCPCS | Covered |
| 0060U | HCPCS | Covered |
| 0068U | HCPCS | Covered |
| 0069U | HCPCS | Covered |
| 0070U | HCPCS | Covered |
| 0071U | HCPCS | Covered |
| 0072U | HCPCS | Covered |
| 0073U | HCPCS | Covered |
| 0074U | HCPCS | Covered |
| 0075U | HCPCS | Covered |
| 0076U | HCPCS | Covered |
| 0079U | HCPCS | Covered |
| 0084U | HCPCS | Covered |
| 0086U | HCPCS | Covered |
| 0087U | HCPCS | Covered |
| 0088U | HCPCS | Covered |
| 0089U | HCPCS | Covered |
| 0090U | HCPCS | Covered |
| 0094U | HCPCS | Covered |
| 0096U | HCPCS | Covered |
| 0101U | HCPCS | Covered |
| 0102U | HCPCS | Covered |
| 0103U | HCPCS | Covered |
| 0109U | HCPCS | Covered |
| 0111U | HCPCS | Covered |
| 0112U | HCPCS | Covered |
| 0113U | HCPCS | Covered |
| 0114U | HCPCS | Covered |
| 0118U | HCPCS | Covered |
| 0120U | HCPCS | Covered |
| 0129U | HCPCS | Covered |
| 0130U | HCPCS | Covered |
| 0133U | HCPCS | Covered |
| 0134U | HCPCS | Covered |
| 0136U | HCPCS | Covered |
| 0137U | HCPCS | Covered |
| 0138U | HCPCS | Covered |
| 0140U | HCPCS | Covered |
| 0141U | HCPCS | Covered |
| 0142U | HCPCS | Covered |
| 0152U | HCPCS | Covered |
| 0153U | HCPCS | Covered |
| 0154U | HCPCS | Covered |
| 0155U | HCPCS | Covered |
| 0156U | HCPCS | Covered |
| 0157U | HCPCS | Covered |
| 0158U | HCPCS | Covered |
| 0159U | HCPCS | Covered |
| 0160U | HCPCS | Covered |
| 0161U | HCPCS | Covered |
| 0162U | HCPCS | Covered |
| 0169U | HCPCS | Covered |
| 0170U | HCPCS | Covered |
| 0171U | HCPCS | Covered |
| 0172U | HCPCS | Covered |
| 0173U | HCPCS | Covered |
| 0175U | HCPCS | Covered |
| 0177U | HCPCS | Covered |
| 0179U | HCPCS | Covered |
| 0180U | HCPCS | Covered |
| 0181U | HCPCS | Covered |
| 0182U | HCPCS | Covered |
| 0183U | HCPCS | Covered |
| 0184U | HCPCS | Covered |
| 0185U | HCPCS | Covered |
| 0186U | HCPCS | Covered |
| 0187U | HCPCS | Covered |
| 0188U | HCPCS | Covered |
| 0189U | HCPCS | Covered |
| 0190U | HCPCS | Covered |
| 0191U | HCPCS | Covered |
| 0192U | HCPCS | Covered |
| 0193U | HCPCS | Covered |
| 0194U | HCPCS | Covered |
| 0195U | HCPCS | Covered |
| 0196U | HCPCS | Covered |
| 0197U | HCPCS | Covered |
| 0198U | HCPCS | Covered |
| 0199U | HCPCS | Covered |
| 0200U | HCPCS | Covered |
| 0201U | HCPCS | Covered |
| 0203U | HCPCS | Covered |
| 0205U | HCPCS | Covered |
| 0209U | HCPCS | Covered |
| 0211U | HCPCS | Covered |
| 0212U | HCPCS | Covered |
| 0213U | HCPCS | Covered |
| 0214U | HCPCS | Covered |
| 0215U | HCPCS | Covered |
| 0216U | HCPCS | Covered |
| 0217U | HCPCS | Covered |
| 0218U | HCPCS | Covered |
| 0219U | HCPCS | Covered |
| 0221U | HCPCS | Covered |
| 0222U | HCPCS | Covered |
| 0227U | HCPCS | Covered |
| 0229U | HCPCS | Covered |
| 0230U | HCPCS | Covered |
| 0231U | HCPCS | Covered |
| 0232U | HCPCS | Covered |
| 0233U | HCPCS | Covered |
| 0234U | HCPCS | Covered |
| 0235U | HCPCS | Covered |
| 0236U | HCPCS | Covered |
| 0237U | HCPCS | Covered |
