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 |
|---|---|---|
| 31579 | CPT | Covered |
| 92507 | CPT | Covered |
| 92508 | CPT | Covered |
| 92521 | CPT | Covered |
| 92522 | CPT | Covered |
| 92523 | CPT | Covered |
| 92524 | CPT | Covered |
| 92597 | CPT | Covered |
| 92607 | CPT | Covered |
| 92608 | CPT | Covered |
| 92609 | CPT | Covered |
| 92626 | CPT | Covered |
| 92627 | CPT | Covered |
| 96105 | CPT | Covered |
| 96110 | CPT | Covered |
| 96112 | CPT | Covered |
| 96113 | CPT | Covered |
| 96125 | CPT | Covered |
| 97129 | CPT | Covered |
| 97130 | CPT | Covered |
| 97533 | CPT | Covered |
| F01.50 | ICD10CM | Covered |
| F01.511 | ICD10CM | Covered |
| F01.518 | ICD10CM | Covered |
| F01.52 | ICD10CM | Covered |
| F01.53 | ICD10CM | Covered |
| F01.54 | ICD10CM | Covered |
| F03.90 | ICD10CM | Covered |
| F03.911 | ICD10CM | Covered |
| F03.918 | ICD10CM | Covered |
| F03.92 | ICD10CM | Covered |
| F03.93 | ICD10CM | Covered |
| F03.94 | ICD10CM | Covered |
| F80.0 | ICD10CM | Covered |
| F80.1 | ICD10CM | Covered |
| F80.2 | ICD10CM | Covered |
| F80.4 | ICD10CM | Covered |
| F80.81 | ICD10CM | Covered |
| F80.89 | ICD10CM | Covered |
| F81.0 | ICD10CM | Covered |
| F81.2 | ICD10CM | Covered |
| F81.81 | ICD10CM | Covered |
| F81.89 | ICD10CM | Covered |
| F82 | ICD10CM | Covered |
| F88 | ICD10CM | Covered |
| F90.2 | ICD10CM | Covered |
| F98.5 | ICD10CM | Covered |
| G20.A1 | ICD10CM | Covered |
| G20.A2 | ICD10CM | Covered |
| G20.B1 | ICD10CM | Covered |
| G20.B2 | ICD10CM | Covered |
| G21.4 | ICD10CM | Covered |
| G30.0 | ICD10CM | Covered |
| G30.1 | ICD10CM | Covered |
| G30.8 | ICD10CM | Covered |
| G31.09 | ICD10CM | Covered |
| G31.1 | ICD10CM | Covered |
| G52.1 | ICD10CM | Covered |
| G52.2 | ICD10CM | Covered |
| G52.3 | ICD10CM | Covered |
| G52.7 | ICD10CM | Covered |
| G52.8 | ICD10CM | Covered |
| G60.8 | ICD10CM | Covered |
| H90.0 | ICD10CM | Covered |
| H90.11 | ICD10CM | Covered |
| H90.12 | ICD10CM | Covered |
| H90.2 | ICD10CM | Covered |
| H90.3 | ICD10CM | Covered |
| H90.41 | ICD10CM | Covered |
| H90.42 | ICD10CM | Covered |
| H90.5 | ICD10CM | Covered |
| H90.6 | ICD10CM | Covered |
| H90.71 | ICD10CM | Covered |
| H90.72 | ICD10CM | Covered |
| H90.8 | ICD10CM | Covered |
| H93.25 | ICD10CM | Covered |
| H93.91 | ICD10CM | Covered |
| H93.92 | ICD10CM | Covered |
| H93.93 | ICD10CM | Covered |
| I69.010 | ICD10CM | Covered |
| I69.011 | ICD10CM | Covered |
| I69.012 | ICD10CM | Covered |
| I69.013 | ICD10CM | Covered |
| I69.014 | ICD10CM | Covered |
| I69.015 | ICD10CM | Covered |
| I69.018 | ICD10CM | Covered |
| I69.020 | ICD10CM | Covered |
| I69.021 | ICD10CM | Covered |
| I69.022 | ICD10CM | Covered |
| I69.023 | ICD10CM | Covered |
| I69.028 | ICD10CM | Covered |
| I69.092 | ICD10CM | Covered |
