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 |
|---|---|---|
| F01.50 | ICD10CM | Covered |
| F01.511 | ICD10CM | Covered |
| F01.518 | ICD10CM | Covered |
| F01.52 | ICD10CM | Covered |
| F01.53 | ICD10CM | Covered |
| F01.54 | ICD10CM | Covered |
| F02.811 | ICD10CM | Covered |
| F02.818 | 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 |
| F05 | ICD10CM | Covered |
| F06.0 | ICD10CM | Covered |
| F06.1 | ICD10CM | Covered |
| F06.2 | ICD10CM | Covered |
| F06.31 | ICD10CM | Covered |
| F06.32 | ICD10CM | Covered |
| F06.33 | ICD10CM | Covered |
| F06.34 | ICD10CM | Covered |
| F06.4 | ICD10CM | Covered |
| F06.8 | ICD10CM | Covered |
| F10.10 | ICD10CM | Covered |
| F10.120 | ICD10CM | Covered |
| F10.121 | ICD10CM | Covered |
| F10.130 | ICD10CM | Covered |
| F10.131 | ICD10CM | Covered |
| F10.132 | ICD10CM | Covered |
| F10.14 | ICD10CM | Covered |
| F10.150 | ICD10CM | Covered |
| F10.151 | ICD10CM | Covered |
| F10.180 | ICD10CM | Covered |
| F10.181 | ICD10CM | Covered |
| F10.188 | ICD10CM | Covered |
| F10.19 | ICD10CM | Covered |
| F10.20 | ICD10CM | Covered |
| F10.21 | ICD10CM | Covered |
| F10.220 | ICD10CM | Covered |
| F10.221 | ICD10CM | Covered |
| F10.230 | ICD10CM | Covered |
| F10.231 | ICD10CM | Covered |
| F10.232 | ICD10CM | Covered |
| F10.24 | ICD10CM | Covered |
| F10.250 | ICD10CM | Covered |
| F10.251 | ICD10CM | Covered |
| F10.280 | ICD10CM | Covered |
| F10.281 | ICD10CM | Covered |
| F10.288 | ICD10CM | Covered |
| F10.29 | ICD10CM | Covered |
| F10.94 | ICD10CM | Covered |
| F10.980 | ICD10CM | Covered |
| F10.981 | ICD10CM | Covered |
| F10.988 | ICD10CM | Covered |
| F10.99 | ICD10CM | Covered |
| F11.10 | ICD10CM | Covered |
| F11.120 | ICD10CM | Covered |
| F11.121 | ICD10CM | Covered |
| F11.13 | ICD10CM | Covered |
| F11.14 | ICD10CM | Covered |
| F11.150 | ICD10CM | Covered |
| F11.151 | ICD10CM | Covered |
| F11.181 | ICD10CM | Covered |
| F11.188 | ICD10CM | Covered |
| F11.20 | ICD10CM | Covered |
| F11.21 | ICD10CM | Covered |
| F11.220 | ICD10CM | Covered |
| F11.221 | ICD10CM | Covered |
| F11.222 | ICD10CM | Covered |
| F11.23 | ICD10CM | Covered |
| F11.24 | ICD10CM | Covered |
| F11.250 | ICD10CM | Covered |
| F11.251 | ICD10CM | Covered |
| F11.281 | ICD10CM | Covered |
| F11.282 | ICD10CM | Covered |
| F11.288 | ICD10CM | Covered |
| F11.922 | ICD10CM | Covered |
| F12.10 | ICD10CM | Covered |
| F12.121 | ICD10CM | Covered |
| F12.122 | ICD10CM | Covered |
| F12.13 | ICD10CM | Covered |
| F12.150 | ICD10CM | Covered |
| F12.151 | ICD10CM | Covered |
| F12.180 | ICD10CM | Covered |
| F12.188 | ICD10CM | Covered |
| F12.221 | ICD10CM | Covered |
| F12.222 | ICD10CM | Covered |
| F12.23 | ICD10CM | Covered |
| F12.250 | ICD10CM | Covered |
| F12.251 | ICD10CM | Covered |
| F12.280 | ICD10CM | Covered |
| F12.288 | ICD10CM | Covered |
| F13.10 | ICD10CM | Covered |
| F13.120 | ICD10CM | Covered |
| F13.121 | ICD10CM | Covered |
| F13.130 | ICD10CM | Covered |
| F13.131 | ICD10CM | Covered |
| F13.132 | ICD10CM | Covered |
| F13.14 | ICD10CM | Covered |
| F13.150 | ICD10CM | Covered |
| F13.151 | ICD10CM | Covered |
| F13.180 | ICD10CM | Covered |
| F13.181 | ICD10CM | Covered |
