About this policy
Jurisdiction: JK MAC Part B. States: Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, Vermont. 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 |
|---|---|---|
| 80305 | CPT | Covered |
| 80306 | CPT | Covered |
| 80307 | CPT | Covered |
| G0480 | HCPCS | Covered |
| G0481 | HCPCS | Covered |
| G0482 | HCPCS | Covered |
| G0483 | HCPCS | Covered |
| G0659 | HCPCS | Covered |
| E87.20 | ICD10CM | Covered |
| E87.21 | ICD10CM | Covered |
| E87.22 | ICD10CM | Covered |
| E87.29 | ICD10CM | Covered |
| F10.11 | ICD10CM | Covered |
| F10.20 | ICD10CM | Covered |
| F11.11 | ICD10CM | Covered |
| F11.120 | ICD10CM | Covered |
| F11.13 | ICD10CM | Covered |
| F11.20 | ICD10CM | Covered |
| F11.220 | ICD10CM | Covered |
| F11.221 | ICD10CM | Covered |
| F11.222 | ICD10CM | Covered |
| F11.229 | ICD10CM | Covered |
| F11.23 | ICD10CM | Covered |
| F11.24 | ICD10CM | Covered |
| F11.250 | ICD10CM | Covered |
| F11.251 | ICD10CM | Covered |
| F11.259 | ICD10CM | Covered |
| F11.281 | ICD10CM | Covered |
| F11.282 | ICD10CM | Covered |
| F11.288 | ICD10CM | Covered |
| F11.29 | ICD10CM | Covered |
| F12.10 | ICD10CM | Covered |
| F12.11 | ICD10CM | Covered |
| F12.13 | ICD10CM | Covered |
| F12.20 | ICD10CM | Covered |
| F12.21 | ICD10CM | Covered |
| F12.23 | ICD10CM | Covered |
| F12.93 | ICD10CM | Covered |
| F13.10 | ICD10CM | Covered |
| F13.11 | ICD10CM | Covered |
| F13.130 | ICD10CM | Covered |
| F13.131 | ICD10CM | Covered |
| F13.132 | ICD10CM | Covered |
| F13.20 | ICD10CM | Covered |
| F13.21 | ICD10CM | Covered |
| F14.10 | ICD10CM | Covered |
| F14.11 | ICD10CM | Covered |
| F14.120 | ICD10CM | Covered |
| F14.13 | ICD10CM | Covered |
| F14.20 | ICD10CM | Covered |
| F14.21 | ICD10CM | Covered |
| F14.93 | ICD10CM | Covered |
| F15.10 | ICD10CM | Covered |
| F15.11 | ICD10CM | Covered |
| F15.13 | ICD10CM | Covered |
| F15.20 | ICD10CM | Covered |
| F15.21 | ICD10CM | Covered |
| F16.11 | ICD10CM | Covered |
| F17.210 | ICD10CM | Covered |
| F18.10 | ICD10CM | Covered |
| F18.11 | ICD10CM | Covered |
| F18.120 | ICD10CM | Covered |
| F18.90 | ICD10CM | Covered |
| F19.10 | ICD10CM | Covered |
| F19.11 | ICD10CM | Covered |
| F19.130 | ICD10CM | Covered |
| F19.131 | ICD10CM | Covered |
| F19.132 | ICD10CM | Covered |
| F19.20 | ICD10CM | Covered |
| F19.21 | ICD10CM | Covered |
| F20.0 | ICD10CM | Covered |
| F20.1 | ICD10CM | Covered |
| F20.2 | ICD10CM | Covered |
| F20.89 | ICD10CM | Covered |
| F45.42 | 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 |
| G40.301 | ICD10CM | Covered |
| G40.309 | ICD10CM | Covered |
| G40.311 | ICD10CM | Covered |
| G40.319 | ICD10CM | Covered |
| G40.401 | ICD10CM | Covered |
| G40.409 | ICD10CM | Covered |
| G40.411 | ICD10CM | Covered |
| G40.419 | ICD10CM | Covered |
| G40.901 | ICD10CM | Covered |
| G40.909 | ICD10CM | Covered |
| G40.911 | ICD10CM | Covered |
| G40.919 | ICD10CM | Covered |