| I69.111 | ICD10CM | Covered |
| I69.112 | ICD10CM | Covered |
| I69.113 | ICD10CM | Covered |
| I69.114 | ICD10CM | Covered |
| I69.115 | ICD10CM | Covered |
| I69.118 | ICD10CM | Covered |
| I69.120 | ICD10CM | Covered |
| I69.121 | ICD10CM | Covered |
| I69.122 | ICD10CM | Covered |
| I69.123 | ICD10CM | Covered |
| I69.128 | ICD10CM | Covered |
| I69.192 | ICD10CM | Covered |
| I69.210 | ICD10CM | Covered |
| I69.211 | ICD10CM | Covered |
| I69.212 | ICD10CM | Covered |
| I69.213 | ICD10CM | Covered |
| I69.214 | ICD10CM | Covered |
| I69.215 | ICD10CM | Covered |
| I69.218 | ICD10CM | Covered |
| I69.220 | ICD10CM | Covered |
| I69.221 | ICD10CM | Covered |
| I69.222 | ICD10CM | Covered |
| I69.223 | ICD10CM | Covered |
| I69.228 | ICD10CM | Covered |
| I69.292 | ICD10CM | Covered |
| I69.310 | ICD10CM | Covered |
| I69.311 | ICD10CM | Covered |
| I69.312 | ICD10CM | Covered |
| I69.313 | ICD10CM | Covered |
| I69.314 | ICD10CM | Covered |
| I69.315 | ICD10CM | Covered |
| I69.318 | ICD10CM | Covered |
| I69.320 | ICD10CM | Covered |
| I69.321 | ICD10CM | Covered |
| I69.322 | ICD10CM | Covered |
| I69.323 | ICD10CM | Covered |
| I69.328 | ICD10CM | Covered |
| I69.392 | ICD10CM | Covered |
| I69.810 | ICD10CM | Covered |
| I69.811 | ICD10CM | Covered |
| I69.812 | ICD10CM | Covered |
| I69.813 | ICD10CM | Covered |
| I69.814 | ICD10CM | Covered |
| I69.815 | ICD10CM | Covered |
| I69.818 | ICD10CM | Covered |
| I69.820 | ICD10CM | Covered |
| I69.821 | ICD10CM | Covered |
| I69.822 | ICD10CM | Covered |
| I69.823 | ICD10CM | Covered |
| I69.828 | ICD10CM | Covered |
| I69.892 | ICD10CM | Covered |
| I69.928 | ICD10CM | Covered |
| I69.998 | ICD10CM | Covered |
| J38.00 | ICD10CM | Covered |
| J38.01 | ICD10CM | Covered |
| J38.02 | ICD10CM | Covered |
| J38.2 | ICD10CM | Covered |
| J38.3 | ICD10CM | Covered |
| R41.840 | ICD10CM | Covered |
| R41.841 | ICD10CM | Covered |
| R41.842 | ICD10CM | Covered |
| R41.843 | ICD10CM | Covered |
| R41.844 | ICD10CM | Covered |
| R41.85 | ICD10CM | Covered |
| R41.89 | ICD10CM | Covered |
| R47.01 | ICD10CM | Covered |
| R47.02 | ICD10CM | Covered |
| R47.1 | ICD10CM | Covered |
| R47.81 | ICD10CM | Covered |
| R47.82 | ICD10CM | Covered |
| R47.89 | ICD10CM | Covered |
| R48.0 | ICD10CM | Covered |
| R48.1 | ICD10CM | Covered |
| R48.2 | ICD10CM | Covered |
| R48.8 | ICD10CM | Covered |
| R49.0 | ICD10CM | Covered |
| R49.1 | ICD10CM | Covered |
| R49.9 | ICD10CM | Covered |
| S06.0X0A | ICD10CM | Covered |
| S06.0X1A | ICD10CM | Covered |
| S06.0XAA | ICD10CM | Covered |
| S06.0XAD | ICD10CM | Covered |
| S06.0XAS | ICD10CM | Covered |
| S06.1X0A | ICD10CM | Covered |
| S06.1X1A | ICD10CM | Covered |
| S06.1X2A | ICD10CM | Covered |
| S06.1X3A | ICD10CM | Covered |
| S06.1X4A | ICD10CM | Covered |
