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 |
|---|---|---|
| 0937T | HCPCS | Covered |
| 0938T | HCPCS | Covered |
| 0939T | HCPCS | Covered |
| 0940T | HCPCS | Covered |
| 93224 | HCPCS | Covered |
| 93225 | HCPCS | Covered |
| 93226 | HCPCS | Covered |
| 93227 | HCPCS | Covered |
| 93228 | HCPCS | Covered |
| 93229 | HCPCS | Covered |
| 93241 | HCPCS | Covered |
| 93242 | HCPCS | Covered |
| 93243 | HCPCS | Covered |
| 93244 | HCPCS | Covered |
| 93245 | HCPCS | Covered |
| 93246 | HCPCS | Covered |
| 93247 | HCPCS | Covered |
| 93248 | HCPCS | Covered |
| 93268 | HCPCS | Covered |
| 93270 | HCPCS | Covered |
| 93271 | HCPCS | Covered |
| 93272 | HCPCS | Covered |
| G45.0 | ICD10CM | Covered |
| G45.2 | ICD10CM | Covered |
| G45.3 | ICD10CM | Covered |
| G45.8 | ICD10CM | Covered |
| G45.9 | ICD10CM | Covered |
| G46.0 | ICD10CM | Covered |
| G46.3 | ICD10CM | Covered |
| G46.4 | ICD10CM | Covered |
| G46.5 | ICD10CM | Covered |
| G46.6 | ICD10CM | Covered |
| G90.01 | ICD10CM | Covered |
| H34.01 | ICD10CM | Covered |
| H34.02 | ICD10CM | Covered |
| H53.121 | ICD10CM | Covered |
| H53.122 | ICD10CM | Covered |
| I20.0 | ICD10CM | Covered |
| I20.1 | ICD10CM | Covered |
| I20.81 | ICD10CM | Covered |
| I20.89 | ICD10CM | Covered |
| I20.9 | ICD10CM | Covered |
| I21.01 | ICD10CM | Covered |
| I21.02 | ICD10CM | Covered |
| I21.09 | ICD10CM | Covered |
| I21.11 | ICD10CM | Covered |
| I21.19 | ICD10CM | Covered |
| I21.21 | ICD10CM | Covered |
| I21.29 | ICD10CM | Covered |
| I21.4 | ICD10CM | Covered |
| I21.A1 | ICD10CM | Covered |
| I21.A9 | ICD10CM | Covered |
| I21.B | ICD10CM | Covered |
| I22.0 | ICD10CM | Covered |
| I22.1 | ICD10CM | Covered |
| I22.2 | ICD10CM | Covered |
| I22.8 | ICD10CM | Covered |
| I23.7 | ICD10CM | Covered |
| I24.0 | ICD10CM | Covered |
| I24.81 | ICD10CM | Covered |
| I24.89 | ICD10CM | Covered |
| I25.110 | ICD10CM | Covered |
| I25.111 | ICD10CM | Covered |
| I25.112 | ICD10CM | Covered |
| I25.118 | ICD10CM | Covered |
| I25.2 | ICD10CM | Covered |
| I25.5 | ICD10CM | Covered |
| I25.6 | ICD10CM | Covered |
| I25.710 | ICD10CM | Covered |
| I25.711 | ICD10CM | Covered |
| I25.712 | ICD10CM | Covered |
| I25.718 | ICD10CM | Covered |
| I25.720 | ICD10CM | Covered |
| I25.721 | ICD10CM | Covered |
| I25.722 | ICD10CM | Covered |
| I25.728 | ICD10CM | Covered |
| I25.730 | ICD10CM | Covered |
| I25.731 | ICD10CM | Covered |
| I25.732 | ICD10CM | Covered |
| I25.738 | ICD10CM | Covered |
| I25.750 | ICD10CM | Covered |
| I25.751 | ICD10CM | Covered |
| I25.752 | ICD10CM | Covered |
| I25.758 | ICD10CM | Covered |
| I25.760 | ICD10CM | Covered |
| I25.761 | ICD10CM | Covered |
