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 |
|---|---|---|
| 93925 | HCPCS | Covered |
| 93926 | HCPCS | Covered |
| 93930 | HCPCS | Covered |
| 93931 | HCPCS | Covered |
| A48.0 | ICD10CM | Covered |
| E08.51 | ICD10CM | Covered |
| E08.52 | ICD10CM | Covered |
| E08.59 | ICD10CM | Covered |
| E09.51 | ICD10CM | Covered |
| E09.52 | ICD10CM | Covered |
| E09.59 | ICD10CM | Covered |
| E10.51 | ICD10CM | Covered |
| E10.52 | ICD10CM | Covered |
| E10.59 | ICD10CM | Covered |
| E11.51 | ICD10CM | Covered |
| E11.52 | ICD10CM | Covered |
| E11.59 | ICD10CM | Covered |
| E11.621 | ICD10CM | Covered |
| E11.622 | ICD10CM | Covered |
| E11.628 | ICD10CM | Covered |
| E13.51 | ICD10CM | Covered |
| E13.52 | ICD10CM | Covered |
| E13.59 | ICD10CM | Covered |
| I25.10 | ICD10CM | Covered |
| I70.211 | ICD10CM | Covered |
| I70.212 | ICD10CM | Covered |
| I70.213 | ICD10CM | Covered |
| I70.221 | ICD10CM | Covered |
| I70.222 | ICD10CM | Covered |
| I70.223 | ICD10CM | Covered |
| I70.231 | ICD10CM | Covered |
| I70.232 | ICD10CM | Covered |
| I70.233 | ICD10CM | Covered |
| I70.234 | ICD10CM | Covered |
| I70.235 | ICD10CM | Covered |
| I70.238 | ICD10CM | Covered |
| I70.241 | ICD10CM | Covered |
| I70.242 | ICD10CM | Covered |
| I70.243 | ICD10CM | Covered |
| I70.244 | ICD10CM | Covered |
| I70.245 | ICD10CM | Covered |
| I70.248 | ICD10CM | Covered |
| I70.261 | ICD10CM | Covered |
| I70.262 | ICD10CM | Covered |
| I70.263 | ICD10CM | Covered |
| I70.291 | ICD10CM | Covered |
| I70.292 | ICD10CM | Covered |
| I70.293 | ICD10CM | Covered |
| I70.511 | ICD10CM | Covered |
| I70.512 | ICD10CM | Covered |
| I70.513 | ICD10CM | Covered |
| I70.521 | ICD10CM | Covered |
| I70.522 | ICD10CM | Covered |
| I70.523 | ICD10CM | Covered |
| I70.531 | ICD10CM | Covered |
| I70.532 | ICD10CM | Covered |
| I70.533 | ICD10CM | Covered |
| I70.534 | ICD10CM | Covered |
| I70.535 | ICD10CM | Covered |
| I70.538 | ICD10CM | Covered |
| I70.541 | ICD10CM | Covered |
| I70.542 | ICD10CM | Covered |
| I70.543 | ICD10CM | Covered |
| I70.544 | ICD10CM | Covered |
| I70.545 | ICD10CM | Covered |
| I70.548 | ICD10CM | Covered |
| I70.561 | ICD10CM | Covered |
| I70.562 | ICD10CM | Covered |
| I70.563 | ICD10CM | Covered |
| I70.591 | ICD10CM | Covered |
| I70.592 | ICD10CM | Covered |
| I70.593 | ICD10CM | Covered |
| I70.611 | ICD10CM | Covered |
| I70.612 | ICD10CM | Covered |
| I70.613 | ICD10CM | Covered |
| I70.621 | ICD10CM | Covered |
| I70.622 | ICD10CM | Covered |
| I70.623 | ICD10CM | Covered |
| I70.631 | ICD10CM | Covered |
| I70.632 | ICD10CM | Covered |
| I70.633 | ICD10CM | Covered |
| I70.634 | ICD10CM | Covered |
| I70.635 | ICD10CM | Covered |
| I70.638 | ICD10CM | Covered |
