About this policy
Jurisdiction: J15 MAC Part B. States: Kentucky, Ohio. Type: Active LCD
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 |
|---|---|---|
| 76514 | CPT | Covered |
| H18.11 | ICD10CM | Covered |
| H18.12 | ICD10CM | Covered |
| H18.13 | ICD10CM | Covered |
| H18.461 | ICD10CM | Covered |
| H18.462 | ICD10CM | Covered |
| H18.463 | ICD10CM | Covered |
| H18.511 | ICD10CM | Covered |
| H18.512 | ICD10CM | Covered |
| H18.513 | ICD10CM | Covered |
| H18.591 | ICD10CM | Covered |
| H18.592 | ICD10CM | Covered |
| H18.593 | ICD10CM | Covered |
| H18.601 | ICD10CM | Covered |
| H18.602 | ICD10CM | Covered |
| H18.603 | ICD10CM | Covered |
| H18.611 | ICD10CM | Covered |
| H18.612 | ICD10CM | Covered |
| H18.613 | ICD10CM | Covered |
| H18.621 | ICD10CM | Covered |
| H18.622 | ICD10CM | Covered |
| H18.623 | ICD10CM | Covered |
| H21.551 | ICD10CM | Covered |
| H21.552 | ICD10CM | Covered |
| H21.553 | ICD10CM | Covered |
| H40.001 | ICD10CM | Covered |
| H40.002 | ICD10CM | Covered |
| H40.003 | ICD10CM | Covered |
| H40.011 | ICD10CM | Covered |
| H40.012 | ICD10CM | Covered |
| H40.013 | ICD10CM | Covered |
| H40.021 | ICD10CM | Covered |
| H40.022 | ICD10CM | Covered |
| H40.023 | ICD10CM | Covered |
| H40.031 | ICD10CM | Covered |
| H40.032 | ICD10CM | Covered |
| H40.033 | ICD10CM | Covered |
| H40.041 | ICD10CM | Covered |
| H40.042 | ICD10CM | Covered |
| H40.043 | ICD10CM | Covered |
| H40.051 | ICD10CM | Covered |
| H40.052 | ICD10CM | Covered |
| H40.053 | ICD10CM | Covered |
| H40.061 | ICD10CM | Covered |
| H40.062 | ICD10CM | Covered |
| H40.063 | ICD10CM | Covered |
| H40.10X1 | ICD10CM | Covered |
| H40.10X2 | ICD10CM | Covered |
| H40.10X3 | ICD10CM | Covered |
| H40.10X4 | ICD10CM | Covered |
| H40.1111 | ICD10CM | Covered |
| H40.1112 | ICD10CM | Covered |
| H40.1113 | ICD10CM | Covered |
| H40.1114 | ICD10CM | Covered |
| H40.1121 | ICD10CM | Covered |
| H40.1122 | ICD10CM | Covered |
| H40.1123 | ICD10CM | Covered |
| H40.1124 | ICD10CM | Covered |
| H40.1131 | ICD10CM | Covered |
| H40.1132 | ICD10CM | Covered |
| H40.1133 | ICD10CM | Covered |
| H40.1134 | ICD10CM | Covered |
| H40.1210 | ICD10CM | Covered |
| H40.1211 | ICD10CM | Covered |
| H40.1212 | ICD10CM | Covered |
| H40.1213 | ICD10CM | Covered |
| H40.1214 | ICD10CM | Covered |
| H40.1220 | ICD10CM | Covered |
| H40.1221 | ICD10CM | Covered |
| H40.1222 | ICD10CM | Covered |
| H40.1223 | ICD10CM | Covered |
| H40.1224 | ICD10CM | Covered |
| H40.1230 | ICD10CM | Covered |
| H40.1231 | ICD10CM | Covered |
| H40.1232 | ICD10CM | Covered |
| H40.1233 | ICD10CM | Covered |
| H40.1234 | ICD10CM | Covered |
| H40.1290 | ICD10CM | Covered |
| H40.1310 | ICD10CM | Covered |
| H40.1311 | ICD10CM | Covered |
| H40.1312 | ICD10CM | Covered |
| H40.1313 | ICD10CM | Covered |
| H40.1314 | ICD10CM | Covered |
| H40.1320 | ICD10CM | Covered |
| H40.1321 | ICD10CM | Covered |
| H40.1322 | ICD10CM | Covered |
| H40.1323 | ICD10CM | Covered |
| H40.1324 | ICD10CM | Covered |
| H40.1330 | ICD10CM | Covered |
| H40.1331 | ICD10CM | Covered |
| H40.1332 | ICD10CM | Covered |
| H40.1333 | ICD10CM | Covered |
| H40.1334 | ICD10CM | Covered |
| H40.1410 | ICD10CM | Covered |
| H40.1411 | ICD10CM | Covered |
| H40.1412 | ICD10CM | Covered |
| H40.1413 | ICD10CM | Covered |
| H40.1414 | ICD10CM | Covered |
| H40.1420 | ICD10CM | Covered |
| H40.1421 | ICD10CM | Covered |
| H40.1422 | ICD10CM | Covered |
| H40.1423 | ICD10CM | Covered |
| H40.1424 | ICD10CM | Covered |
| H40.1430 | ICD10CM | Covered |