| G89.29 | ICD10CM | Covered |
| G89.4 | ICD10CM | Covered |
| I44.0 | ICD10CM | Covered |
| I44.1 | ICD10CM | Covered |
| I44.30 | ICD10CM | Covered |
| I45.81 | ICD10CM | Covered |
| I47.0 | ICD10CM | Covered |
| I47.10 | ICD10CM | Covered |
| I47.11 | ICD10CM | Covered |
| I47.19 | ICD10CM | Covered |
| I47.20 | ICD10CM | Covered |
| I47.21 | ICD10CM | Covered |
| I47.29 | ICD10CM | Covered |
| I49.2 | ICD10CM | Covered |
| M25.50 | ICD10CM | Covered |
| M47.21 | ICD10CM | Covered |
| M47.22 | ICD10CM | Covered |
| M47.23 | ICD10CM | Covered |
| M47.26 | ICD10CM | Covered |
| M47.27 | ICD10CM | Covered |
| M47.28 | ICD10CM | Covered |
| M47.811 | ICD10CM | Covered |
| M47.812 | ICD10CM | Covered |
| M47.813 | ICD10CM | Covered |
| M47.816 | ICD10CM | Covered |
| M47.817 | ICD10CM | Covered |
| M47.818 | ICD10CM | Covered |
| M47.891 | ICD10CM | Covered |
| M47.892 | ICD10CM | Covered |
| M47.893 | ICD10CM | Covered |
| M47.896 | ICD10CM | Covered |
| M47.897 | ICD10CM | Covered |
| M47.898 | ICD10CM | Covered |
| M51.14 | ICD10CM | Covered |
| M51.15 | ICD10CM | Covered |
| M51.16 | ICD10CM | Covered |
| M51.17 | ICD10CM | Covered |
| M51.360 | ICD10CM | Covered |
| M51.361 | ICD10CM | Covered |
| M51.362 | ICD10CM | Covered |
| M51.369 | ICD10CM | Covered |
| M51.370 | ICD10CM | Covered |
| M51.371 | ICD10CM | Covered |
| M51.372 | ICD10CM | Covered |
| M51.379 | ICD10CM | Covered |
| M54.14 | ICD10CM | Covered |
| M54.15 | ICD10CM | Covered |
| M54.16 | ICD10CM | Covered |
| M54.17 | ICD10CM | Covered |
| M54.18 | ICD10CM | Covered |
| M54.2 | ICD10CM | Covered |
| M54.51 | ICD10CM | Covered |
| M54.9 | ICD10CM | Covered |
| M60.811 | ICD10CM | Covered |
| M60.812 | ICD10CM | Covered |
| M60.821 | ICD10CM | Covered |
| M60.822 | ICD10CM | Covered |
| M60.831 | ICD10CM | Covered |
| M60.832 | ICD10CM | Covered |
| M60.841 | ICD10CM | Covered |
| M60.842 | ICD10CM | Covered |
| M60.851 | ICD10CM | Covered |
| M60.852 | ICD10CM | Covered |
| M60.861 | ICD10CM | Covered |
| M60.862 | ICD10CM | Covered |
| M60.871 | ICD10CM | Covered |
| M60.872 | ICD10CM | Covered |
| M60.88 | ICD10CM | Covered |
| M60.89 | ICD10CM | Covered |
| M60.9 | ICD10CM | Covered |
| M79.10 | ICD10CM | Covered |
| M79.11 | ICD10CM | Covered |
| M79.12 | ICD10CM | Covered |
| M79.18 | ICD10CM | Covered |
| M79.2 | ICD10CM | Covered |
| M79.7 | ICD10CM | Covered |
| R40.0 | ICD10CM | Covered |
| R40.1 | ICD10CM | Covered |
| R40.20 | ICD10CM | Covered |
| R40.2110 | ICD10CM | Covered |
| R40.2111 | ICD10CM | Covered |
| R40.2112 | ICD10CM | Covered |
| R40.2113 | ICD10CM | Covered |
| R40.2114 | ICD10CM | Covered |
| R40.2120 | ICD10CM | Covered |
| R40.2121 | ICD10CM | Covered |
| R40.2122 | ICD10CM | Covered |
| R40.2123 | ICD10CM | Covered |
| R40.2124 | ICD10CM | Covered |
| R40.2210 | ICD10CM | Covered |
| R40.2211 | ICD10CM | Covered |
| R40.2212 | ICD10CM | Covered |