| F13.188 | ICD10CM | Covered |
| F13.20 | ICD10CM | Covered |
| F13.21 | ICD10CM | Covered |
| F13.220 | ICD10CM | Covered |
| F13.221 | ICD10CM | Covered |
| F13.230 | ICD10CM | Covered |
| F13.231 | ICD10CM | Covered |
| F13.232 | ICD10CM | Covered |
| F13.24 | ICD10CM | Covered |
| F13.250 | ICD10CM | Covered |
| F13.251 | ICD10CM | Covered |
| F13.26 | ICD10CM | Covered |
| F13.27 | ICD10CM | Covered |
| F13.280 | ICD10CM | Covered |
| F13.281 | ICD10CM | Covered |
| F13.282 | ICD10CM | Covered |
| F13.288 | ICD10CM | Covered |
| F13.29 | ICD10CM | Covered |
| F14.10 | ICD10CM | Covered |
| F14.120 | ICD10CM | Covered |
| F14.121 | ICD10CM | Covered |
| F14.122 | ICD10CM | Covered |
| F14.14 | ICD10CM | Covered |
| F14.150 | ICD10CM | Covered |
| F14.151 | ICD10CM | Covered |
| F14.180 | ICD10CM | Covered |
| F14.181 | ICD10CM | Covered |
| F14.188 | ICD10CM | Covered |
| F14.20 | ICD10CM | Covered |
| F14.21 | ICD10CM | Covered |
| F14.220 | ICD10CM | Covered |
| F14.221 | ICD10CM | Covered |
| F14.222 | ICD10CM | Covered |
| F14.23 | ICD10CM | Covered |
| F14.24 | ICD10CM | Covered |
| F14.250 | ICD10CM | Covered |
| F14.251 | ICD10CM | Covered |
| F14.280 | ICD10CM | Covered |
| F14.281 | ICD10CM | Covered |
| F14.288 | ICD10CM | Covered |
| F15.10 | ICD10CM | Covered |
| F15.120 | ICD10CM | Covered |
| F15.121 | ICD10CM | Covered |
| F15.122 | ICD10CM | Covered |
| F15.13 | ICD10CM | Covered |
| F15.14 | ICD10CM | Covered |
| F15.150 | ICD10CM | Covered |
| F15.151 | ICD10CM | Covered |
| F15.180 | ICD10CM | Covered |
| F15.181 | ICD10CM | Covered |
| F15.188 | ICD10CM | Covered |
| F15.20 | ICD10CM | Covered |
| F15.21 | ICD10CM | Covered |
| F15.220 | ICD10CM | Covered |
| F15.221 | ICD10CM | Covered |
| F15.222 | ICD10CM | Covered |
| F15.23 | ICD10CM | Covered |
| F15.24 | ICD10CM | Covered |
| F15.250 | ICD10CM | Covered |
| F15.251 | ICD10CM | Covered |
| F15.280 | ICD10CM | Covered |
| F15.281 | ICD10CM | Covered |
| F15.282 | ICD10CM | Covered |
| F15.288 | ICD10CM | Covered |
| F16.10 | ICD10CM | Covered |
| F16.120 | ICD10CM | Covered |
| F16.121 | ICD10CM | Covered |
| F16.122 | ICD10CM | Covered |
| F16.14 | ICD10CM | Covered |
| F16.150 | ICD10CM | Covered |
| F16.151 | ICD10CM | Covered |
| F16.180 | ICD10CM | Covered |
| F16.183 | ICD10CM | Covered |
| F16.188 | ICD10CM | Covered |
| F16.21 | ICD10CM | Covered |
| F16.221 | ICD10CM | Covered |
| F16.24 | ICD10CM | Covered |
| F16.250 | ICD10CM | Covered |
| F16.251 | ICD10CM | Covered |
| F16.280 | ICD10CM | Covered |
| F16.283 | ICD10CM | Covered |
| F16.288 | ICD10CM | Covered |
| F17.210 | ICD10CM | Covered |
| F17.211 | ICD10CM | Covered |
| F17.218 | ICD10CM | Covered |
| F17.220 | ICD10CM | Covered |
| F17.221 | ICD10CM | Covered |
| F17.228 | ICD10CM | Covered |
| F17.290 | ICD10CM | Covered |
| F17.291 | ICD10CM | Covered |
| F17.298 | ICD10CM | Covered |
| F18.10 | ICD10CM | Covered |
| F18.120 | ICD10CM | Covered |
| F18.121 | ICD10CM | Covered |
| F18.14 | ICD10CM | Covered |
| F18.150 | ICD10CM | Covered |
| F18.151 | ICD10CM | Covered |
| F18.180 | ICD10CM | Covered |
| F18.188 | ICD10CM | Covered |
| F18.20 | ICD10CM | Covered |
