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 |
|---|---|---|
| 76376 | CPT | Covered |
| 76377 | CPT | Covered |
| 93312 | CPT | Covered |
| 93313 | CPT | Covered |
| 93314 | CPT | Covered |
| 93315 | CPT | Covered |
| 93316 | CPT | Covered |
| 93317 | CPT | Covered |
| 93318 | CPT | Covered |
| 93320 | CPT | Covered |
| 93321 | CPT | Covered |
| 93325 | CPT | Covered |
| C8925 | HCPCS | Covered |
| C8926 | HCPCS | Covered |
| C8927 | HCPCS | Covered |
| A02.1 | ICD10CM | Covered |
| A18.84 | ICD10CM | Covered |
| A22.7 | ICD10CM | Covered |
| A26.7 | ICD10CM | Covered |
| A32.7 | ICD10CM | Covered |
| A40.0 | ICD10CM | Covered |
| A40.1 | ICD10CM | Covered |
| A40.3 | ICD10CM | Covered |
| A40.8 | ICD10CM | Covered |
| A41.01 | ICD10CM | Covered |
| A41.02 | ICD10CM | Covered |
| A41.1 | ICD10CM | Covered |
| A41.3 | ICD10CM | Covered |
| A41.4 | ICD10CM | Covered |
| A41.50 | ICD10CM | Covered |
| A41.51 | ICD10CM | Covered |
| A41.52 | ICD10CM | Covered |
| A41.53 | ICD10CM | Covered |
| A41.59 | ICD10CM | Covered |
| A41.81 | ICD10CM | Covered |
| A41.89 | ICD10CM | Covered |
| A41.9 | ICD10CM | Covered |
| A42.7 | ICD10CM | Covered |
| A52.01 | ICD10CM | Covered |
| A52.02 | ICD10CM | Covered |
| A54.86 | ICD10CM | Covered |
| B37.7 | ICD10CM | Covered |
| C38.0 | ICD10CM | Covered |
| C45.2 | ICD10CM | Covered |
| C79.89 | ICD10CM | Covered |
| C79.9 | ICD10CM | Covered |
| D15.1 | ICD10CM | Covered |
| D48.7 | ICD10CM | Covered |
| D49.89 | ICD10CM | Covered |
| G06.0 | ICD10CM | Covered |
| G06.1 | ICD10CM | Covered |
| G45.0 | ICD10CM | Covered |
| G45.1 | ICD10CM | Covered |
| G45.2 | ICD10CM | Covered |
| G45.8 | ICD10CM | Covered |
| G45.9 | ICD10CM | Covered |
| G46.0 | ICD10CM | Covered |
| G46.1 | ICD10CM | Covered |
| G46.2 | ICD10CM | Covered |
| I01.1 | ICD10CM | Covered |
| I01.2 | ICD10CM | Covered |
| I02.0 | ICD10CM | Covered |
| I05.0 | ICD10CM | Covered |
| I05.1 | ICD10CM | Covered |
| I05.2 | ICD10CM | Covered |
| I05.8 | ICD10CM | Covered |
| I08.0 | ICD10CM | Covered |
| I08.1 | ICD10CM | Covered |
| I08.2 | ICD10CM | Covered |
| I08.3 | ICD10CM | Covered |
| I08.8 | ICD10CM | Covered |
| I09.0 | ICD10CM | Covered |
| I09.89 | ICD10CM | Covered |
| I09.9 | ICD10CM | Covered |
| I23.0 | ICD10CM | Covered |
| I23.1 | ICD10CM | Covered |
| I23.2 | ICD10CM | Covered |
| I23.3 | ICD10CM | Covered |
| I23.4 | ICD10CM | Covered |
| I23.5 | ICD10CM | Covered |
| I23.6 | ICD10CM | Covered |
| I23.7 | ICD10CM | Covered |
| I23.8 | ICD10CM | Covered |
| I25.3 | ICD10CM | Covered |
| I25.41 | ICD10CM | Covered |
| I25.42 | ICD10CM | Covered |
| I25.82 | ICD10CM | Covered |
| I25.84 | ICD10CM | Covered |
| I26.01 | ICD10CM | Covered |
| I26.02 | ICD10CM | Covered |
| I26.09 | ICD10CM | Covered |
| I26.90 | ICD10CM | Covered |
| I26.92 | ICD10CM | Covered |
| I26.93 | ICD10CM | Covered |
| I26.94 | ICD10CM | Covered |
| I26.99 | ICD10CM | Covered |