| 0238U | HCPCS | Covered |
| 0239U | HCPCS | Covered |
| 0242U | HCPCS | Covered |
| 0244U | HCPCS | Covered |
| 0245U | HCPCS | Covered |
| 0246U | HCPCS | Covered |
| 0250U | HCPCS | Covered |
| 0252U | HCPCS | Covered |
| 0253U | HCPCS | Covered |
| 0254U | HCPCS | Covered |
| 0258U | HCPCS | Covered |
| 0260U | HCPCS | Covered |
| 0262U | HCPCS | Covered |
| 0264U | HCPCS | Covered |
| 0265U | HCPCS | Covered |
| 0266U | HCPCS | Covered |
| 0267U | HCPCS | Covered |
| 0268U | HCPCS | Covered |
| 0269U | HCPCS | Covered |
| 0270U | HCPCS | Covered |
| 0271U | HCPCS | Covered |
| 0272U | HCPCS | Covered |
| 0273U | HCPCS | Covered |
| 0274U | HCPCS | Covered |
| 0276U | HCPCS | Covered |
| 0277U | HCPCS | Covered |
| 0278U | HCPCS | Covered |
| 0282U | HCPCS | Covered |
| 0285U | HCPCS | Covered |
| 0286U | HCPCS | Covered |
| 0287U | HCPCS | Covered |
| 0288U | HCPCS | Covered |
| 0289U | HCPCS | Covered |
| 0290U | HCPCS | Covered |
| 0291U | HCPCS | Covered |
| 0292U | HCPCS | Covered |
| 0293U | HCPCS | Covered |
| 0294U | HCPCS | Covered |
| 0296U | HCPCS | Covered |
| 0297U | HCPCS | Covered |
| 0298U | HCPCS | Covered |
| 0299U | HCPCS | Covered |
| 0300U | HCPCS | Covered |
| 0301U | HCPCS | Covered |
| 0302U | HCPCS | Covered |
| 0306U | HCPCS | Covered |
| 0307U | HCPCS | Covered |
| 0313U | HCPCS | Covered |
| 0314U | HCPCS | Covered |
| 0315U | HCPCS | Covered |
| 0317U | HCPCS | Covered |
| 0326U | HCPCS | Covered |
| 0329U | HCPCS | Covered |
| 0331U | HCPCS | Covered |
| 0332U | HCPCS | Covered |
| 0333U | HCPCS | Covered |
| 0334U | HCPCS | Covered |
| 0335U | HCPCS | Covered |
| 0336U | HCPCS | Covered |
| 0339U | HCPCS | Covered |
| 0340U | HCPCS | Covered |
| 0341U | HCPCS | Covered |
| 0343U | HCPCS | Covered |
| 0355U | HCPCS | Covered |
| 0356U | HCPCS | Covered |
| 0362U | HCPCS | Covered |
| 0363U | HCPCS | Covered |
| 0364U | HCPCS | Covered |
| 0368U | HCPCS | Covered |
| 0371U | HCPCS | Covered |
| 0372U | HCPCS | Covered |
| 0378U | HCPCS | Covered |
| 0379U | HCPCS | Covered |
| 0388U | HCPCS | Covered |
| 0389U | HCPCS | Covered |
| 0391U | HCPCS | Covered |
| 0392U | HCPCS | Covered |
| 0398U | HCPCS | Covered |
| 0400U | HCPCS | Covered |
| 0403U | HCPCS | Covered |
| 0405U | HCPCS | Covered |
| 0409U | HCPCS | Covered |
| 0410U | HCPCS | Covered |
| 0411U | HCPCS | Covered |
| 0413U | HCPCS | Covered |
| 0417U | HCPCS | Covered |
| 0419U | HCPCS | Covered |
| 0420U | HCPCS | Covered |
| 0424U | HCPCS | Covered |
| 0433U | HCPCS | Covered |
| 0444U | HCPCS | Covered |
| 0463U | HCPCS | Covered |
| 0466U | HCPCS | Covered |
| 0470U | HCPCS | Covered |
| 0473U | HCPCS | Covered |
| 0478U | HCPCS | Covered |
| 0481U | HCPCS | Covered |
| 0485U | HCPCS | Covered |
| 0494U | HCPCS | Covered |
| 0560U | HCPCS | Covered |
| 0561U | HCPCS | Covered |
| 0562U | HCPCS | Covered |
| 0582U | HCPCS | Covered |
| 0583U | HCPCS | Covered |
