Dynamic Splinting Devices

Policy ID: O-10-020

Section: Orthotic & Prosthetic Devices

Effective Date: July 01, 2018

Revised Date: March 26, 2025

Revision Effective Date: April 01, 2025

Last Reviewed: May 13, 2025

Applies To: Commercial and Medicaid Expansion

Description

Dynamic splinting devices are spring-loaded and designed to provide a low load, prolonged stretch (LLPS) to joints that have reduced range of motion secondary to immobilization, surgery, contracture, fracture, dislocation, or a number of additional non-traumatic disorders.

Bi-directional static progressive (SP) stretch devices are used for multiple short treatment sessions per day with the joint angle progressively advanced at each session.

Individual-actuated serial stretch (PASS) devices provide a low-to-high level load to the joint using pneumatic or hydraulic systems that are adjusted by the individual.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; and/or

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Dynamic Low-Load Prolonged-duration Stretch (LLPS)

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Dynamic low-load prolonged-duration stretch (LLPS) devices for the toe, knee, elbow, wrist, or finger may be considered medically necessary when ONE or more of the following are met:

The individual is in the subacute injury or post-operative period (greater than or equal to three (3) weeks but less than or equal to four (4) months after injury or operation) and ONE or more of the following
- LLPS is being used in addition to physical therapy for an individual with signs and symptoms of persistent joint stiffness or contracture
- LLPS is being used for an individual whose limited range of motion poses a meaningful (as judged by the physician) functional limitation, and who has not responded to other therapy (including physical therapy)
The individual is in the acute post-operative period following an additional procedure to improve range of motion of a previously affected joint
The individual is unable to benefit from standard physical therapy modalities due to an inability to exercise

NOTE:

LLPS meeting medical necessity criteria will be approved for an initial period of up to four (4) months.
LLPS meeting medical necessity criteria and utilized beyond four (4) months will be approved if the individual shows significant improvement after the initial period and improvement continues to be demonstrated.

Replacement of soft interface material for dynamic adjustable extension/flexion devices may be considered medically necessary per coverage criteria.

Dynamic low-load prolonged-duration stretch (LLPS) devices used for all other conditions are considered not medically necessary.

Procedure Codes

E1800

E1802

E1803

E1804

E1805

E1807

E1808

E1810

E1812

E1813

E1814

E1820

E1825

E1826

E1827

E1828

E1829

E1830

Experimental/Investigational

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

The following devices are considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Dynamic (LLPS) devices which are specific to the ankle and shoulder
SaeboFlex
Bi-directional static progressive (SP) stretch devices
Replacement of soft interface material for bi-directional static progressive (SP) stretch devices
Patient-actuated serial stretch (PASS) devices

Dynamic splinting not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature. The following are examples. This is not an all-inclusive list:

Carpal tunnel syndrome
Cerebral palsy
Foot-drop associated with neuromuscular diseases
Head and spinal cord injuries
Injuries of the ankle and shoulder
Multiple sclerosis
Muscular dystrophy
Plantar fasciitis
Rheumatoid arthritis
Stroke
Trismus