| H40.1431 | ICD10CM | Covered |
| H40.1432 | ICD10CM | Covered |
| H40.1433 | ICD10CM | Covered |
| H40.1434 | ICD10CM | Covered |
| H40.151 | ICD10CM | Covered |
| H40.152 | ICD10CM | Covered |
| H40.153 | ICD10CM | Covered |
| H40.20X1 | ICD10CM | Covered |
| H40.20X2 | ICD10CM | Covered |
| H40.20X3 | ICD10CM | Covered |
| H40.20X4 | ICD10CM | Covered |
| H40.211 | ICD10CM | Covered |
| H40.212 | ICD10CM | Covered |
| H40.213 | ICD10CM | Covered |
| H40.2210 | ICD10CM | Covered |
| H40.2211 | ICD10CM | Covered |
| H40.2212 | ICD10CM | Covered |
| H40.2213 | ICD10CM | Covered |
| H40.2214 | ICD10CM | Covered |
| H40.2220 | ICD10CM | Covered |
| H40.2221 | ICD10CM | Covered |
| H40.2222 | ICD10CM | Covered |
| H40.2223 | ICD10CM | Covered |
| H40.2224 | ICD10CM | Covered |
| H40.2231 | ICD10CM | Covered |
| H40.2232 | ICD10CM | Covered |
| H40.2233 | ICD10CM | Covered |
| H40.2234 | ICD10CM | Covered |
| H40.2291 | ICD10CM | Covered |
| H40.2292 | ICD10CM | Covered |
| H40.2293 | ICD10CM | Covered |
| H40.2294 | 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 |
| H40.31X1 | ICD10CM | Covered |
| H40.31X2 | ICD10CM | Covered |
| H40.31X3 | ICD10CM | Covered |
| H40.31X4 | ICD10CM | Covered |
| H40.32X1 | ICD10CM | Covered |
| H40.32X2 | ICD10CM | Covered |
| H40.32X3 | ICD10CM | Covered |
| H40.32X4 | ICD10CM | Covered |
| H40.33X1 | ICD10CM | Covered |
| H40.33X2 | ICD10CM | Covered |
| H40.33X3 | ICD10CM | Covered |
| H40.33X4 | ICD10CM | Covered |
| H40.41X1 | ICD10CM | Covered |
| H40.41X2 | ICD10CM | Covered |
| H40.41X3 | ICD10CM | Covered |
| H40.41X4 | ICD10CM | Covered |
| H40.42X1 | ICD10CM | Covered |
| H40.42X2 | ICD10CM | Covered |
| H40.42X3 | ICD10CM | Covered |
| H40.42X4 | ICD10CM | Covered |
| H40.43X1 | ICD10CM | Covered |
| H40.43X2 | ICD10CM | Covered |
| H40.43X3 | ICD10CM | Covered |
| H40.43X4 | ICD10CM | Covered |
| H40.51X1 | ICD10CM | Covered |
| H40.51X2 | ICD10CM | Covered |
| H40.51X3 | ICD10CM | Covered |
| H40.51X4 | ICD10CM | Covered |
| H40.52X1 | ICD10CM | Covered |
| H40.52X2 | ICD10CM | Covered |
| H40.52X3 | ICD10CM | Covered |
| H40.52X4 | ICD10CM | Covered |
| H40.53X1 | ICD10CM | Covered |
| H40.53X2 | ICD10CM | Covered |
| H40.53X3 | ICD10CM | Covered |
| H40.53X4 | ICD10CM | Covered |
| H40.60X1 | ICD10CM | Covered |
| H40.60X2 | ICD10CM | Covered |
| H40.60X3 | ICD10CM | Covered |
| H40.60X4 | ICD10CM | Covered |
| H40.61X1 | ICD10CM | Covered |
| H40.61X2 | ICD10CM | Covered |
| H40.61X3 | ICD10CM | Covered |
| H40.61X4 | ICD10CM | Covered |
| H40.62X1 | ICD10CM | Covered |
| H40.62X2 | ICD10CM | Covered |
| H40.62X3 | ICD10CM | Covered |
| H40.62X4 | ICD10CM | Covered |
| H40.63X1 | ICD10CM | Covered |
| H40.63X2 | ICD10CM | Covered |
| H40.63X3 | ICD10CM | Covered |
| H40.63X4 | ICD10CM | Covered |
| H40.811 | ICD10CM | Covered |
| H40.812 | ICD10CM | Covered |
| H40.813 | ICD10CM | Covered |
| H40.821 | ICD10CM | Covered |
| H40.822 | ICD10CM | Covered |
| H40.823 | ICD10CM | Covered |
| H40.831 | ICD10CM | Covered |
| H40.832 | ICD10CM | Covered |
| H40.833 | ICD10CM | Covered |
| H40.841 | ICD10CM | Covered |
| H40.842 | ICD10CM | Covered |
| H40.843 | ICD10CM | Covered |
| H40.89 | ICD10CM | Covered |
| H40.9 | ICD10CM | Covered |
| H42 | ICD10CM | Covered |
| Q15.0 | ICD10CM | Covered |
| T85.318A | ICD10CM | Covered |
| T85.328A | ICD10CM | Covered |
| T86.8401 | ICD10CM | Covered |
| T86.8402 | ICD10CM | Covered |
| T86.8403 | ICD10CM | Covered |
| T86.8411 | ICD10CM | Covered |
| T86.8412 | ICD10CM | Covered |
| T86.8413 | ICD10CM | Covered |