| I70.641 | ICD10CM | Covered |
| I70.642 | ICD10CM | Covered |
| I70.643 | ICD10CM | Covered |
| I70.644 | ICD10CM | Covered |
| I70.645 | ICD10CM | Covered |
| I70.648 | ICD10CM | Covered |
| I70.661 | ICD10CM | Covered |
| I70.662 | ICD10CM | Covered |
| I70.663 | ICD10CM | Covered |
| I70.691 | ICD10CM | Covered |
| I70.692 | ICD10CM | Covered |
| I70.693 | ICD10CM | Covered |
| I70.92 | ICD10CM | Covered |
| I72.1 | ICD10CM | Covered |
| I72.3 | ICD10CM | Covered |
| I72.4 | ICD10CM | Covered |
| I73.00 | ICD10CM | Covered |
| I73.01 | ICD10CM | Covered |
| I73.1 | ICD10CM | Covered |
| I73.9 | ICD10CM | Covered |
| I74.2 | ICD10CM | Covered |
| I74.3 | ICD10CM | Covered |
| I74.5 | ICD10CM | Covered |
| I75.011 | ICD10CM | Covered |
| I75.012 | ICD10CM | Covered |
| I75.013 | ICD10CM | Covered |
| I75.021 | ICD10CM | Covered |
| I75.022 | ICD10CM | Covered |
| I75.023 | ICD10CM | Covered |
| I76 | ICD10CM | Covered |
| I77.0 | ICD10CM | Covered |
| I77.1 | ICD10CM | Covered |
| I77.2 | ICD10CM | Covered |
| I77.3 | ICD10CM | Covered |
| I77.5 | ICD10CM | Covered |
| I77.72 | ICD10CM | Covered |
| I77.76 | ICD10CM | Covered |
| I77.77 | ICD10CM | Covered |
| I77.82 | ICD10CM | Covered |
| I77.89 | ICD10CM | Covered |
| I96 | ICD10CM | Covered |
| M30.0 | ICD10CM | Covered |
| M30.1 | ICD10CM | Covered |
| M30.8 | ICD10CM | Covered |
| M31.0 | ICD10CM | Covered |
| M31.10 | ICD10CM | Covered |
| M31.11 | ICD10CM | Covered |
| M31.19 | ICD10CM | Covered |
| M31.7 | ICD10CM | Covered |
| M31.8 | ICD10CM | Covered |
| Q27.31 | ICD10CM | Covered |
| Q27.32 | ICD10CM | Covered |
| S25.111A | ICD10CM | Covered |
| S25.111D | ICD10CM | Covered |
| S25.111S | ICD10CM | Covered |
| S25.112A | ICD10CM | Covered |
| S25.112D | ICD10CM | Covered |
| S25.112S | ICD10CM | Covered |
| S25.121A | ICD10CM | Covered |
| S25.121D | ICD10CM | Covered |
| S25.121S | ICD10CM | Covered |
| S25.122A | ICD10CM | Covered |
| S25.122D | ICD10CM | Covered |
| S25.122S | ICD10CM | Covered |
| S25.191A | ICD10CM | Covered |
| S25.191D | ICD10CM | Covered |
| S25.191S | ICD10CM | Covered |
| S25.192A | ICD10CM | Covered |
| S25.192D | ICD10CM | Covered |
| S25.192S | ICD10CM | Covered |
| S45.011A | ICD10CM | Covered |
| S45.011D | ICD10CM | Covered |
| S45.011S | ICD10CM | Covered |
| S45.012A | ICD10CM | Covered |
| S45.012D | ICD10CM | Covered |
| S45.012S | ICD10CM | Covered |
| S45.091A | ICD10CM | Covered |
| S45.091D | ICD10CM | Covered |
| S45.091S | ICD10CM | Covered |
| S45.092A | ICD10CM | Covered |
| S45.092D | ICD10CM | Covered |
| S45.092S | ICD10CM | Covered |
| S45.111A | ICD10CM | Covered |
| S45.111D | ICD10CM | Covered |
| S45.111S | ICD10CM | Covered |
| S45.112A | ICD10CM | Covered |