| R40.2213 | ICD10CM | Covered |
| R40.2214 | ICD10CM | Covered |
| R40.2220 | ICD10CM | Covered |
| R40.2221 | ICD10CM | Covered |
| R40.2222 | ICD10CM | Covered |
| R40.2223 | ICD10CM | Covered |
| R40.2224 | ICD10CM | Covered |
| R40.2310 | ICD10CM | Covered |
| R40.2311 | ICD10CM | Covered |
| R40.2312 | ICD10CM | Covered |
| R40.2313 | ICD10CM | Covered |
| R40.2314 | ICD10CM | Covered |
| R40.2320 | ICD10CM | Covered |
| R40.2321 | ICD10CM | Covered |
| R40.2322 | ICD10CM | Covered |
| R40.2323 | ICD10CM | Covered |
| R40.2324 | ICD10CM | Covered |
| R40.2340 | ICD10CM | Covered |
| R40.2341 | ICD10CM | Covered |
| R40.2342 | ICD10CM | Covered |
| R40.2343 | ICD10CM | Covered |
| R40.2344 | ICD10CM | Covered |
| R40.2A | ICD10CM | Covered |
| R41.0 | ICD10CM | Covered |
| R41.82 | ICD10CM | Covered |
| R41.85 | ICD10CM | Covered |
| R44.0 | ICD10CM | Covered |
| R44.2 | ICD10CM | Covered |
| R44.3 | ICD10CM | Covered |
| R45.851 | ICD10CM | Covered |
| R56.9 | ICD10CM | Covered |
| T14.91XA | ICD10CM | Covered |
| T14.91XD | ICD10CM | Covered |
| T14.91XS | ICD10CM | Covered |
| T39.011A | ICD10CM | Covered |
| T39.012A | ICD10CM | Covered |
| T39.013A | ICD10CM | Covered |
| T39.014A | ICD10CM | Covered |
| T39.091A | ICD10CM | Covered |
| T39.092A | ICD10CM | Covered |
| T39.093A | ICD10CM | Covered |
| T39.094A | ICD10CM | Covered |
| T39.1X1A | ICD10CM | Covered |
| T39.1X2A | ICD10CM | Covered |
| T39.1X3A | ICD10CM | Covered |
| T39.1X4A | ICD10CM | Covered |
| T39.2X1A | ICD10CM | Covered |
| T39.2X2A | ICD10CM | Covered |
| T39.2X3A | ICD10CM | Covered |
| T39.2X4A | ICD10CM | Covered |
| T39.311A | ICD10CM | Covered |
| T39.312A | ICD10CM | Covered |
| T39.313A | ICD10CM | Covered |
| T39.314A | ICD10CM | Covered |
| T39.391A | ICD10CM | Covered |
| T39.392A | ICD10CM | Covered |
| T39.393A | ICD10CM | Covered |
| T39.394A | ICD10CM | Covered |
| T40.0X1A | ICD10CM | Covered |
| T40.0X2A | ICD10CM | Covered |
| T40.0X3A | ICD10CM | Covered |
| T40.0X4A | ICD10CM | Covered |
| T40.1X1A | ICD10CM | Covered |
| T40.1X2A | ICD10CM | Covered |
| T40.1X3A | ICD10CM | Covered |
| T40.1X4A | ICD10CM | Covered |
| T40.2X1A | ICD10CM | Covered |
| T40.2X2A | ICD10CM | Covered |
| T40.2X3A | ICD10CM | Covered |
| T40.2X4A | ICD10CM | Covered |
| T40.3X1A | ICD10CM | Covered |
| T40.3X2A | ICD10CM | Covered |
| T40.3X3A | ICD10CM | Covered |
| T40.3X4A | ICD10CM | Covered |
| T40.491A | ICD10CM | Covered |
| T40.491D | ICD10CM | Covered |
| T40.492A | ICD10CM | Covered |
| T40.492D | ICD10CM | Covered |
| T40.493A | ICD10CM | Covered |
| T40.493D | ICD10CM | Covered |
| T40.494A | ICD10CM | Covered |
| T40.494D | ICD10CM | Covered |
| T40.601A | ICD10CM | Covered |
| T40.602A | ICD10CM | Covered |
| T40.603A | ICD10CM | Covered |
| T40.604A | ICD10CM | Covered |
| T40.691A | ICD10CM | Covered |
| T40.692A | ICD10CM | Covered |
| T40.693A | ICD10CM | Covered |