| I28.0 | ICD10CM | Covered |
| I28.1 | ICD10CM | Covered |
| I31.4 | ICD10CM | Covered |
| I33.0 | ICD10CM | Covered |
| I34.0 | ICD10CM | Covered |
| I34.1 | ICD10CM | Covered |
| I34.2 | ICD10CM | Covered |
| I34.81 | ICD10CM | Covered |
| I34.89 | ICD10CM | Covered |
| I35.0 | ICD10CM | Covered |
| I35.1 | ICD10CM | Covered |
| I35.2 | ICD10CM | Covered |
| I35.8 | ICD10CM | Covered |
| I36.0 | ICD10CM | Covered |
| I36.1 | ICD10CM | Covered |
| I36.2 | ICD10CM | Covered |
| I36.8 | ICD10CM | Covered |
| I37.0 | ICD10CM | Covered |
| I37.1 | ICD10CM | Covered |
| I37.2 | ICD10CM | Covered |
| I37.8 | ICD10CM | Covered |
| I38 | ICD10CM | Covered |
| I39 | ICD10CM | Covered |
| I40.0 | 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 |
| I42.8 | ICD10CM | Covered |
| I43 | 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 |
| I51.0 | ICD10CM | Covered |
| I51.1 | ICD10CM | Covered |
| I51.2 | ICD10CM | Covered |
| I51.3 | ICD10CM | Covered |
| I51.4 | ICD10CM | Covered |
| I51.7 | ICD10CM | Covered |
| I51.81 | ICD10CM | Covered |
| I51.89 | ICD10CM | Covered |
| I60.01 | ICD10CM | Covered |
| I60.02 | ICD10CM | Covered |
| I60.11 | ICD10CM | Covered |
| I60.12 | ICD10CM | Covered |
| I60.31 | ICD10CM | Covered |
| I60.32 | ICD10CM | Covered |
| I60.4 | ICD10CM | Covered |
| I60.51 | ICD10CM | Covered |
| I60.52 | ICD10CM | Covered |
| I60.6 | ICD10CM | Covered |
| I60.8 | ICD10CM | Covered |
| I62.9 | ICD10CM | Covered |
| I63.311 | ICD10CM | Covered |
| I63.312 | ICD10CM | Covered |
| I63.321 | ICD10CM | Covered |
| I63.322 | ICD10CM | Covered |
| I63.331 | ICD10CM | Covered |
| I63.332 | ICD10CM | Covered |
| I63.341 | ICD10CM | Covered |
| I63.342 | ICD10CM | Covered |
| I63.39 | ICD10CM | Covered |
| I63.411 | ICD10CM | Covered |
| I63.412 | ICD10CM | Covered |
| I63.421 | ICD10CM | Covered |
| I63.422 | ICD10CM | Covered |
| I63.431 | ICD10CM | Covered |
| I63.432 | ICD10CM | Covered |
| I63.441 | ICD10CM | Covered |
| I63.442 | ICD10CM | Covered |
| I63.49 | ICD10CM | Covered |
| I63.511 | ICD10CM | Covered |
| I63.512 | ICD10CM | Covered |
| I63.521 | ICD10CM | Covered |
| I63.522 | ICD10CM | Covered |
| I63.531 | ICD10CM | Covered |
| I63.532 | ICD10CM | Covered |
| I63.541 | ICD10CM | Covered |
| I63.542 | ICD10CM | Covered |
| I63.59 | ICD10CM | Covered |
| I63.6 | ICD10CM | Covered |
| I63.81 | ICD10CM | Covered |
| I63.89 | ICD10CM | Covered |
| I66.01 | ICD10CM | Covered |
| I66.02 | ICD10CM | Covered |
| I66.03 | ICD10CM | Covered |
| I66.11 | ICD10CM | Covered |
| I66.12 | ICD10CM | Covered |
| I66.13 | ICD10CM | Covered |
| I66.21 | ICD10CM | Covered |
| I66.22 | ICD10CM | Covered |
| I66.23 | ICD10CM | Covered |
| I66.3 | ICD10CM | Covered |
| I67.841 | ICD10CM | Covered |
| I67.848 | ICD10CM | Covered |
| I67.850 | ICD10CM | Covered |
| I67.858 | ICD10CM | Covered |
| I67.89 | ICD10CM | Covered |
| I70.0 | ICD10CM | Covered |
| I71.00 | ICD10CM | Covered |