| S45.112D | ICD10CM | Covered |
| S45.112S | ICD10CM | Covered |
| S45.191A | ICD10CM | Covered |
| S45.191D | ICD10CM | Covered |
| S45.191S | ICD10CM | Covered |
| S45.192A | ICD10CM | Covered |
| S45.192D | ICD10CM | Covered |
| S45.192S | ICD10CM | Covered |
| S55.011A | ICD10CM | Covered |
| S55.011D | ICD10CM | Covered |
| S55.011S | ICD10CM | Covered |
| S55.012A | ICD10CM | Covered |
| S55.012D | ICD10CM | Covered |
| S55.012S | ICD10CM | Covered |
| S55.091A | ICD10CM | Covered |
| S55.091D | ICD10CM | Covered |
| S55.091S | ICD10CM | Covered |
| S55.092A | ICD10CM | Covered |
| S55.092D | ICD10CM | Covered |
| S55.092S | ICD10CM | Covered |
| S55.111A | ICD10CM | Covered |
| S55.111D | ICD10CM | Covered |
| S55.111S | ICD10CM | Covered |
| S55.112A | ICD10CM | Covered |
| S55.112D | ICD10CM | Covered |
| S55.112S | ICD10CM | Covered |
| S55.191A | ICD10CM | Covered |
| S55.191D | ICD10CM | Covered |
| S55.191S | ICD10CM | Covered |
| S55.192A | ICD10CM | Covered |
| S55.192D | ICD10CM | Covered |
| S55.192S | ICD10CM | Covered |
| S65.011A | ICD10CM | Covered |
| S65.011D | ICD10CM | Covered |
| S65.011S | ICD10CM | Covered |
| S65.012A | ICD10CM | Covered |
| S65.012D | ICD10CM | Covered |
| S65.012S | ICD10CM | Covered |
| S65.091A | ICD10CM | Covered |
| S65.091D | ICD10CM | Covered |
| S65.091S | ICD10CM | Covered |
| S65.092A | ICD10CM | Covered |
| S65.092D | ICD10CM | Covered |
| S65.092S | ICD10CM | Covered |
| S65.111A | ICD10CM | Covered |
| S65.111D | ICD10CM | Covered |
| S65.111S | ICD10CM | Covered |
| S65.112A | ICD10CM | Covered |
| S65.112D | ICD10CM | Covered |
| S65.112S | ICD10CM | Covered |
| S65.191A | ICD10CM | Covered |
| S65.191D | ICD10CM | Covered |
| S65.191S | ICD10CM | Covered |
| S65.192A | ICD10CM | Covered |
| S65.192D | ICD10CM | Covered |
| S65.192S | ICD10CM | Covered |
| S65.211A | ICD10CM | Covered |
| S65.211D | ICD10CM | Covered |
| S65.211S | ICD10CM | Covered |
| S65.212A | ICD10CM | Covered |
| S65.212D | ICD10CM | Covered |
| S65.212S | ICD10CM | Covered |
| S65.291A | ICD10CM | Covered |
| S65.291D | ICD10CM | Covered |
| S65.291S | ICD10CM | Covered |
| S65.292A | ICD10CM | Covered |
| S65.292D | ICD10CM | Covered |
| S65.292S | ICD10CM | Covered |
| S65.311A | ICD10CM | Covered |
| S65.311D | ICD10CM | Covered |
| S65.311S | ICD10CM | Covered |
| S65.312A | ICD10CM | Covered |
| S65.312D | ICD10CM | Covered |
| S65.312S | ICD10CM | Covered |
| S65.391A | ICD10CM | Covered |
| S65.391D | ICD10CM | Covered |
| S65.391S | ICD10CM | Covered |
| S65.392A | ICD10CM | Covered |
| S65.392D | ICD10CM | Covered |
| S65.392S | ICD10CM | Covered |
| S75.011A | ICD10CM | Covered |
| S75.011D | ICD10CM | Covered |