| F18.21 | ICD10CM | Covered |
| F18.220 | ICD10CM | Covered |
| F18.221 | ICD10CM | Covered |
| F18.24 | ICD10CM | Covered |
| F18.250 | ICD10CM | Covered |
| F18.251 | ICD10CM | Covered |
| F18.27 | ICD10CM | Covered |
| F18.280 | ICD10CM | Covered |
| F18.288 | ICD10CM | Covered |
| F19.10 | ICD10CM | Covered |
| F19.120 | ICD10CM | Covered |
| F19.121 | ICD10CM | Covered |
| F19.122 | ICD10CM | Covered |
| F19.130 | ICD10CM | Covered |
| F19.131 | ICD10CM | Covered |
| F19.132 | ICD10CM | Covered |
| F19.14 | ICD10CM | Covered |
| F19.150 | ICD10CM | Covered |
| F19.151 | ICD10CM | Covered |
| F19.180 | ICD10CM | Covered |
| F19.181 | ICD10CM | Covered |
| F19.188 | ICD10CM | Covered |
| F19.20 | ICD10CM | Covered |
| F19.21 | ICD10CM | Covered |
| F19.220 | ICD10CM | Covered |
| F19.221 | ICD10CM | Covered |
| F19.222 | ICD10CM | Covered |
| F19.230 | ICD10CM | Covered |
| F19.231 | ICD10CM | Covered |
| F19.232 | ICD10CM | Covered |
| F19.24 | ICD10CM | Covered |
| F19.250 | ICD10CM | Covered |
| F19.251 | ICD10CM | Covered |
| F19.26 | ICD10CM | Covered |
| F19.27 | ICD10CM | Covered |
| F19.280 | ICD10CM | Covered |
| F19.281 | ICD10CM | Covered |
| F19.282 | ICD10CM | Covered |
| F19.288 | ICD10CM | Covered |
| F20.0 | ICD10CM | Covered |
| F20.1 | ICD10CM | Covered |
| F20.2 | ICD10CM | Covered |
| F20.3 | ICD10CM | Covered |
| F20.5 | ICD10CM | Covered |
| F20.81 | ICD10CM | Covered |
| F20.89 | ICD10CM | Covered |
| F22 | ICD10CM | Covered |
| F23 | ICD10CM | Covered |
| F24 | ICD10CM | Covered |
| F25.0 | ICD10CM | Covered |
| F25.1 | ICD10CM | Covered |
| F25.8 | ICD10CM | Covered |
| F28 | ICD10CM | Covered |
| F30.11 | ICD10CM | Covered |
| F30.12 | ICD10CM | Covered |
| F30.13 | ICD10CM | Covered |
| F30.2 | ICD10CM | Covered |
| F30.3 | ICD10CM | Covered |
| F30.4 | ICD10CM | Covered |
| F31.11 | ICD10CM | Covered |
| F31.12 | ICD10CM | Covered |
| F31.13 | ICD10CM | Covered |
| F31.2 | ICD10CM | Covered |
| F31.31 | ICD10CM | Covered |
| F31.32 | ICD10CM | Covered |
| F31.4 | ICD10CM | Covered |
| F31.5 | ICD10CM | Covered |
| F31.61 | ICD10CM | Covered |
| F31.62 | ICD10CM | Covered |
| F31.63 | ICD10CM | Covered |
| F31.64 | ICD10CM | Covered |
| F31.70 | ICD10CM | Covered |
| F31.71 | ICD10CM | Covered |
| F31.72 | ICD10CM | Covered |
| F31.73 | ICD10CM | Covered |
| F31.74 | ICD10CM | Covered |
| F31.75 | ICD10CM | Covered |
| F31.76 | ICD10CM | Covered |
| F31.77 | ICD10CM | Covered |
| F31.78 | ICD10CM | Covered |
| F31.81 | ICD10CM | Covered |
| F31.9 | ICD10CM | Covered |
| F32.0 | ICD10CM | Covered |
| F32.1 | ICD10CM | Covered |
| F32.2 | ICD10CM | Covered |
| F32.3 | ICD10CM | Covered |
| F32.4 | ICD10CM | Covered |
| F32.5 | ICD10CM | Covered |
| F33.0 | ICD10CM | Covered |
| F33.1 | ICD10CM | Covered |
| F33.2 | ICD10CM | Covered |
| F33.3 | ICD10CM | Covered |
| F33.41 | ICD10CM | Covered |
| F33.42 | ICD10CM | Covered |
| F39 | ICD10CM | Covered |
| F40.01 | ICD10CM | Covered |
| F41.0 | ICD10CM | Covered |
| F42.2 | ICD10CM | Covered |
| F42.3 | ICD10CM | Covered |
| F42.4 | ICD10CM | Covered |
| F42.8 | ICD10CM | Covered |
| F42.9 | ICD10CM | Covered |
| F43.0 | ICD10CM | Covered |