| I71.011 | ICD10CM | Covered |
| I71.012 | ICD10CM | Covered |
| I71.03 | ICD10CM | Covered |
| I71.11 | ICD10CM | Covered |
| I71.12 | ICD10CM | Covered |
| I71.13 | ICD10CM | Covered |
| I71.21 | ICD10CM | Covered |
| I71.22 | ICD10CM | Covered |
| I71.23 | ICD10CM | Covered |
| I71.51 | ICD10CM | Covered |
| I71.52 | ICD10CM | Covered |
| I71.61 | ICD10CM | Covered |
| I71.62 | ICD10CM | Covered |
| I74.11 | ICD10CM | Covered |
| I74.2 | ICD10CM | Covered |
| I74.3 | ICD10CM | Covered |
| I74.5 | ICD10CM | Covered |
| I74.8 | ICD10CM | Covered |
| I74.9 | ICD10CM | Covered |
| I75.89 | ICD10CM | Covered |
| I76 | ICD10CM | Covered |
| I77.2 | ICD10CM | Covered |
| I82.220 | ICD10CM | Covered |
| I82.221 | ICD10CM | Covered |
| I87.1 | ICD10CM | Covered |
| I95.89 | ICD10CM | Covered |
| I95.9 | ICD10CM | Covered |
| I97.0 | ICD10CM | Covered |
| I97.110 | ICD10CM | Covered |
| I97.111 | ICD10CM | Covered |
| I97.120 | ICD10CM | Covered |
| I97.121 | ICD10CM | Covered |
| I97.130 | ICD10CM | Covered |
| I97.131 | ICD10CM | Covered |
| I97.190 | ICD10CM | Covered |
| I97.191 | ICD10CM | Covered |
| K68.11 | ICD10CM | Covered |
| M32.11 | ICD10CM | Covered |
| O90.3 | ICD10CM | Covered |
| Q20.0 | ICD10CM | Covered |
| Q20.1 | ICD10CM | Covered |
| Q20.2 | ICD10CM | Covered |
| Q20.3 | ICD10CM | Covered |
| Q20.4 | ICD10CM | Covered |
| Q20.5 | ICD10CM | Covered |
| Q20.8 | ICD10CM | Covered |
| Q21.0 | ICD10CM | Covered |
| Q21.10 | ICD10CM | Covered |
| Q21.11 | ICD10CM | Covered |
| Q21.12 | ICD10CM | Covered |
| Q21.13 | ICD10CM | Covered |
| Q21.14 | ICD10CM | Covered |
| Q21.15 | ICD10CM | Covered |
| Q21.16 | ICD10CM | Covered |
| Q21.19 | ICD10CM | Covered |
| Q21.20 | ICD10CM | Covered |
| Q21.21 | ICD10CM | Covered |
| Q21.22 | ICD10CM | Covered |
| Q21.23 | ICD10CM | Covered |
| Q21.3 | ICD10CM | Covered |
| Q22.0 | ICD10CM | Covered |
| Q22.1 | ICD10CM | Covered |
| Q22.2 | ICD10CM | Covered |
| Q22.3 | ICD10CM | Covered |
| Q22.4 | ICD10CM | Covered |
| Q22.5 | ICD10CM | Covered |
| Q22.6 | ICD10CM | Covered |
| Q22.8 | ICD10CM | Covered |
| Q23.0 | ICD10CM | Covered |
| Q23.1 | ICD10CM | Covered |
| Q23.2 | ICD10CM | Covered |
| Q23.3 | ICD10CM | Covered |
| Q23.4 | ICD10CM | Covered |
| Q24.2 | ICD10CM | Covered |
| Q24.3 | ICD10CM | Covered |
| Q24.4 | ICD10CM | Covered |
| Q24.5 | ICD10CM | Covered |
| Q24.8 | ICD10CM | Covered |
| Q25.0 | ICD10CM | Covered |
| Q25.1 | ICD10CM | Covered |
| Q25.21 | ICD10CM | Covered |
| Q25.29 | ICD10CM | Covered |
| Q25.3 | ICD10CM | Covered |
| Q25.41 | ICD10CM | Covered |
| Q25.42 | ICD10CM | Covered |
| Q25.43 | ICD10CM | Covered |
| Q25.44 | ICD10CM | Covered |
| Q25.45 | ICD10CM | Covered |
| Q25.46 | ICD10CM | Covered |
| Q25.47 | ICD10CM | Covered |
| Q25.48 | ICD10CM | Covered |
| Q25.49 | ICD10CM | Covered |
| Q25.5 | ICD10CM | Covered |
| Q25.6 | ICD10CM | Covered |
| Q25.71 | ICD10CM | Covered |
| Q25.72 | ICD10CM | Covered |