| S75.011S | ICD10CM | Covered |
| S75.012A | ICD10CM | Covered |
| S75.012D | ICD10CM | Covered |
| S75.012S | ICD10CM | Covered |
| S75.021A | ICD10CM | Covered |
| S75.021D | ICD10CM | Covered |
| S75.021S | ICD10CM | Covered |
| S75.022A | ICD10CM | Covered |
| S75.022D | ICD10CM | Covered |
| S75.022S | ICD10CM | Covered |
| S75.091A | ICD10CM | Covered |
| S75.091D | ICD10CM | Covered |
| S75.091S | ICD10CM | Covered |
| S75.092A | ICD10CM | Covered |
| S75.092D | ICD10CM | Covered |
| S75.092S | ICD10CM | Covered |
| S85.011A | ICD10CM | Covered |
| S85.011D | ICD10CM | Covered |
| S85.011S | ICD10CM | Covered |
| S85.012A | ICD10CM | Covered |
| S85.012D | ICD10CM | Covered |
| S85.012S | ICD10CM | Covered |
| S85.091A | ICD10CM | Covered |
| S85.091D | ICD10CM | Covered |
| S85.091S | ICD10CM | Covered |
| S85.092A | ICD10CM | Covered |
| S85.092D | ICD10CM | Covered |
| S85.092S | ICD10CM | Covered |
| S85.141A | ICD10CM | Covered |
| S85.141D | ICD10CM | Covered |
| S85.141S | ICD10CM | Covered |
| S85.142A | ICD10CM | Covered |
| S85.142D | ICD10CM | Covered |
| S85.142S | ICD10CM | Covered |
| S85.151A | ICD10CM | Covered |
| S85.151D | ICD10CM | Covered |
| S85.151S | ICD10CM | Covered |
| S85.152A | ICD10CM | Covered |
| S85.152D | ICD10CM | Covered |
| S85.152S | ICD10CM | Covered |
| S85.171A | ICD10CM | Covered |
| S85.171D | ICD10CM | Covered |
| S85.171S | ICD10CM | Covered |
| S85.172A | ICD10CM | Covered |
| S85.172D | ICD10CM | Covered |
| S85.172S | ICD10CM | Covered |
| S85.181A | ICD10CM | Covered |
| S85.181D | ICD10CM | Covered |
| S85.181S | ICD10CM | Covered |
| S85.182A | ICD10CM | Covered |
| S85.182D | ICD10CM | Covered |
| S85.182S | ICD10CM | Covered |
| S85.211A | ICD10CM | Covered |
| S85.211D | ICD10CM | Covered |
| S85.211S | ICD10CM | Covered |
| S85.212A | ICD10CM | Covered |
| S85.212D | ICD10CM | Covered |
| S85.212S | ICD10CM | Covered |
| S85.291A | ICD10CM | Covered |
| S85.291D | ICD10CM | Covered |
| S85.291S | ICD10CM | Covered |
| S85.292A | ICD10CM | Covered |
| S85.292D | ICD10CM | Covered |
| S85.292S | ICD10CM | Covered |
| S95.011A | ICD10CM | Covered |
| S95.011D | ICD10CM | Covered |
| S95.011S | ICD10CM | Covered |
| S95.012A | ICD10CM | Covered |
| S95.012D | ICD10CM | Covered |
| S95.012S | ICD10CM | Covered |
| S95.091A | ICD10CM | Covered |
| S95.091D | ICD10CM | Covered |
| S95.091S | ICD10CM | Covered |
| S95.092A | ICD10CM | Covered |
| S95.092D | ICD10CM | Covered |
| S95.092S | ICD10CM | Covered |
| S95.111A | ICD10CM | Covered |
| S95.111D | ICD10CM | Covered |
| S95.111S | ICD10CM | Covered |
| S95.112A | ICD10CM | Covered |
| S95.112D | ICD10CM | Covered |
| S95.112S | ICD10CM | Covered |
