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 |
|---|---|---|
| 11981 | HCPCS | Covered |
| 11982 | HCPCS | Covered |
| 11983 | HCPCS | Covered |
| 96402 | HCPCS | Covered |
| J1950 | HCPCS | Covered |
| J1952 | HCPCS | Covered |
| J1954 | HCPCS | Covered |
| J3315 | HCPCS | Covered |
| J9202 | HCPCS | Covered |
| J9217 | HCPCS | Covered |
| J9219 | HCPCS | Covered |
| J9225 | HCPCS | Covered |
| C08.0 | ICD10CM | Covered |
| C08.1 | ICD10CM | Covered |
| C08.9 | ICD10CM | Covered |
| C48.0 | ICD10CM | Covered |
| C48.1 | ICD10CM | Covered |
| C48.2 | ICD10CM | Covered |
| C48.8 | ICD10CM | Covered |
| C50.011 | ICD10CM | Covered |
| C50.012 | ICD10CM | Covered |
| C50.019 | ICD10CM | Covered |
| C50.021 | ICD10CM | Covered |
| C50.022 | ICD10CM | Covered |
| C50.029 | ICD10CM | Covered |
| C50.111 | ICD10CM | Covered |
| C50.112 | ICD10CM | Covered |
| C50.119 | ICD10CM | Covered |
| C50.121 | ICD10CM | Covered |
| C50.122 | ICD10CM | Covered |
| C50.129 | ICD10CM | Covered |
| C50.211 | ICD10CM | Covered |
| C50.212 | ICD10CM | Covered |
| C50.219 | ICD10CM | Covered |
| C50.221 | ICD10CM | Covered |
| C50.222 | ICD10CM | Covered |
| C50.229 | ICD10CM | Covered |
| C50.311 | ICD10CM | Covered |
| C50.312 | ICD10CM | Covered |
| C50.319 | ICD10CM | Covered |
| C50.321 | ICD10CM | Covered |
| C50.322 | ICD10CM | Covered |
| C50.329 | ICD10CM | Covered |
| C50.411 | ICD10CM | Covered |
| C50.412 | ICD10CM | Covered |
| C50.419 | ICD10CM | Covered |
| C50.421 | ICD10CM | Covered |
| C50.422 | ICD10CM | Covered |
| C50.429 | ICD10CM | Covered |
| C50.511 | ICD10CM | Covered |
| C50.512 | ICD10CM | Covered |
| C50.519 | ICD10CM | Covered |
| C50.521 | ICD10CM | Covered |
| C50.522 | ICD10CM | Covered |
| C50.529 | ICD10CM | Covered |
| C50.611 | ICD10CM | Covered |
| C50.612 | ICD10CM | Covered |
| C50.619 | ICD10CM | Covered |
| C50.621 | ICD10CM | Covered |
| C50.622 | ICD10CM | Covered |
| C50.629 | ICD10CM | Covered |
| C50.811 | ICD10CM | Covered |
| C50.812 | ICD10CM | Covered |
| C50.819 | ICD10CM | Covered |
| C50.821 | ICD10CM | Covered |
| C50.822 | ICD10CM | Covered |
| C50.829 | ICD10CM | Covered |
| C50.911 | ICD10CM | Covered |
| C50.912 | ICD10CM | Covered |
| C50.919 | ICD10CM | Covered |
| C50.921 | ICD10CM | Covered |
| C50.922 | ICD10CM | Covered |
| C50.929 | ICD10CM | Covered |
| C50.A1 | ICD10CM | Covered |
| C50.A2 | ICD10CM | Covered |
| C56.1 | ICD10CM | Covered |
| C56.2 | ICD10CM | Covered |
| C56.3 | ICD10CM | Covered |
| C56.9 | ICD10CM | Covered |
| C57.00 | ICD10CM | Covered |
| C57.01 | ICD10CM | Covered |
| C57.02 | ICD10CM | Covered |
| C61 | ICD10CM | Covered |
| D05.00 | ICD10CM | Covered |
| D05.01 | ICD10CM | Covered |
| D05.02 | ICD10CM | Covered |
| D05.10 | ICD10CM | Covered |
| D05.11 | ICD10CM | Covered |
| D05.12 | ICD10CM | Covered |
| D05.80 | ICD10CM | Covered |
| D05.81 | ICD10CM | Covered |
| D05.82 | ICD10CM | Covered |
| D05.90 | ICD10CM | Covered |
| D05.91 | ICD10CM | Covered |
| D05.92 | ICD10CM | Covered |
| D07.5 | ICD10CM | Covered |