| Q25.79 | ICD10CM | Covered |
| Q25.8 | ICD10CM | Covered |
| Q26.0 | ICD10CM | Covered |
| Q26.1 | ICD10CM | Covered |
| Q26.2 | ICD10CM | Covered |
| Q26.3 | ICD10CM | Covered |
| Q26.4 | ICD10CM | Covered |
| Q26.8 | ICD10CM | Covered |
| Q26.9 | ICD10CM | Covered |
| Q87.40 | ICD10CM | Covered |
| Q87.410 | ICD10CM | Covered |
| Q87.418 | ICD10CM | Covered |
| Q87.42 | ICD10CM | Covered |
| Q87.43 | ICD10CM | Covered |
| R57.0 | ICD10CM | Covered |
| R57.1 | ICD10CM | Covered |
| R57.8 | ICD10CM | Covered |
| R57.9 | ICD10CM | Covered |
| R65.20 | ICD10CM | Covered |
| R65.21 | ICD10CM | Covered |
| R78.81 | ICD10CM | Covered |
| R93.1 | ICD10CM | Covered |
| R93.89 | ICD10CM | Covered |
| S25.01XA | ICD10CM | Covered |
| S25.02XA | ICD10CM | Covered |
| S25.09XA | ICD10CM | Covered |
| S25.21XA | ICD10CM | Covered |
| S25.22XA | ICD10CM | Covered |
| S25.29XA | ICD10CM | Covered |
| S25.401A | ICD10CM | Covered |
| S25.402A | ICD10CM | Covered |
| S25.411A | ICD10CM | Covered |
| S25.412A | ICD10CM | Covered |
| S25.421A | ICD10CM | Covered |
| S25.422A | ICD10CM | Covered |
| S25.491A | ICD10CM | Covered |
| S25.492A | ICD10CM | Covered |
| S25.499A | ICD10CM | Covered |
| S25.91XA | ICD10CM | Covered |
| S25.99XA | ICD10CM | Covered |
| S26.01XA | ICD10CM | Covered |
| S26.020A | ICD10CM | Covered |
| S26.021A | ICD10CM | Covered |
| S26.022A | ICD10CM | Covered |
| S26.09XA | ICD10CM | Covered |
| S26.11XA | ICD10CM | Covered |
| S26.12XA | ICD10CM | Covered |
| S26.19XA | ICD10CM | Covered |
| S26.91XA | ICD10CM | Covered |
| S26.92XA | ICD10CM | Covered |
| S26.99XA | ICD10CM | Covered |
| T79.4XXA | ICD10CM | Covered |
| T80.0XXA | ICD10CM | Covered |
| T81.10XA | ICD10CM | Covered |
| T81.11XA | ICD10CM | Covered |
| T81.12XA | ICD10CM | Covered |
| T81.19XA | ICD10CM | Covered |
| T81.40XA | ICD10CM | Covered |
| T81.40XD | ICD10CM | Covered |
| T81.40XS | ICD10CM | Covered |
| T81.41XA | ICD10CM | Covered |
| T81.41XD | ICD10CM | Covered |
| T81.41XS | ICD10CM | Covered |
| T81.42XA | ICD10CM | Covered |
| T81.42XD | ICD10CM | Covered |
| T81.42XS | ICD10CM | Covered |
| T81.43XA | ICD10CM | Covered |
| T81.43XD | ICD10CM | Covered |
| T81.43XS | ICD10CM | Covered |
| T81.44XA | ICD10CM | Covered |
| T81.44XD | ICD10CM | Covered |
| T81.44XS | ICD10CM | Covered |
| T81.49XA | ICD10CM | Covered |
| T81.49XD | ICD10CM | Covered |
| T81.49XS | ICD10CM | Covered |
| T81.718A | ICD10CM | Covered |
| T81.72XA | ICD10CM | Covered |
| T82.01XA | ICD10CM | Covered |
| T82.02XA | ICD10CM | Covered |
| T82.03XA | ICD10CM | Covered |
| T82.09XA | ICD10CM | Covered |
| T82.110A | ICD10CM | Covered |
| T82.111A | ICD10CM | Covered |
| T82.118A | ICD10CM | Covered |
| T82.120A | ICD10CM | Covered |
| T82.121A | ICD10CM | Covered |
| T82.128A | ICD10CM | Covered |
| T82.190A | ICD10CM | Covered |
| T82.191A | ICD10CM | Covered |
| T82.198A | ICD10CM | Covered |
