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 |
|---|---|---|
| 90785 | HCPCS | Covered |
| 90791 | HCPCS | Covered |
| 90792 | HCPCS | Covered |
| 96127 | HCPCS | Covered |
| 96146 | HCPCS | Covered |
| 96160 | HCPCS | Covered |
| 96161 | HCPCS | Covered |
| 99202 | HCPCS | Covered |
| 99203 | HCPCS | Covered |
| 99204 | HCPCS | Covered |
| 99205 | HCPCS | Covered |
| 99211 | HCPCS | Covered |
| 99212 | HCPCS | Covered |
| 99213 | HCPCS | Covered |
| 99214 | HCPCS | Covered |
| 99215 | HCPCS | Covered |
| 99242 | HCPCS | Covered |
| 99243 | HCPCS | Covered |
| 99244 | HCPCS | Covered |
| 99245 | HCPCS | Covered |
| 99341 | HCPCS | Covered |
| 99342 | HCPCS | Covered |
| 99344 | HCPCS | Covered |
| 99345 | HCPCS | Covered |
| 99347 | HCPCS | Covered |
| 99348 | HCPCS | Covered |
| 99349 | HCPCS | Covered |
| 99350 | HCPCS | Covered |
| 99366 | HCPCS | Covered |
| 99367 | HCPCS | Covered |
| 99368 | HCPCS | Covered |
| 99483 | HCPCS | Covered |
| 99497 | HCPCS | Covered |
| 99498 | HCPCS | Covered |
| 99605 | HCPCS | Covered |
| 99606 | HCPCS | Covered |
| 99607 | HCPCS | Covered |
| F01.50 | ICD10CM | Covered |
| F01.A0 | ICD10CM | Covered |
| F01.A11 | ICD10CM | Covered |
| F01.A18 | ICD10CM | Covered |
| F01.A2 | ICD10CM | Covered |
| F01.A3 | ICD10CM | Covered |
| F01.A4 | ICD10CM | Covered |
| F01.B0 | ICD10CM | Covered |
| F01.B11 | ICD10CM | Covered |
| F01.B18 | ICD10CM | Covered |
| F01.B2 | ICD10CM | Covered |
| F01.B3 | ICD10CM | Covered |
| F01.B4 | ICD10CM | Covered |
| F01.C0 | ICD10CM | Covered |
| F01.C11 | ICD10CM | Covered |
| F01.C18 | ICD10CM | Covered |
| F01.C2 | ICD10CM | Covered |
| F01.C3 | ICD10CM | Covered |
| F01.C4 | ICD10CM | Covered |
| F02.80 | ICD10CM | Covered |
| F02.A0 | ICD10CM | Covered |
| F02.A11 | ICD10CM | Covered |
| F02.A18 | ICD10CM | Covered |
| F02.A2 | ICD10CM | Covered |
| F02.A3 | ICD10CM | Covered |
| F02.A4 | ICD10CM | Covered |
| F02.B0 | ICD10CM | Covered |
| F02.B11 | ICD10CM | Covered |
| F02.B18 | ICD10CM | Covered |
| F02.B2 | ICD10CM | Covered |
| F02.B3 | ICD10CM | Covered |
| F02.B4 | ICD10CM | Covered |
| F02.C0 | ICD10CM | Covered |
| F02.C11 | ICD10CM | Covered |
| F02.C18 | ICD10CM | Covered |
| F02.C2 | ICD10CM | Covered |
| F02.C3 | ICD10CM | Covered |
| F02.C4 | ICD10CM | Covered |
| F03.90 | ICD10CM | Covered |
| F03.911 | ICD10CM | Covered |
| F03.918 | ICD10CM | Covered |
| F03.92 | ICD10CM | Covered |
| F03.93 | ICD10CM | Covered |
| F03.94 | ICD10CM | Covered |
| F03.A0 | ICD10CM | Covered |
| F03.A11 | ICD10CM | Covered |
| F03.A18 | ICD10CM | Covered |
| F03.A2 | ICD10CM | Covered |
| F03.A3 | ICD10CM | Covered |
| F03.A4 | ICD10CM | Covered |
| F03.B0 | ICD10CM | Covered |
| F03.B11 | ICD10CM | Covered |
| F03.B18 | ICD10CM | Covered |
| F03.B2 | ICD10CM | Covered |
| F03.B3 | ICD10CM | Covered |
| F03.B4 | ICD10CM | Covered |
| F03.C0 | ICD10CM | Covered |
| F03.C11 | ICD10CM | Covered |
| F03.C18 | ICD10CM | Covered |
| F03.C2 | ICD10CM | Covered |
| F03.C3 | ICD10CM | Covered |
| F03.C4 | ICD10CM | Covered |
| F06.70 | ICD10CM | Covered |
| F06.71 | ICD10CM | Covered |
| F10.27 | ICD10CM | Covered |
| F10.97 | ICD10CM | Covered |
| F13.27 | ICD10CM | Covered |
| F13.288 | ICD10CM | Covered |
| F13.97 | ICD10CM | Covered |
| F18.17 | ICD10CM | Covered |
| F18.188 | ICD10CM | Covered |
| F18.27 | ICD10CM | Covered |
| F18.288 | ICD10CM | Covered |
| F18.97 | ICD10CM | Covered |
| F18.988 | ICD10CM | Covered |
| F19.17 | ICD10CM | Covered |
| F19.188 | ICD10CM | Covered |
| F19.27 | ICD10CM | Covered |
| F19.288 | ICD10CM | Covered |
| F19.97 | ICD10CM | Covered |
| F19.988 | ICD10CM | Covered |
| G10 | ICD10CM | Covered |
| G30.0 | ICD10CM | Covered |
| G30.1 | ICD10CM | Covered |
| G30.8 | ICD10CM | Covered |
| G31.01 | ICD10CM | Covered |
| G31.09 | ICD10CM | Covered |
| G31.2 | ICD10CM | Covered |
| G31.80 | ICD10CM | Covered |
| G31.83 | ICD10CM | Covered |
| G31.84 | ICD10CM | Covered |
| G31.85 | ICD10CM | Covered |
| G31.86 | ICD10CM | Covered |
| G31.87 | ICD10CM | Covered |
| I69.010 | ICD10CM | Covered |
| I69.011 | ICD10CM | Covered |
| I69.014 | ICD10CM | Covered |
| I69.015 | ICD10CM | Covered |
| I69.210 | ICD10CM | Covered |
| I69.211 | ICD10CM | Covered |
| I69.214 | ICD10CM | Covered |
| I69.215 | ICD10CM | Covered |
| I69.310 | ICD10CM | Covered |
| I69.311 | ICD10CM | Covered |
| I69.314 | ICD10CM | Covered |
| I69.315 | ICD10CM | Covered |
| I69.810 | ICD10CM | Covered |
| I69.811 | ICD10CM | Covered |
| I69.814 | ICD10CM | Covered |
| I69.815 | ICD10CM | Covered |
| R41.81 | ICD10CM | Covered |