| S06.1X5A | ICD10CM | Covered |
| S06.1X6A | ICD10CM | Covered |
| S06.1X7A | ICD10CM | Covered |
| S06.1X8A | ICD10CM | Covered |
| S06.1X9A | ICD10CM | Covered |
| S06.1XAA | ICD10CM | Covered |
| S06.1XAD | ICD10CM | Covered |
| S06.1XAS | ICD10CM | Covered |
| S06.2X0A | ICD10CM | Covered |
| S06.2X1A | ICD10CM | Covered |
| S06.2X2A | ICD10CM | Covered |
| S06.2X3A | ICD10CM | Covered |
| S06.2X4A | ICD10CM | Covered |
| S06.2X5A | ICD10CM | Covered |
| S06.2X6A | ICD10CM | Covered |
| S06.2X7A | ICD10CM | Covered |
| S06.2X8A | ICD10CM | Covered |
| S06.2X9A | ICD10CM | Covered |
| S06.2XAA | ICD10CM | Covered |
| S06.2XAD | ICD10CM | Covered |
| S06.2XAS | ICD10CM | Covered |
| S06.300A | ICD10CM | Covered |
| S06.301A | ICD10CM | Covered |
| S06.302A | ICD10CM | Covered |
| S06.303A | ICD10CM | Covered |
| S06.304A | ICD10CM | Covered |
| S06.305A | ICD10CM | Covered |
| S06.306A | ICD10CM | Covered |
| S06.307A | ICD10CM | Covered |
| S06.308A | ICD10CM | Covered |
| S06.309A | ICD10CM | Covered |
| S06.30AA | ICD10CM | Covered |
| S06.30AD | ICD10CM | Covered |
| S06.30AS | ICD10CM | Covered |
| S06.31AA | ICD10CM | Covered |
| S06.31AD | ICD10CM | Covered |
| S06.31AS | ICD10CM | Covered |
| S06.32AA | ICD10CM | Covered |
| S06.32AD | ICD10CM | Covered |
| S06.32AS | ICD10CM | Covered |
| S06.330A | ICD10CM | Covered |
| S06.331A | ICD10CM | Covered |
| S06.333A | ICD10CM | Covered |
| S06.335A | ICD10CM | Covered |
| S06.336A | ICD10CM | Covered |
| S06.339A | ICD10CM | Covered |
| S06.33AA | ICD10CM | Covered |
| S06.33AD | ICD10CM | Covered |
| S06.33AS | ICD10CM | Covered |
| S06.340A | ICD10CM | Covered |
| S06.341A | ICD10CM | Covered |
| S06.342A | ICD10CM | Covered |
| S06.343A | ICD10CM | Covered |
| S06.344A | ICD10CM | Covered |
| S06.345A | ICD10CM | Covered |
| S06.346A | ICD10CM | Covered |
| S06.347A | ICD10CM | Covered |
| S06.348A | ICD10CM | Covered |
| S06.349A | ICD10CM | Covered |
| S06.34AA | ICD10CM | Covered |
| S06.34AD | ICD10CM | Covered |
| S06.34AS | ICD10CM | Covered |
| S06.350A | ICD10CM | Covered |
| S06.351A | ICD10CM | Covered |
| S06.352A | ICD10CM | Covered |
| S06.353A | ICD10CM | Covered |
| S06.354A | ICD10CM | Covered |
| S06.355A | ICD10CM | Covered |
| S06.356A | ICD10CM | Covered |
| S06.357A | ICD10CM | Covered |
| S06.358A | ICD10CM | Covered |
| S06.359A | ICD10CM | Covered |
| S06.35AA | ICD10CM | Covered |
| S06.35AD | ICD10CM | Covered |
| S06.35AS | ICD10CM | Covered |
| S06.360A | ICD10CM | Covered |
| S06.361A | ICD10CM | Covered |
| S06.362A | ICD10CM | Covered |
| S06.363A | ICD10CM | Covered |
| S06.364A | ICD10CM | Covered |
| S06.365A | ICD10CM | Covered |
| S06.366A | ICD10CM | Covered |
| S06.367A | ICD10CM | Covered |
| S06.368A | ICD10CM | Covered |