| F43.10 | ICD10CM | Covered |
| F43.11 | ICD10CM | Covered |
| F43.12 | ICD10CM | Covered |
| F43.21 | ICD10CM | Covered |
| F43.22 | ICD10CM | Covered |
| F43.23 | ICD10CM | Covered |
| F43.24 | ICD10CM | Covered |
| F43.25 | ICD10CM | Covered |
| F45.41 | ICD10CM | Covered |
| F45.8 | ICD10CM | Covered |
| F45.9 | ICD10CM | Covered |
| F50.011 | ICD10CM | Covered |
| F50.012 | ICD10CM | Covered |
| F50.013 | ICD10CM | Covered |
| F50.021 | ICD10CM | Covered |
| F50.022 | ICD10CM | Covered |
| F50.023 | ICD10CM | Covered |
| F50.22 | ICD10CM | Covered |
| F50.23 | ICD10CM | Covered |
| F50.24 | ICD10CM | Covered |
| F51.01 | ICD10CM | Covered |
| F51.02 | ICD10CM | Covered |
| F51.03 | ICD10CM | Covered |
| F51.09 | ICD10CM | Covered |
| F51.11 | ICD10CM | Covered |
| F51.12 | ICD10CM | Covered |
| F51.19 | ICD10CM | Covered |
| F51.3 | ICD10CM | Covered |
| F51.4 | ICD10CM | Covered |
| F51.5 | ICD10CM | Covered |
| F51.8 | ICD10CM | Covered |
| F51.9 | ICD10CM | Covered |
| F52.0 | ICD10CM | Covered |
| F52.1 | ICD10CM | Covered |
| F52.21 | ICD10CM | Covered |
| F52.22 | ICD10CM | Covered |
| F52.31 | ICD10CM | Covered |
| F52.32 | ICD10CM | Covered |
| F52.4 | ICD10CM | Covered |
| F52.6 | ICD10CM | Covered |
| F52.8 | ICD10CM | Covered |
| F52.9 | ICD10CM | Covered |
| F53.0 | ICD10CM | Covered |
| F53.1 | ICD10CM | Covered |
| F55.0 | ICD10CM | Covered |
| F55.1 | ICD10CM | Covered |
| F55.2 | ICD10CM | Covered |
| F55.3 | ICD10CM | Covered |
| F55.4 | ICD10CM | Covered |
| F55.8 | ICD10CM | Covered |
| F59 | ICD10CM | Covered |
| F60.3 | ICD10CM | Covered |
| F63.3 | ICD10CM | Covered |
| F63.81 | ICD10CM | Covered |
| F64.1 | ICD10CM | Covered |
| F64.2 | ICD10CM | Covered |
| F64.8 | ICD10CM | Covered |
| F65.0 | ICD10CM | Covered |
| F65.1 | ICD10CM | Covered |
| F65.2 | ICD10CM | Covered |
| F65.3 | ICD10CM | Covered |
| F65.4 | ICD10CM | Covered |
| F65.50 | ICD10CM | Covered |
| F65.51 | ICD10CM | Covered |
| F65.52 | ICD10CM | Covered |
| F65.81 | ICD10CM | Covered |
| F65.89 | ICD10CM | Covered |
| F65.9 | ICD10CM | Covered |
| F66 | ICD10CM | Covered |
| F70 | ICD10CM | Covered |
| F71 | ICD10CM | Covered |
| F72 | ICD10CM | Covered |
| F73 | ICD10CM | Covered |
| F78.A1 | ICD10CM | Covered |
| F78.A9 | 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 |
| F84.0 | ICD10CM | Covered |
| F84.3 | ICD10CM | Covered |
| F84.5 | ICD10CM | Covered |
| F84.8 | ICD10CM | Covered |
| F84.9 | ICD10CM | Covered |
| F88 | ICD10CM | Covered |
| F90.0 | ICD10CM | Covered |
| F90.1 | ICD10CM | Covered |
| F90.2 | ICD10CM | Covered |
| F90.8 | ICD10CM | Covered |
| F93.0 | ICD10CM | Covered |
| F93.8 | ICD10CM | Covered |
| F98.0 | ICD10CM | Covered |
| F98.1 | ICD10CM | Covered |
| F98.3 | ICD10CM | Covered |
| F98.5 | ICD10CM | Covered |
| G44.209 | ICD10CM | Covered |
| H93.25 | ICD10CM | Covered |
| R37 | ICD10CM | Covered |
| R40.0 | ICD10CM | Covered |
| R40.1 | ICD10CM | Covered |
| R45.1 | ICD10CM | Covered |
| R45.81 | ICD10CM | Covered |
| R45.82 | ICD10CM | Covered |
| R45.850 | ICD10CM | Covered |
| R45.851 | ICD10CM | Covered |
| R45.88 | ICD10CM | Covered |
| R48.0 | ICD10CM | Covered |
| Z87.890 | ICD10CM | Covered |