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 |
|---|---|---|
| 66830 | HCPCS | Covered |
| 66840 | HCPCS | Covered |
| 66850 | HCPCS | Covered |
| 66852 | HCPCS | Covered |
| 66920 | HCPCS | Covered |
| 66930 | HCPCS | Covered |
| 66940 | HCPCS | Covered |
| 66982 | HCPCS | Covered |
| 66983 | HCPCS | Covered |
| 66984 | HCPCS | Covered |
| 66987 | HCPCS | Covered |
| 66988 | HCPCS | Covered |
| 66989 | HCPCS | Covered |
| 66991 | HCPCS | 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 |
| 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 |
| E10.311 | 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 |
| 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 |
| 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 |
| H20.21 | ICD10CM | Covered |
| H20.22 | ICD10CM | Covered |
| H20.23 | ICD10CM | Covered |
| H21.221 | ICD10CM | Covered |
| H21.222 | ICD10CM | Covered |
| H21.223 | ICD10CM | Covered |
| H21.261 | ICD10CM | Covered |
| H21.262 | ICD10CM | Covered |
| H21.263 | ICD10CM | Covered |
| H21.271 | ICD10CM | Covered |
| H21.272 | ICD10CM | Covered |
| H21.273 | ICD10CM | Covered |
| H21.29 | ICD10CM | Covered |
| H21.531 | ICD10CM | Covered |
| H21.532 | ICD10CM | Covered |
| H21.533 | ICD10CM | Covered |
| H21.561 | ICD10CM | Covered |
| H21.562 | ICD10CM | Covered |
| H21.563 | ICD10CM | Covered |
| H21.81 | ICD10CM | Covered |
| H21.82 | ICD10CM | Covered |
| H21.89 | ICD10CM | Covered |
| H22 | ICD10CM | Covered |
| H25.011 | ICD10CM | Covered |
| H25.012 | ICD10CM | Covered |
| H25.013 | ICD10CM | Covered |
| H25.031 | ICD10CM | Covered |
| H25.032 | ICD10CM | Covered |
| H25.033 | ICD10CM | Covered |
| H25.041 | ICD10CM | Covered |
| H25.042 | ICD10CM | Covered |
| H25.043 | ICD10CM | Covered |
| H25.11 | ICD10CM | Covered |
| H25.12 | ICD10CM | Covered |
| H25.13 | ICD10CM | Covered |
| H25.21 | ICD10CM | Covered |
| H25.22 | ICD10CM | Covered |
| H25.23 | ICD10CM | Covered |
| H25.811 | ICD10CM | Covered |
| H25.812 | ICD10CM | Covered |
| H25.813 | ICD10CM | Covered |
| H25.89 | ICD10CM | Covered |
| H26.011 | ICD10CM | Covered |
| H26.012 | ICD10CM | Covered |
| H26.013 | ICD10CM | Covered |
| H26.031 | ICD10CM | Covered |
| H26.032 | ICD10CM | Covered |
| H26.033 | ICD10CM | Covered |
| H26.041 | ICD10CM | Covered |
| H26.042 | ICD10CM | Covered |
| H26.043 | ICD10CM | Covered |
| H26.051 | ICD10CM | Covered |
| H26.052 | ICD10CM | Covered |
| H26.053 | ICD10CM | Covered |
| H26.061 | ICD10CM | Covered |
| H26.062 | ICD10CM | Covered |
| H26.063 | ICD10CM | Covered |
| H26.09 | ICD10CM | Covered |
| H26.111 | ICD10CM | Covered |
| H26.112 | ICD10CM | Covered |
| H26.113 | ICD10CM | Covered |
| H26.121 | ICD10CM | Covered |
| H26.122 | ICD10CM | Covered |
| H26.123 | ICD10CM | Covered |
| H26.131 | ICD10CM | Covered |
| H26.132 | ICD10CM | Covered |
| H26.133 | ICD10CM | Covered |
| H26.211 | ICD10CM | Covered |
| H26.212 | ICD10CM | Covered |
| H26.213 | ICD10CM | Covered |
| H26.221 | ICD10CM | Covered |
| H26.222 | ICD10CM | Covered |
| H26.223 | ICD10CM | Covered |
| H26.231 | ICD10CM | Covered |
| H26.232 | ICD10CM | Covered |
| H26.233 | ICD10CM | Covered |
| H26.31 | ICD10CM | Covered |
| H26.32 | ICD10CM | Covered |
| H26.33 | ICD10CM | Covered |
| H26.411 | ICD10CM | Covered |
| H26.412 | ICD10CM | Covered |
| H26.413 | ICD10CM | Covered |
| H26.491 | ICD10CM | Covered |
| H26.492 | ICD10CM | Covered |
| H26.493 | ICD10CM | Covered |
| H26.8 | ICD10CM | Covered |
| H27.111 | ICD10CM | Covered |
| H27.112 | ICD10CM | Covered |
| H27.113 | ICD10CM | Covered |
| H27.121 | ICD10CM | Covered |
| H27.122 | ICD10CM | Covered |
| H27.123 | ICD10CM | Covered |