| T40.694A | ICD10CM | Covered |
| T40.711A | ICD10CM | Covered |
| T40.712A | ICD10CM | Covered |
| T40.713A | ICD10CM | Covered |
| T40.714A | ICD10CM | Covered |
| T40.8X1A | ICD10CM | Covered |
| T40.8X2A | ICD10CM | Covered |
| T40.8X3A | ICD10CM | Covered |
| T40.8X4A | ICD10CM | Covered |
| T40.901A | ICD10CM | Covered |
| T40.902A | ICD10CM | Covered |
| T40.903A | ICD10CM | Covered |
| T40.904A | ICD10CM | Covered |
| T40.991A | ICD10CM | Covered |
| T40.992A | ICD10CM | Covered |
| T40.993A | ICD10CM | Covered |
| T40.994A | ICD10CM | Covered |
| T42.0X1A | ICD10CM | Covered |
| T42.0X2A | ICD10CM | Covered |
| T42.0X3A | ICD10CM | Covered |
| T42.0X4A | ICD10CM | Covered |
| T42.3X1A | ICD10CM | Covered |
| T42.3X2A | ICD10CM | Covered |
| T42.3X3A | ICD10CM | Covered |
| T42.3X4A | ICD10CM | Covered |
| T42.4X1A | ICD10CM | Covered |
| T42.4X2A | ICD10CM | Covered |
| T42.4X3A | ICD10CM | Covered |
| T42.4X4A | ICD10CM | Covered |
| T42.6X1A | ICD10CM | Covered |
| T42.6X2A | ICD10CM | Covered |
| T42.6X3A | ICD10CM | Covered |
| T42.6X4A | ICD10CM | Covered |
| T42.71XA | ICD10CM | Covered |
| T42.72XA | ICD10CM | Covered |
| T42.73XA | ICD10CM | Covered |
| T42.74XA | ICD10CM | Covered |
| T43.011A | ICD10CM | Covered |
| T43.012A | ICD10CM | Covered |
| T43.013A | ICD10CM | Covered |
| T43.014A | ICD10CM | Covered |
| T43.021A | ICD10CM | Covered |
| T43.022A | ICD10CM | Covered |
| T43.023A | ICD10CM | Covered |
| T43.024A | ICD10CM | Covered |
| T43.1X1A | ICD10CM | Covered |
| T43.1X2A | ICD10CM | Covered |
| T43.1X3A | ICD10CM | Covered |
| T43.1X4A | ICD10CM | Covered |
| T43.201A | ICD10CM | Covered |
| T43.202A | ICD10CM | Covered |
| T43.203A | ICD10CM | Covered |
| T43.204A | ICD10CM | Covered |
| T43.211A | ICD10CM | Covered |
| T43.212A | ICD10CM | Covered |
| T43.213A | ICD10CM | Covered |
| T43.214A | ICD10CM | Covered |
| T43.221A | ICD10CM | Covered |
| T43.222A | ICD10CM | Covered |
| T43.223A | ICD10CM | Covered |
| T43.224A | ICD10CM | Covered |
| T43.291A | ICD10CM | Covered |
| T43.292A | ICD10CM | Covered |
| T43.293A | ICD10CM | Covered |
| T43.294A | ICD10CM | Covered |
| T43.3X1A | ICD10CM | Covered |
| T43.3X2A | ICD10CM | Covered |
| T43.3X3A | ICD10CM | Covered |
| T43.3X4A | ICD10CM | Covered |
| T43.4X1A | ICD10CM | Covered |
| T43.4X2A | ICD10CM | Covered |
| T43.4X3A | ICD10CM | Covered |
| T43.4X4A | ICD10CM | Covered |
| T43.501A | ICD10CM | Covered |
| T43.502A | ICD10CM | Covered |
| T43.503A | ICD10CM | Covered |
| T43.504A | ICD10CM | Covered |
| T43.591A | ICD10CM | Covered |
| T43.592A | ICD10CM | Covered |
| T43.593A | ICD10CM | Covered |
| T43.594A | ICD10CM | Covered |
| T43.601A | ICD10CM | Covered |
| T43.602A | ICD10CM | Covered |
| T43.603A | ICD10CM | Covered |
| T43.604A | ICD10CM | Covered |
| T43.611A | ICD10CM | Covered |
| T43.612A | ICD10CM | Covered |
| T43.613A | ICD10CM | Covered |