| S95.191A | ICD10CM | Covered |
| S95.191D | ICD10CM | Covered |
| S95.191S | ICD10CM | Covered |
| S95.192A | ICD10CM | Covered |
| S95.192D | ICD10CM | Covered |
| S95.192S | ICD10CM | Covered |
| T80.1XXA | ICD10CM | Covered |
| T80.1XXD | ICD10CM | Covered |
| T80.1XXS | ICD10CM | Covered |
| T81.718A | ICD10CM | Covered |
| T81.718D | ICD10CM | Covered |
| T81.718S | ICD10CM | Covered |
| T82.312A | ICD10CM | Covered |
| T82.312D | ICD10CM | Covered |
| T82.312S | ICD10CM | Covered |
| T82.318A | ICD10CM | Covered |
| T82.318D | ICD10CM | Covered |
| T82.318S | ICD10CM | Covered |
| T82.322A | ICD10CM | Covered |
| T82.322D | ICD10CM | Covered |
| T82.322S | ICD10CM | Covered |
| T82.328A | ICD10CM | Covered |
| T82.328D | ICD10CM | Covered |
| T82.328S | ICD10CM | Covered |
| T82.332A | ICD10CM | Covered |
| T82.332D | ICD10CM | Covered |
| T82.332S | ICD10CM | Covered |
| T82.338A | ICD10CM | Covered |
| T82.338D | ICD10CM | Covered |
| T82.338S | ICD10CM | Covered |
| T82.392A | ICD10CM | Covered |
| T82.392D | ICD10CM | Covered |
| T82.392S | ICD10CM | Covered |
| T82.398A | ICD10CM | Covered |
| T82.398D | ICD10CM | Covered |
| T82.398S | ICD10CM | Covered |
| T82.518A | ICD10CM | Covered |
| T82.518D | ICD10CM | Covered |
| T82.518S | ICD10CM | Covered |
| T82.528A | ICD10CM | Covered |
| T82.528D | ICD10CM | Covered |
| T82.528S | ICD10CM | Covered |
| T82.538A | ICD10CM | Covered |
| T82.538D | ICD10CM | Covered |
| T82.538S | ICD10CM | Covered |
| T82.598A | ICD10CM | Covered |
| T82.598D | ICD10CM | Covered |
| T82.598S | ICD10CM | Covered |
| T82.7XXA | ICD10CM | Covered |
| T82.7XXD | ICD10CM | Covered |
| T82.7XXS | ICD10CM | Covered |
| T82.818A | ICD10CM | Covered |
| T82.818D | ICD10CM | Covered |
| T82.818S | ICD10CM | Covered |
| T82.828A | ICD10CM | Covered |
| T82.828D | ICD10CM | Covered |
| T82.828S | ICD10CM | Covered |
| T82.838A | ICD10CM | Covered |
| T82.838D | ICD10CM | Covered |
| T82.838S | ICD10CM | Covered |
| T82.848A | ICD10CM | Covered |
| T82.848D | ICD10CM | Covered |
| T82.848S | ICD10CM | Covered |
| T82.856A | ICD10CM | Covered |
| T82.856D | ICD10CM | Covered |
| T82.856S | ICD10CM | Covered |
| T82.858A | ICD10CM | Covered |
| T82.858D | ICD10CM | Covered |
| T82.858S | ICD10CM | Covered |
| T82.868A | ICD10CM | Covered |
| T82.868D | ICD10CM | Covered |
| T82.868S | ICD10CM | Covered |
| T82.898A | ICD10CM | Covered |
| T82.898D | ICD10CM | Covered |
| T82.898S | ICD10CM | Covered |
| T87.0X1 | ICD10CM | Covered |
| T87.0X2 | ICD10CM | Covered |
| T87.1X1 | ICD10CM | Covered |
| T87.1X2 | ICD10CM | Covered |
| Z01.810 | ICD10CM | Covered |
| Z48.812 | ICD10CM | Covered |
| Z95.820 | ICD10CM | Covered |
| Z98.62 | ICD10CM | Covered |