| S06.369A | ICD10CM | Covered |
| S06.36AA | ICD10CM | Covered |
| S06.36AD | ICD10CM | Covered |
| S06.36AS | ICD10CM | Covered |
| S06.370A | ICD10CM | Covered |
| S06.371A | ICD10CM | Covered |
| S06.372A | ICD10CM | Covered |
| S06.373A | ICD10CM | Covered |
| S06.374A | ICD10CM | Covered |
| S06.375A | ICD10CM | Covered |
| S06.376A | ICD10CM | Covered |
| S06.377A | ICD10CM | Covered |
| S06.378A | ICD10CM | Covered |
| S06.379A | ICD10CM | Covered |
| S06.37AA | ICD10CM | Covered |
| S06.37AD | ICD10CM | Covered |
| S06.37AS | ICD10CM | Covered |
| S06.380A | ICD10CM | Covered |
| S06.381A | ICD10CM | Covered |
| S06.382A | ICD10CM | Covered |
| S06.383A | ICD10CM | Covered |
| S06.384A | ICD10CM | Covered |
| S06.385A | ICD10CM | Covered |
| S06.386A | ICD10CM | Covered |
| S06.387A | ICD10CM | Covered |
| S06.388A | ICD10CM | Covered |
| S06.389A | ICD10CM | Covered |
| S06.38AA | ICD10CM | Covered |
| S06.38AD | ICD10CM | Covered |
| S06.38AS | ICD10CM | Covered |
| S06.4X0A | ICD10CM | Covered |
| S06.4X1A | ICD10CM | Covered |
| S06.4X2A | ICD10CM | Covered |
| S06.4X3A | ICD10CM | Covered |
| S06.4X4A | ICD10CM | Covered |
| S06.4X5A | ICD10CM | Covered |
| S06.4X6A | ICD10CM | Covered |
| S06.4X7A | ICD10CM | Covered |
| S06.4X8A | ICD10CM | Covered |
| S06.4X9A | ICD10CM | Covered |
| S06.4XAA | ICD10CM | Covered |
| S06.4XAD | ICD10CM | Covered |
| S06.4XAS | ICD10CM | Covered |
| S06.5X0A | ICD10CM | Covered |
| S06.5X1A | ICD10CM | Covered |
| S06.5X2A | ICD10CM | Covered |
| S06.5X3A | ICD10CM | Covered |
| S06.5X4A | ICD10CM | Covered |
| S06.5X5A | ICD10CM | Covered |
| S06.5X6A | ICD10CM | Covered |
| S06.5X7A | ICD10CM | Covered |
| S06.5X8A | ICD10CM | Covered |
| S06.5X9A | ICD10CM | Covered |
| S06.5XAA | ICD10CM | Covered |
| S06.5XAD | ICD10CM | Covered |
| S06.5XAS | ICD10CM | Covered |
| S06.6X0A | ICD10CM | Covered |
| S06.6X1A | ICD10CM | Covered |
| S06.6X2A | ICD10CM | Covered |
| S06.6X3A | ICD10CM | Covered |
| S06.6X4A | ICD10CM | Covered |
| S06.6X5A | ICD10CM | Covered |
| S06.6X6A | ICD10CM | Covered |
| S06.6X7A | ICD10CM | Covered |
| S06.6X8A | ICD10CM | Covered |
| S06.6X9A | ICD10CM | Covered |
| S06.6XAA | ICD10CM | Covered |
| S06.6XAD | ICD10CM | Covered |
| S06.6XAS | ICD10CM | Covered |
| S06.810A | ICD10CM | Covered |
| S06.811A | ICD10CM | Covered |
| S06.812A | ICD10CM | Covered |
| S06.813A | ICD10CM | Covered |
| S06.814A | ICD10CM | Covered |
| S06.815A | ICD10CM | Covered |
| S06.816A | ICD10CM | Covered |
| S06.817A | ICD10CM | Covered |
| S06.818A | ICD10CM | Covered |
| S06.819A | ICD10CM | Covered |
| S06.81AA | ICD10CM | Covered |
| S06.81AD | ICD10CM | Covered |
| S06.81AS | ICD10CM | Covered |
| S06.820A | ICD10CM | Covered |
| S06.821A | ICD10CM | Covered |
| S06.822A | ICD10CM | Covered |