| H27.131 | ICD10CM | Covered |
| H27.132 | ICD10CM | Covered |
| H27.133 | ICD10CM | Covered |
| H28 | ICD10CM | Covered |
| H33.011 | ICD10CM | Covered |
| H33.012 | ICD10CM | Covered |
| H33.013 | ICD10CM | Covered |
| H33.021 | ICD10CM | Covered |
| H33.022 | ICD10CM | Covered |
| H33.023 | ICD10CM | Covered |
| H33.031 | ICD10CM | Covered |
| H33.032 | ICD10CM | Covered |
| H33.033 | ICD10CM | Covered |
| H33.041 | ICD10CM | Covered |
| H33.042 | ICD10CM | Covered |
| H33.043 | ICD10CM | Covered |
| H33.051 | ICD10CM | Covered |
| H33.052 | ICD10CM | Covered |
| H33.053 | ICD10CM | Covered |
| H33.41 | ICD10CM | Covered |
| H33.42 | ICD10CM | Covered |
| H33.43 | ICD10CM | Covered |
| H33.8 | ICD10CM | Covered |
| H35.041 | ICD10CM | Covered |
| H35.042 | ICD10CM | Covered |
| H35.043 | ICD10CM | Covered |
| H35.071 | ICD10CM | Covered |
| H35.072 | ICD10CM | Covered |
| H35.073 | ICD10CM | Covered |
| H35.21 | ICD10CM | Covered |
| H35.22 | ICD10CM | Covered |
| H35.23 | ICD10CM | Covered |
| H35.3230 | ICD10CM | Covered |
| H35.3231 | ICD10CM | Covered |
| H35.3232 | ICD10CM | Covered |
| H35.3233 | ICD10CM | Covered |
| H35.341 | ICD10CM | Covered |
| H35.342 | ICD10CM | Covered |
| H35.343 | ICD10CM | Covered |
| H35.371 | ICD10CM | Covered |
| H35.372 | ICD10CM | Covered |
| H35.373 | ICD10CM | Covered |
| H35.81 | ICD10CM | Covered |
| H40.031 | ICD10CM | Covered |
| H40.032 | ICD10CM | Covered |
| H40.033 | ICD10CM | Covered |
| H40.061 | ICD10CM | Covered |
| H40.062 | ICD10CM | Covered |
| H40.063 | ICD10CM | Covered |
| H40.10X2 | ICD10CM | Covered |
| H40.10X3 | ICD10CM | Covered |
| H40.1111 | ICD10CM | Covered |
| H40.1112 | ICD10CM | Covered |
| H40.1113 | ICD10CM | Covered |
| H40.1121 | ICD10CM | Covered |
| H40.1122 | ICD10CM | Covered |
| H40.1123 | ICD10CM | Covered |
| H40.1131 | ICD10CM | Covered |
| H40.1132 | ICD10CM | Covered |
| H40.1133 | ICD10CM | Covered |
| H40.2211 | ICD10CM | Covered |
| H40.2212 | ICD10CM | Covered |
| H40.2213 | ICD10CM | Covered |
| H40.2221 | ICD10CM | Covered |
| H40.2222 | ICD10CM | Covered |
| H40.2223 | ICD10CM | Covered |
| H40.2231 | ICD10CM | Covered |
| H40.2232 | ICD10CM | Covered |
| H40.2233 | ICD10CM | Covered |
| H40.231 | ICD10CM | Covered |
| H40.232 | ICD10CM | Covered |
| H40.233 | ICD10CM | Covered |
| H40.241 | ICD10CM | Covered |
| H40.242 | ICD10CM | Covered |
| H40.243 | ICD10CM | Covered |
| H40.51X1 | ICD10CM | Covered |
| H40.51X2 | ICD10CM | Covered |
| H40.51X3 | ICD10CM | Covered |
| H40.52X1 | ICD10CM | Covered |
| H40.52X2 | ICD10CM | Covered |
| H40.52X3 | ICD10CM | Covered |
| H40.53X1 | ICD10CM | Covered |
| H40.53X2 | ICD10CM | Covered |
| H40.53X3 | ICD10CM | Covered |
| H40.89 | ICD10CM | Covered |
| H40.9 | ICD10CM | Covered |
| H43.11 | ICD10CM | Covered |
| H43.12 | ICD10CM | Covered |
| H43.13 | ICD10CM | Covered |
| H43.821 | ICD10CM | Covered |
| H43.822 | ICD10CM | Covered |
| H43.823 | ICD10CM | Covered |
| H52.31 | ICD10CM | Covered |
| H52.32 | ICD10CM | Covered |
| H53.2 | ICD10CM | Covered |
| H57.00 | ICD10CM | Covered |
| H57.01 | ICD10CM | Covered |
| H57.02 | ICD10CM | Covered |
| H57.03 | ICD10CM | Covered |
| H57.04 | ICD10CM | Covered |
| H57.051 | ICD10CM | Covered |
| H57.052 | ICD10CM | Covered |
| H57.053 | ICD10CM | Covered |
| H57.09 | ICD10CM | Covered |
| H57.9 | ICD10CM | Covered |
| H59.021 | ICD10CM | Covered |
| H59.022 | ICD10CM | Covered |
| H59.023 | ICD10CM | Covered |
| Q12.0 | ICD10CM | Covered |
| Q12.1 | ICD10CM | Covered |
| Q12.2 | ICD10CM | Covered |
| Q12.3 | ICD10CM | Covered |
| Q12.4 | ICD10CM | Covered |
| Q12.8 | ICD10CM | Covered |
| Q13.1 | ICD10CM | Covered |
| Q13.9 | ICD10CM | Covered |