| 0585U | HCPCS | Covered |
| 0586U | HCPCS | Covered |
| 0591U | HCPCS | Covered |
| 0592U | HCPCS | Covered |
| 0605U | HCPCS | Covered |
| 0628U | HCPCS | Covered |
| 0634U | HCPCS | Covered |
| 81105 | HCPCS | Covered |
| 81106 | HCPCS | Covered |
| 81107 | HCPCS | Covered |
| 81108 | HCPCS | Covered |
| 81109 | HCPCS | Covered |
| 81110 | HCPCS | Covered |
| 81111 | HCPCS | Covered |
| 81112 | HCPCS | Covered |
| 81120 | HCPCS | Covered |
| 81121 | HCPCS | Covered |
| 81161 | HCPCS | Covered |
| 81162 | HCPCS | Covered |
| 81163 | HCPCS | Covered |
| 81164 | HCPCS | Covered |
| 81165 | HCPCS | Covered |
| 81166 | HCPCS | Covered |
| 81167 | HCPCS | Covered |
| 81168 | HCPCS | Covered |
| 81170 | HCPCS | Covered |
| 81171 | HCPCS | Covered |
| 81172 | HCPCS | Covered |
| 81173 | HCPCS | Covered |
| 81174 | HCPCS | Covered |
| 81175 | HCPCS | Covered |
| 81176 | HCPCS | Covered |
| 81177 | HCPCS | Covered |
| 81178 | HCPCS | Covered |
| 81179 | HCPCS | Covered |
| 81180 | HCPCS | Covered |
| 81181 | HCPCS | Covered |
| 81182 | HCPCS | Covered |
| 81183 | HCPCS | Covered |
| 81184 | HCPCS | Covered |
| 81185 | HCPCS | Covered |
| 81186 | HCPCS | Covered |
| 81187 | HCPCS | Covered |
| 81188 | HCPCS | Covered |
| 81189 | HCPCS | Covered |
| 81190 | HCPCS | Covered |
| 81191 | HCPCS | Covered |
| 81192 | HCPCS | Covered |
| 81193 | HCPCS | Covered |
| 81194 | HCPCS | Covered |
| 81195 | HCPCS | Covered |
| 81200 | HCPCS | Covered |
| 81201 | HCPCS | Covered |
| 81202 | HCPCS | Covered |
| 81203 | HCPCS | Covered |
| 81204 | HCPCS | Covered |
| 81205 | HCPCS | Covered |
| 81206 | HCPCS | Covered |
| 81207 | HCPCS | Covered |
| 81208 | HCPCS | Covered |
| 81209 | HCPCS | Covered |
| 81210 | HCPCS | Covered |
| 81212 | HCPCS | Covered |
| 81215 | HCPCS | Covered |
| 81216 | HCPCS | Covered |
| 81217 | HCPCS | Covered |
| 81218 | HCPCS | Covered |
| 81219 | HCPCS | Covered |
| 81220 | HCPCS | Covered |
| 81221 | HCPCS | Covered |
| 81222 | HCPCS | Covered |
| 81223 | HCPCS | Covered |
| 81224 | HCPCS | Covered |
| 81225 | HCPCS | Covered |
| 81226 | HCPCS | Covered |
| 81227 | HCPCS | Covered |
| 81228 | HCPCS | Covered |
| 81229 | HCPCS | Covered |
| 81230 | HCPCS | Covered |
| 81231 | HCPCS | Covered |
| 81232 | HCPCS | Covered |
| 81233 | HCPCS | Covered |
| 81234 | HCPCS | Covered |
| 81235 | HCPCS | Covered |
| 81236 | HCPCS | Covered |
| 81237 | HCPCS | Covered |
| 81238 | HCPCS | Covered |
| 81239 | HCPCS | Covered |
| 81240 | HCPCS | Covered |
| 81241 | HCPCS | Covered |
| 81242 | HCPCS | Covered |
| 81243 | HCPCS | Covered |
| 81244 | HCPCS | Covered |
| 81245 | HCPCS | Covered |
| 81246 | HCPCS | Covered |
| 81247 | HCPCS | Covered |
| 81248 | HCPCS | Covered |
| 81249 | HCPCS | Covered |
| 81250 | HCPCS | Covered |
| 81251 | HCPCS | Covered |
| 81252 | HCPCS | Covered |
| 81253 | HCPCS | Covered |
| 81254 | HCPCS | Covered |
| 81255 | HCPCS | Covered |