| T43.614A | ICD10CM | Covered |
| T43.621A | ICD10CM | Covered |
| T43.622A | ICD10CM | Covered |
| T43.623A | ICD10CM | Covered |
| T43.624A | ICD10CM | Covered |
| T43.631A | ICD10CM | Covered |
| T43.632A | ICD10CM | Covered |
| T43.633A | ICD10CM | Covered |
| T43.634A | ICD10CM | Covered |
| T43.641A | ICD10CM | Covered |
| T43.641D | ICD10CM | Covered |
| T43.641S | ICD10CM | Covered |
| T43.642A | ICD10CM | Covered |
| T43.642D | ICD10CM | Covered |
| T43.642S | ICD10CM | Covered |
| T43.643A | ICD10CM | Covered |
| T43.643D | ICD10CM | Covered |
| T43.643S | ICD10CM | Covered |
| T43.644A | ICD10CM | Covered |
| T43.644D | ICD10CM | Covered |
| T43.644S | ICD10CM | Covered |
| T43.691A | ICD10CM | Covered |
| T43.692A | ICD10CM | Covered |
| T43.693A | ICD10CM | Covered |
| T43.694A | ICD10CM | Covered |
| T43.8X1A | ICD10CM | Covered |
| T43.8X2A | ICD10CM | Covered |
| T43.8X3A | ICD10CM | Covered |
| T43.8X4A | ICD10CM | Covered |
| T43.91XA | ICD10CM | Covered |
| T43.92XA | ICD10CM | Covered |
| T43.93XA | ICD10CM | Covered |
| T43.94XA | ICD10CM | Covered |
| T45.0X1A | ICD10CM | Covered |
| T45.0X2A | ICD10CM | Covered |
| T45.0X3A | ICD10CM | Covered |
| T45.0X4A | ICD10CM | Covered |
| T46.0X1A | ICD10CM | Covered |
| T46.0X2A | ICD10CM | Covered |
| T46.0X3A | ICD10CM | Covered |
| T46.0X4A | ICD10CM | Covered |
| T50.901A | ICD10CM | Covered |
| T50.902A | ICD10CM | Covered |
| T50.903A | ICD10CM | Covered |
| T50.904A | ICD10CM | Covered |
| T50.911A | ICD10CM | Covered |
| T50.911D | ICD10CM | Covered |
| T50.911S | ICD10CM | Covered |
| T50.912A | ICD10CM | Covered |
| T50.912D | ICD10CM | Covered |
| T50.912S | ICD10CM | Covered |
| T50.913A | ICD10CM | Covered |
| T50.913D | ICD10CM | Covered |
| T50.913S | ICD10CM | Covered |
| T50.914A | ICD10CM | Covered |
| T50.914D | ICD10CM | Covered |
| T50.914S | ICD10CM | Covered |
| T50.915A | ICD10CM | Covered |
| T50.915D | ICD10CM | Covered |
| T50.915S | ICD10CM | Covered |
| T50.916A | ICD10CM | Covered |
| T50.916D | ICD10CM | Covered |
| T50.916S | ICD10CM | Covered |
| Z51.81 | ICD10CM | Covered |
| Z79.3 | ICD10CM | Covered |
| Z79.891 | ICD10CM | Covered |
| Z79.899 | ICD10CM | Covered |
| Z87.891 | ICD10CM | Covered |
| Z91.120 | ICD10CM | Covered |
| Z91.128 | ICD10CM | Covered |
| Z91.130 | ICD10CM | Covered |
| Z91.138 | ICD10CM | Covered |
| Z91.141 | ICD10CM | Covered |
| Z91.148 | ICD10CM | Covered |
| Z91.190 | ICD10CM | Covered |
| Z91.198 | ICD10CM | Covered |
| Z91.199 | ICD10CM | Covered |
| Z91.51 | ICD10CM | Covered |
| Z91.A10 | ICD10CM | Covered |
| Z91.A18 | ICD10CM | Covered |
| Z91.A20 | ICD10CM | Covered |
| Z91.A28 | ICD10CM | Covered |
| Z91.A3 | ICD10CM | Covered |
| Z91.A41 | ICD10CM | Covered |
| Z91.A48 | ICD10CM | Covered |
| Z91.A51 | ICD10CM | Covered |
| Z91.A58 | ICD10CM | Covered |
| Z91.A91 | ICD10CM | Covered |
| Z91.A98 | ICD10CM | Covered |