| I25.762 | ICD10CM | Covered |
| I25.768 | ICD10CM | Covered |
| I25.790 | ICD10CM | Covered |
| I25.791 | ICD10CM | Covered |
| I25.792 | ICD10CM | Covered |
| I25.798 | ICD10CM | Covered |
| I42.0 | ICD10CM | Covered |
| I42.1 | ICD10CM | Covered |
| I42.2 | ICD10CM | Covered |
| I42.3 | ICD10CM | Covered |
| I42.4 | ICD10CM | Covered |
| I42.5 | ICD10CM | Covered |
| I42.6 | ICD10CM | Covered |
| I42.7 | ICD10CM | Covered |
| I43 | ICD10CM | Covered |
| I44.1 | ICD10CM | Covered |
| I44.2 | ICD10CM | Covered |
| I44.4 | ICD10CM | Covered |
| I44.5 | ICD10CM | Covered |
| I44.69 | ICD10CM | Covered |
| I45.0 | ICD10CM | Covered |
| I45.19 | ICD10CM | Covered |
| I45.2 | ICD10CM | Covered |
| I45.3 | ICD10CM | Covered |
| I45.5 | ICD10CM | Covered |
| I45.6 | ICD10CM | Covered |
| I45.81 | ICD10CM | Covered |
| I45.89 | ICD10CM | Covered |
| I46.2 | ICD10CM | Covered |
| I46.8 | ICD10CM | Covered |
| I47.0 | ICD10CM | Covered |
| I47.11 | ICD10CM | Covered |
| I47.19 | ICD10CM | Covered |
| I47.21 | ICD10CM | Covered |
| I47.29 | ICD10CM | Covered |
| I48.0 | ICD10CM | Covered |
| I48.11 | ICD10CM | Covered |
| I48.19 | ICD10CM | Covered |
| I48.20 | ICD10CM | Covered |
| I48.21 | ICD10CM | Covered |
| I48.3 | ICD10CM | Covered |
| I48.4 | ICD10CM | Covered |
| I48.91 | ICD10CM | Covered |
| I48.92 | ICD10CM | Covered |
| I49.01 | ICD10CM | Covered |
| I49.02 | ICD10CM | Covered |
| I49.1 | ICD10CM | Covered |
| I49.2 | ICD10CM | Covered |
| I49.3 | ICD10CM | Covered |
| I49.40 | ICD10CM | Covered |
| I49.49 | ICD10CM | Covered |
| I49.5 | ICD10CM | Covered |
| I49.8 | ICD10CM | Covered |
| I63.00 | ICD10CM | Covered |
| I63.011 | ICD10CM | Covered |
| I63.012 | ICD10CM | Covered |
| I63.013 | ICD10CM | Covered |
| I63.019 | ICD10CM | Covered |
| I63.02 | ICD10CM | Covered |
| I63.031 | ICD10CM | Covered |
| I63.032 | ICD10CM | Covered |
| I63.033 | ICD10CM | Covered |
| I63.039 | ICD10CM | Covered |
| I63.09 | ICD10CM | Covered |
| I63.10 | ICD10CM | Covered |
| I63.111 | ICD10CM | Covered |
| I63.112 | ICD10CM | Covered |
| I63.113 | ICD10CM | Covered |
| I63.119 | ICD10CM | Covered |
| I63.12 | ICD10CM | Covered |
| I63.131 | ICD10CM | Covered |
| I63.132 | ICD10CM | Covered |
| I63.133 | ICD10CM | Covered |
| I63.139 | ICD10CM | Covered |
| I63.19 | ICD10CM | Covered |
| I63.20 | ICD10CM | Covered |
| I63.211 | ICD10CM | Covered |
| I63.212 | ICD10CM | Covered |
| I63.213 | ICD10CM | Covered |
| I63.219 | ICD10CM | Covered |
| I63.22 | ICD10CM | Covered |
| I63.231 | ICD10CM | Covered |
| I63.232 | ICD10CM | Covered |
| I63.233 | ICD10CM | Covered |
| I63.239 | ICD10CM | Covered |
| I63.29 | ICD10CM | Covered |
| I63.30 | ICD10CM | Covered |
