Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy

Ambetter · PayerPolicy · AMBETTER-CP-MP-174

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Codes in this policy

Each code’s status is what the policy records for it. This page does not show the policy’s criteria. Read them in the payer’s source.

Codes this policy lists and each code’s status in the policy
Code	Code system	Status in this policy
63185	CPT	Covered
63190	CPT	Covered