| D25.0 | ICD10CM | Covered |
| D25.1 | ICD10CM | Covered |
| D25.2 | ICD10CM | Covered |
| D25.9 | ICD10CM | Covered |
| D50.0 | ICD10CM | Covered |
| D62 | ICD10CM | Covered |
| E22.8 | ICD10CM | Covered |
| N80.01 | ICD10CM | Covered |
| N80.02 | ICD10CM | Covered |
| N80.03 | ICD10CM | Covered |
| N80.111 | ICD10CM | Covered |
| N80.112 | ICD10CM | Covered |
| N80.113 | ICD10CM | Covered |
| N80.121 | ICD10CM | Covered |
| N80.122 | ICD10CM | Covered |
| N80.123 | ICD10CM | Covered |
| N80.211 | ICD10CM | Covered |
| N80.212 | ICD10CM | Covered |
| N80.213 | ICD10CM | Covered |
| N80.219 | ICD10CM | Covered |
| N80.221 | ICD10CM | Covered |
| N80.222 | ICD10CM | Covered |
| N80.223 | ICD10CM | Covered |
| N80.229 | ICD10CM | Covered |
| N80.311 | ICD10CM | Covered |
| N80.312 | ICD10CM | Covered |
| N80.321 | ICD10CM | Covered |
| N80.322 | ICD10CM | Covered |
| N80.331 | ICD10CM | Covered |
| N80.332 | ICD10CM | Covered |
| N80.333 | ICD10CM | Covered |
| N80.341 | ICD10CM | Covered |
| N80.342 | ICD10CM | Covered |
| N80.343 | ICD10CM | Covered |
| N80.361 | ICD10CM | Covered |
| N80.362 | ICD10CM | Covered |
| N80.363 | ICD10CM | Covered |
| N80.371 | ICD10CM | Covered |
| N80.372 | ICD10CM | Covered |
| N80.373 | ICD10CM | Covered |
| N80.391 | ICD10CM | Covered |
| N80.392 | ICD10CM | Covered |
| N80.3A1 | ICD10CM | Covered |
| N80.3A2 | ICD10CM | Covered |
| N80.3A3 | ICD10CM | Covered |
| N80.3B1 | ICD10CM | Covered |
| N80.3B2 | ICD10CM | Covered |
| N80.3B3 | ICD10CM | Covered |
| N80.40 | ICD10CM | Covered |
| N80.41 | ICD10CM | Covered |
| N80.42 | ICD10CM | Covered |
| N80.511 | ICD10CM | Covered |
| N80.512 | ICD10CM | Covered |
| N80.521 | ICD10CM | Covered |
| N80.522 | ICD10CM | Covered |
| N80.531 | ICD10CM | Covered |
| N80.532 | ICD10CM | Covered |
| N80.541 | ICD10CM | Covered |
| N80.542 | ICD10CM | Covered |
| N80.551 | ICD10CM | Covered |
| N80.552 | ICD10CM | Covered |
| N80.561 | ICD10CM | Covered |
| N80.562 | ICD10CM | Covered |
| N80.6 | ICD10CM | Covered |
| N80.8 | ICD10CM | Covered |
| N80.9 | ICD10CM | Covered |
| N80.A1 | ICD10CM | Covered |
| N80.A2 | ICD10CM | Covered |
| N80.A41 | ICD10CM | Covered |
| N80.A42 | ICD10CM | Covered |
| N80.A43 | ICD10CM | Covered |
| N80.A51 | ICD10CM | Covered |
| N80.A52 | ICD10CM | Covered |
| N80.A53 | ICD10CM | Covered |
| N80.B1 | ICD10CM | Covered |
| N80.B2 | ICD10CM | Covered |
| N80.B31 | ICD10CM | Covered |
| N80.B32 | ICD10CM | Covered |
| N80.B4 | ICD10CM | Covered |
| N80.B5 | ICD10CM | Covered |
| N80.B6 | ICD10CM | Covered |
| N80.C10 | ICD10CM | Covered |
| N80.C11 | ICD10CM | Covered |
| N80.C2 | ICD10CM | Covered |
| N80.C3 | ICD10CM | Covered |
| N80.C4 | ICD10CM | Covered |
| N80.C9 | ICD10CM | Covered |
| N80.D1 | ICD10CM | Covered |
| N80.D2 | ICD10CM | Covered |
| N80.D3 | ICD10CM | Covered |
| N80.D4 | ICD10CM | Covered |
| N80.D5 | ICD10CM | Covered |
| N80.D6 | ICD10CM | Covered |
| N80.D9 | ICD10CM | Covered |
| Z85.3 | ICD10CM | Covered |
| Z85.46 | ICD10CM | Covered |