| 81256 | HCPCS | Covered |
| 81257 | HCPCS | Covered |
| 81258 | HCPCS | Covered |
| 81259 | HCPCS | Covered |
| 81260 | HCPCS | Covered |
| 81261 | HCPCS | Covered |
| 81262 | HCPCS | Covered |
| 81263 | HCPCS | Covered |
| 81264 | HCPCS | Covered |
| 81265 | HCPCS | Covered |
| 81266 | HCPCS | Covered |
| 81267 | HCPCS | Covered |
| 81268 | HCPCS | Covered |
| 81269 | HCPCS | Covered |
| 81270 | HCPCS | Covered |
| 81271 | HCPCS | Covered |
| 81272 | HCPCS | Covered |
| 81273 | HCPCS | Covered |
| 81274 | HCPCS | Covered |
| 81275 | HCPCS | Covered |
| 81276 | HCPCS | Covered |
| 81277 | HCPCS | Covered |
| 81278 | HCPCS | Covered |
| 81279 | HCPCS | Covered |
| 81283 | HCPCS | Covered |
| 81284 | HCPCS | Covered |
| 81285 | HCPCS | Covered |
| 81286 | HCPCS | Covered |
| 81287 | HCPCS | Covered |
| 81288 | HCPCS | Covered |
| 81289 | HCPCS | Covered |
| 81290 | HCPCS | Covered |
| 81291 | HCPCS | Covered |
| 81292 | HCPCS | Covered |
| 81293 | HCPCS | Covered |
| 81294 | HCPCS | Covered |
| 81295 | HCPCS | Covered |
| 81296 | HCPCS | Covered |
| 81297 | HCPCS | Covered |
| 81298 | HCPCS | Covered |
| 81299 | HCPCS | Covered |
| 81300 | HCPCS | Covered |
| 81301 | HCPCS | Covered |
| 81302 | HCPCS | Covered |
| 81303 | HCPCS | Covered |
| 81304 | HCPCS | Covered |
| 81305 | HCPCS | Covered |
| 81306 | HCPCS | Covered |
| 81307 | HCPCS | Covered |
| 81308 | HCPCS | Covered |
| 81309 | HCPCS | Covered |
| 81310 | HCPCS | Covered |
| 81311 | HCPCS | Covered |
| 81312 | HCPCS | Covered |
| 81313 | HCPCS | Covered |
| 81314 | HCPCS | Covered |
| 81315 | HCPCS | Covered |
| 81316 | HCPCS | Covered |
| 81317 | HCPCS | Covered |
| 81318 | HCPCS | Covered |
| 81319 | HCPCS | Covered |
| 81320 | HCPCS | Covered |
| 81321 | HCPCS | Covered |
| 81322 | HCPCS | Covered |
| 81323 | HCPCS | Covered |
| 81324 | HCPCS | Covered |
| 81325 | HCPCS | Covered |
| 81326 | HCPCS | Covered |
| 81327 | HCPCS | Covered |
| 81328 | HCPCS | Covered |
| 81329 | HCPCS | Covered |
| 81330 | HCPCS | Covered |
| 81331 | HCPCS | Covered |
| 81332 | HCPCS | Covered |
| 81333 | HCPCS | Covered |
| 81334 | HCPCS | Covered |
| 81335 | HCPCS | Covered |
| 81336 | HCPCS | Covered |
| 81337 | HCPCS | Covered |
| 81338 | HCPCS | Covered |
| 81339 | HCPCS | Covered |
| 81340 | HCPCS | Covered |
| 81341 | HCPCS | Covered |
| 81342 | HCPCS | Covered |
| 81343 | HCPCS | Covered |
| 81344 | HCPCS | Covered |
| 81345 | HCPCS | Covered |
| 81346 | HCPCS | Covered |
| 81347 | HCPCS | Covered |
| 81348 | HCPCS | Covered |
| 81349 | HCPCS | Covered |
| 81350 | HCPCS | Covered |
| 81351 | HCPCS | Covered |
| 81352 | HCPCS | Covered |
| 81353 | HCPCS | Covered |
| 81355 | HCPCS | Covered |
| 81357 | HCPCS | Covered |
| 81360 | HCPCS | Covered |
| 81361 | HCPCS | Covered |
| 81362 | HCPCS | Covered |
| 81363 | HCPCS | Covered |
| 81364 | HCPCS | Covered |
| 81370 | HCPCS | Covered |
| 81371 | HCPCS | Covered |