| I63.311 | ICD10CM | Covered |
| I63.312 | ICD10CM | Covered |
| I63.313 | ICD10CM | Covered |
| I63.319 | ICD10CM | Covered |
| I63.321 | ICD10CM | Covered |
| I63.322 | ICD10CM | Covered |
| I63.323 | ICD10CM | Covered |
| I63.329 | ICD10CM | Covered |
| I63.331 | ICD10CM | Covered |
| I63.332 | ICD10CM | Covered |
| I63.333 | ICD10CM | Covered |
| I63.339 | ICD10CM | Covered |
| I63.341 | ICD10CM | Covered |
| I63.342 | ICD10CM | Covered |
| I63.343 | ICD10CM | Covered |
| I63.349 | ICD10CM | Covered |
| I63.39 | ICD10CM | Covered |
| I63.40 | ICD10CM | Covered |
| I63.411 | ICD10CM | Covered |
| I63.412 | ICD10CM | Covered |
| I63.413 | ICD10CM | Covered |
| I63.419 | ICD10CM | Covered |
| I63.421 | ICD10CM | Covered |
| I63.422 | ICD10CM | Covered |
| I63.423 | ICD10CM | Covered |
| I63.429 | ICD10CM | Covered |
| I63.431 | ICD10CM | Covered |
| I63.432 | ICD10CM | Covered |
| I63.433 | ICD10CM | Covered |
| I63.439 | ICD10CM | Covered |
| I63.441 | ICD10CM | Covered |
| I63.442 | ICD10CM | Covered |
| I63.443 | ICD10CM | Covered |
| I63.449 | ICD10CM | Covered |
| I63.49 | ICD10CM | Covered |
| I63.50 | ICD10CM | Covered |
| I63.511 | ICD10CM | Covered |
| I63.512 | ICD10CM | Covered |
| I63.513 | ICD10CM | Covered |
| I63.519 | ICD10CM | Covered |
| I63.521 | ICD10CM | Covered |
| I63.522 | ICD10CM | Covered |
| I63.523 | ICD10CM | Covered |
| I63.529 | ICD10CM | Covered |
| I63.531 | ICD10CM | Covered |
| I63.532 | ICD10CM | Covered |
| I63.533 | ICD10CM | Covered |
| I63.539 | ICD10CM | Covered |
| I63.541 | ICD10CM | Covered |
| I63.542 | ICD10CM | Covered |
| I63.543 | ICD10CM | Covered |
| I63.549 | ICD10CM | Covered |
| I63.59 | ICD10CM | Covered |
| I63.6 | ICD10CM | Covered |
| I63.81 | ICD10CM | Covered |
| I63.89 | ICD10CM | Covered |
| I63.9 | ICD10CM | Covered |
| I74.2 | ICD10CM | Covered |
| I74.3 | ICD10CM | Covered |
| I74.4 | ICD10CM | Covered |
| I74.8 | ICD10CM | Covered |
| I97.120 | ICD10CM | Covered |
| I97.121 | ICD10CM | Covered |
| I97.190 | ICD10CM | Covered |
| I97.191 | ICD10CM | Covered |
| R00.0 | ICD10CM | Covered |
| R00.1 | ICD10CM | Covered |
| R00.2 | ICD10CM | Covered |
| R06.00 | ICD10CM | Covered |
| R06.02 | ICD10CM | Covered |
| R06.09 | ICD10CM | Covered |
| R07.1 | ICD10CM | Covered |
| R07.2 | ICD10CM | Covered |
| R07.89 | ICD10CM | Covered |
| R07.9 | ICD10CM | Covered |
| R40.4 | ICD10CM | Covered |
| R42 | ICD10CM | Covered |
| R55 | ICD10CM | Covered |
| Z45.010 | ICD10CM | Covered |
| Z45.018 | ICD10CM | Covered |
| Z45.02 | ICD10CM | Covered |
| Z86.73 | ICD10CM | Covered |
| Z86.74 | ICD10CM | Covered |
| Z95.0 | ICD10CM | Covered |
| Z95.810 | ICD10CM | Covered |