| T82.310A | ICD10CM | Covered |
| T82.311A | ICD10CM | Covered |
| T82.312A | ICD10CM | Covered |
| T82.318A | ICD10CM | Covered |
| T82.320A | ICD10CM | Covered |
| T82.321A | ICD10CM | Covered |
| T82.322A | ICD10CM | Covered |
| T82.328A | ICD10CM | Covered |
| T82.330A | ICD10CM | Covered |
| T82.331A | ICD10CM | Covered |
| T82.332A | ICD10CM | Covered |
| T82.338A | ICD10CM | Covered |
| T82.390A | ICD10CM | Covered |
| T82.391A | ICD10CM | Covered |
| T82.392A | ICD10CM | Covered |
| T82.398A | ICD10CM | Covered |
| T82.41XA | ICD10CM | Covered |
| T82.42XA | ICD10CM | Covered |
| T82.43XA | ICD10CM | Covered |
| T82.510A | ICD10CM | Covered |
| T82.511A | ICD10CM | Covered |
| T82.513A | ICD10CM | Covered |
| T82.514A | ICD10CM | Covered |
| T82.515A | ICD10CM | Covered |
| T82.518A | ICD10CM | Covered |
| T82.519A | ICD10CM | Covered |
| T82.520A | ICD10CM | Covered |
| T82.521A | ICD10CM | Covered |
| T82.522A | ICD10CM | Covered |
| T82.523A | ICD10CM | Covered |
| T82.524A | ICD10CM | Covered |
| T82.525A | ICD10CM | Covered |
| T82.528A | ICD10CM | Covered |
| T82.529A | ICD10CM | Covered |
| T82.530A | ICD10CM | Covered |
| T82.531A | ICD10CM | Covered |
| T82.533A | ICD10CM | Covered |
| T82.534A | ICD10CM | Covered |
| T82.535A | ICD10CM | Covered |
| T82.538A | ICD10CM | Covered |
| T82.539A | ICD10CM | Covered |
| T82.590A | ICD10CM | Covered |
| T82.591A | ICD10CM | Covered |
| T82.593A | ICD10CM | Covered |
| T82.594A | ICD10CM | Covered |
| T82.595A | ICD10CM | Covered |
| T82.598A | ICD10CM | Covered |
| T82.599A | ICD10CM | Covered |
| T82.6XXA | ICD10CM | Covered |
| T82.7XXA | ICD10CM | Covered |
| T82.817A | ICD10CM | Covered |
| T82.818A | ICD10CM | Covered |
| T82.827A | ICD10CM | Covered |
| T82.837A | ICD10CM | Covered |
| T82.847A | ICD10CM | Covered |
| T82.857A | ICD10CM | Covered |
| T82.867A | ICD10CM | Covered |
| T82.897A | ICD10CM | Covered |
| T82.9XXA | ICD10CM | Covered |
| T84.51XA | ICD10CM | Covered |
| T84.52XA | ICD10CM | Covered |
| T84.53XA | ICD10CM | Covered |
| T84.54XA | ICD10CM | Covered |
| T84.59XA | ICD10CM | Covered |
| T85.79XA | ICD10CM | Covered |
| Z01.30 | ICD10CM | Covered |
| Z01.31 | ICD10CM | Covered |
| Z01.82 | ICD10CM | Covered |
| Z01.89 | ICD10CM | Covered |
| Z48.21 | ICD10CM | Covered |
| Z48.24 | ICD10CM | Covered |
| Z48.280 | ICD10CM | Covered |
| Z52.89 | ICD10CM | Covered |
| Z94.1 | ICD10CM | Covered |
| Z94.2 | ICD10CM | Covered |
| Z94.3 | ICD10CM | Covered |
| Z94.4 | ICD10CM | Covered |
| Z94.5 | ICD10CM | Covered |
| Z94.6 | ICD10CM | Covered |
| Z94.7 | ICD10CM | Covered |
| Z94.81 | ICD10CM | Covered |
| Z94.82 | ICD10CM | Covered |
| Z94.83 | ICD10CM | Covered |
| Z94.84 | ICD10CM | Covered |
| Z94.89 | ICD10CM | Covered |
| Z94.9 | ICD10CM | Covered |
| Z95.0 | ICD10CM | Covered |
| Z95.1 | ICD10CM | Covered |
| Z95.2 | ICD10CM | Covered |
| Z98.890 | ICD10CM | Covered |
| Z98.891 | ICD10CM | Covered |