| S06.823A | ICD10CM | Covered |
| S06.824A | ICD10CM | Covered |
| S06.825A | ICD10CM | Covered |
| S06.826A | ICD10CM | Covered |
| S06.827A | ICD10CM | Covered |
| S06.828A | ICD10CM | Covered |
| S06.829A | ICD10CM | Covered |
| S06.82AA | ICD10CM | Covered |
| S06.82AD | ICD10CM | Covered |
| S06.82AS | ICD10CM | Covered |
| S06.890A | ICD10CM | Covered |
| S06.891A | ICD10CM | Covered |
| S06.892A | ICD10CM | Covered |
| S06.893A | ICD10CM | Covered |
| S06.894A | ICD10CM | Covered |
| S06.895A | ICD10CM | Covered |
| S06.896A | ICD10CM | Covered |
| S06.897A | ICD10CM | Covered |
| S06.898A | ICD10CM | Covered |
| S06.899A | ICD10CM | Covered |
| S06.89AA | ICD10CM | Covered |
| S06.89AD | ICD10CM | Covered |
| S06.89AS | ICD10CM | Covered |
| S06.8A0A | ICD10CM | Covered |
| S06.8A0D | ICD10CM | Covered |
| S06.8A0S | ICD10CM | Covered |
| S06.8A1A | ICD10CM | Covered |
| S06.8A1D | ICD10CM | Covered |
| S06.8A1S | ICD10CM | Covered |
| S06.8A2A | ICD10CM | Covered |
| S06.8A2D | ICD10CM | Covered |
| S06.8A2S | ICD10CM | Covered |
| S06.8A3A | ICD10CM | Covered |
| S06.8A3D | ICD10CM | Covered |
| S06.8A3S | ICD10CM | Covered |
| S06.8A4A | ICD10CM | Covered |
| S06.8A4D | ICD10CM | Covered |
| S06.8A4S | ICD10CM | Covered |
| S06.8A5A | ICD10CM | Covered |
| S06.8A5D | ICD10CM | Covered |
| S06.8A5S | ICD10CM | Covered |
| S06.8A6A | ICD10CM | Covered |
| S06.8A6D | ICD10CM | Covered |
| S06.8A6S | ICD10CM | Covered |
| S06.8A7A | ICD10CM | Covered |
| S06.8A8A | ICD10CM | Covered |
| S06.8A9A | ICD10CM | Covered |
| S06.8A9D | ICD10CM | Covered |
| S06.8A9S | ICD10CM | Covered |
| S06.8AAA | ICD10CM | Covered |
| S06.8AAD | ICD10CM | Covered |
| S06.8AAS | ICD10CM | Covered |
| S06.9X0A | ICD10CM | Covered |
| S06.9X1A | ICD10CM | Covered |
| S06.9X2A | ICD10CM | Covered |
| S06.9X3A | ICD10CM | Covered |
| S06.9X4A | ICD10CM | Covered |
| S06.9X5A | ICD10CM | Covered |
| S06.9X6A | ICD10CM | Covered |
| S06.9X7A | ICD10CM | Covered |
| S06.9X8A | ICD10CM | Covered |
| S06.9X9A | ICD10CM | Covered |
| S06.9XAA | ICD10CM | Covered |
| S06.9XAD | ICD10CM | Covered |
| S06.9XAS | ICD10CM | Covered |
| T85.810A | ICD10CM | Covered |
| T85.818A | ICD10CM | Covered |
| T85.820A | ICD10CM | Covered |
| T85.828A | ICD10CM | Covered |
| T85.830A | ICD10CM | Covered |
| T85.838A | ICD10CM | Covered |
| T85.840A | ICD10CM | Covered |
| T85.848A | ICD10CM | Covered |
| T85.850A | ICD10CM | Covered |
| T85.858A | ICD10CM | Covered |
| T85.860A | ICD10CM | Covered |
| T85.868A | ICD10CM | Covered |
| T86.8481 | ICD10CM | Covered |
| T86.8482 | ICD10CM | Covered |
| T86.8483 | ICD10CM | Covered |
| Z01.818 | ICD10CM | Covered |
| Z44.8 | ICD10CM | Covered |
| Z86.59 | ICD10CM | Covered |
| Z96.3 | ICD10CM | Covered |
| Z97.4 | ICD10CM | Covered |