| 81372 | HCPCS | Covered |
| 81373 | HCPCS | Covered |
| 81374 | HCPCS | Covered |
| 81375 | HCPCS | Covered |
| 81376 | HCPCS | Covered |
| 81377 | HCPCS | Covered |
| 81378 | HCPCS | Covered |
| 81379 | HCPCS | Covered |
| 81380 | HCPCS | Covered |
| 81381 | HCPCS | Covered |
| 81382 | HCPCS | Covered |
| 81383 | HCPCS | Covered |
| 81400 | HCPCS | Covered |
| 81401 | HCPCS | Covered |
| 81402 | HCPCS | Covered |
| 81403 | HCPCS | Covered |
| 81404 | HCPCS | Covered |
| 81405 | HCPCS | Covered |
| 81406 | HCPCS | Covered |
| 81407 | HCPCS | Covered |
| 81408 | HCPCS | Covered |
| 81410 | HCPCS | Covered |
| 81411 | HCPCS | Covered |
| 81412 | HCPCS | Covered |
| 81413 | HCPCS | Covered |
| 81414 | HCPCS | Covered |
| 81415 | HCPCS | Covered |
| 81416 | HCPCS | Covered |
| 81417 | HCPCS | Covered |
| 81418 | HCPCS | Covered |
| 81419 | HCPCS | Covered |
| 81420 | HCPCS | Covered |
| 81422 | HCPCS | Covered |
| 81425 | HCPCS | Covered |
| 81426 | HCPCS | Covered |
| 81427 | HCPCS | Covered |
| 81430 | HCPCS | Covered |
| 81431 | HCPCS | Covered |
| 81432 | HCPCS | Covered |
| 81434 | HCPCS | Covered |
| 81435 | HCPCS | Covered |
| 81437 | HCPCS | Covered |
| 81439 | HCPCS | Covered |
| 81440 | HCPCS | Covered |
| 81441 | HCPCS | Covered |
| 81442 | HCPCS | Covered |
| 81443 | HCPCS | Covered |
| 81445 | HCPCS | Covered |
| 81448 | HCPCS | Covered |
| 81449 | HCPCS | Covered |
| 81450 | HCPCS | Covered |
| 81451 | HCPCS | Covered |
| 81455 | HCPCS | Covered |
| 81456 | HCPCS | Covered |
| 81457 | HCPCS | Covered |
| 81458 | HCPCS | Covered |
| 81459 | HCPCS | Covered |
| 81460 | HCPCS | Covered |
| 81462 | HCPCS | Covered |
| 81463 | HCPCS | Covered |
| 81464 | HCPCS | Covered |
| 81465 | HCPCS | Covered |
| 81470 | HCPCS | Covered |
| 81471 | HCPCS | Covered |
| 81479 | HCPCS | Covered |
| 81490 | HCPCS | Covered |
| 81493 | HCPCS | Covered |
| 81500 | HCPCS | Covered |
| 81503 | HCPCS | Covered |
| 81504 | HCPCS | Covered |
| 81506 | HCPCS | Covered |
| 81507 | HCPCS | Covered |
| 81508 | HCPCS | Covered |
| 81509 | HCPCS | Covered |
| 81510 | HCPCS | Covered |
| 81511 | HCPCS | Covered |
| 81512 | HCPCS | Covered |
| 81513 | HCPCS | Covered |
| 81514 | HCPCS | Covered |
| 81518 | HCPCS | Covered |
| 81519 | HCPCS | Covered |
| 81520 | HCPCS | Covered |
| 81521 | HCPCS | Covered |
| 81522 | HCPCS | Covered |
| 81523 | HCPCS | Covered |
| 81525 | HCPCS | Covered |
| 81528 | HCPCS | Covered |
| 81529 | HCPCS | Covered |
| 81535 | HCPCS | Covered |
| 81536 | HCPCS | Covered |
| 81538 | HCPCS | Covered |
| 81539 | HCPCS | Covered |
| 81540 | HCPCS | Covered |
| 81541 | HCPCS | Covered |
| 81542 | HCPCS | Covered |
| 81546 | HCPCS | Covered |
| 81551 | HCPCS | Covered |
| 81552 | HCPCS | Covered |
| 81554 | HCPCS | Covered |
| 81558 | HCPCS | Covered |
| 81595 | HCPCS | Covered |
| 81596 | HCPCS | Covered |
| 81599 | HCPCS | Covered |
| G0452 | HCPCS | Covered |