Procedure Codes

E1399

E1801

E1806

E1811

E1815

E1816

E1818

E1821

E1822

E1823

E1831

E1832

E1840

E1841

L3999

Diagnosis Codes

COVERED DIAGNOSIS CODES FOR PROCEDURE CODES E1800, E1802 AND E1820

M12.521

M12.522

M24.121

M24.122

M24.221

M24.222

M24.321

M24.322

M24.421

M24.422

M24.521

M24.522

M24.821

M24.822

M62.432

S42.401B

S42.401D

S42.401G

S42.401K

S42.401P

S42.402B

S42.402D

S42.402G

S42.402K

S42.402P

S42.411A

S42.411B

S42.411D

S42.411G

S42.411K

S42.411P

S42.412A

S42.412B

S42.412D

S42.412G

S42.412K

S42.412P

S42.414A

S42.414B

S42.414D

S42.414G

S42.414K

S42.414P

S42.415A

S42.415B

S42.415D

S42.415G

S42.415K

S42.415P

S42.421A

S42.421B

S42.421D

S42.421G

S42.421K

S42.421P

S42.422A

S42.422B

S42.422D

542.422G

S42.422K

S42.422P

S42.424A

S42.424B

S42.424D

S42.424G

S42.424K

S42.424P

S42.425A

S42.425B

S42.425D

S42.425G

S42.425K

S42.425P

S42.431A

S42.431B

S42.431D

S42.431G

S42.431K

S42.431P

S42.432A

S42.432B

S42.432D

S42.432G

S42.432K

S42.432P

S42.434A

S42.434B

S42.434D

S42.434G

842.434K

S42.434P

S42.435A

S42.435B

S42.435D

S42.435G

S42.435K

542.435P

S42.441A

S42.441B

S42.441D

S42.441G

842.441K

S42.441P

S42.442A

S42.442B

S42.442D

S42.442G

S42.442K

S42.442P

542.444A

S42.444B

S42.444D

S42.444G

S42.444K

S42.444P

S42.445A

S42.445B

S42.445D

S42.445G

S42.445K

542.445P

S42.447A

S42.447B

S42.447D

S42.447G

S42.447K

542.447P

S42.448A

S42.448B

542.448D

S42.448G

S42.448K

S42.448P

S42.451A

S42.451B

S42.451D

S42.451G

S42.451K

S42.451P

S42.452A

S42.452B

542.452D

S42.452G

S42.452K

S42.452P

S42.454A

S42.454B

S42.454D

S42.454G

S42.454K

S42.454P

S42.455A

S42.455B

S42.455D

S42.455G

S42.455K

S42.455P

S42.461A

S42.461B

S42.461D

S42.461G

S42.461K

S42.461P

S42.462A

S42.462B

S42.462D

S42.462G

S42.462K

S42.462P

S42.464A

S42.464B

S42.464D

S42.464G

S42.464K

S42.464P

S42.465A

S42.465B

S42.465D

S42.465G

S42.465K

S42.465P

S42.471A

S42.471B

S42.471D

S42.471G

S42.471K

S42.471P

S42.472A

S42.472B

542.472D

S42.472G

S42.472K

542.472P

S42.474A

S42.474B

S42.474D

S42.474G

S42.474K

S42.474P

S42.475A

S42.475B

S42.475D

542.475G

S42.475K

S42.475P

S42.481A

S42.481D

S42.481G

S42.481K

S42.481P

S42.482A

S42.482D

S42.482G

S42.482K

S42.482P

S42.491A

S42.491B

S42.491D

S42.491G

S42.491K

S42.491P

S42.492A

S42.492B

S42.492D

S42.492G

S42.492K

S42.492P

S42.494A

S42.494B

S42.494D

S42.494G

S42.494K

S42.494P

S42.495A

S42.495B

S42.495D

S42.495G

842.495K

S42.495P

S52.001A

S52.001B

S52.001C

S52.001D

S52.001E

S52.001F

S52.001G

S52.001H

S52.001J

S52.001K

S52.001M

S52.001N

S52.001P

552.001Q

S52.001R

S52.001S

S52.002A

S52.002B

S52.002C

S52.002D

S52.002E

S52.002F

S52.002G

S52.002H

S52.002J

S52.002K

S52.002M

S52.002N

S52.002P

S52.002Q

S52.002R

S52.011A

S52.011D

S52.011G

S52.011K

S52.011P

S52.012A

S52.012D

S52.012G

S52.012K

S52.012P

S52.021A

S52.021B

552.021C

S52.021D

S52.021E

S52.021F

S52.021G

S52.021H

S52.021J

S52.021K

S52.021M

S52.021N

S52.021P

S52.021Q

S52.021R

S52.022A

S52.022B

S52.022C

S52.022D

S52.022E

S52.022F

S52.022G

S52.022H

S52.022J

S52.022K

S52.022M

S52.022N

S52.022P

S52.022Q

S52.022R

S52.024A

S52.024B

S52.024C

S52.024D

S52.024E

S52.024F

S52.024G

S52.024H

S52.024J

S52.024K

S52.024M

S52.024N

S52.024P

S52.024Q

S52.024R

S52.025A

S52.025B

552.025C

S52.025D

S52.025E

552.025F

S52.025G

S52.025H

S52.025J

S52.025K

S52.025M

S52.025N

552.025P

S52.025Q

S52.025R

S52.031A

552.031B

S52.031C

S52.031D

S52.031E

S52.031F

S52.031G

S52.031H

552.031J

S52.031K

S52.031M

S52.031N

S52.031P

S52.031Q

S52.031R

552.032A

S52.032B

S52.032C

S52.032D

552.032E

S52.032F

S52.032G

S52.032H

S52.032J

S52.032K

S52.032M

S52.032N

S52.032P

S52.032Q

S52.032R

S52.034A

S52.034B

S52.034C

S52.034D

S52.034E

S52.034F

S52.034G

S52.034H

S52.034J

S52.034K

S52.034M

S52.034N

S52.034P

S52.034Q

552.034R

S52.035A

S52.035B

552.035C

S52.035D

S52.035E

S52.035F

552.035G

S52.035H

S52.035J

S52.035K

S52.035M

S52.035N

S52.035P

552.035Q

S52.035R

S52.041A

S52.041B

S52.041C

S52.041D

S52.041E

S52.041F

552.041G

S52.041H

S52.041J

S52.041K

552.041M

S52.041N

S52.041P

552.041Q

S52.041R

S52.042A

S52.042B

S52.042C

S52.042D

S52.042E

S52.042F

S52.042G

S52.042H

S52.042J

852.042K

S52.042M

S52.042N

S52.042P

S52.042Q

S52.042R

S52.044A

S52.044B

S52.044C

S52.044D

552.044E

S52.044F

S52.044G

S52.044H

S52.044J

S52.044K

S52.044M

S52.044N

S52.044P

S52.044Q

S52.044R

S52.045A

S52.045B

S52.045C

552.045D

S52.045E

S52.045F

S52.045G

S52.045H

S52.045J

S52.045K

552.045M

S52.045N

S52.045P

S52.045Q

S52.045R

S52.091A

S52.091B

S52.091C

S52.091D

S52.091E

S52.091F

S52.091G

S52.091H

S52.091J

S52.091K

S52.091M

S52.091N

S52.091P

S52.091Q

S52.091R

S52.092A

S52.092B

S52.092C

S52.092D

S52.092E

S52.092F

S52.092G

S52.092H

S52.092J

S52.092K

S52.092M

S52.092N

S52.092P

S52.092Q

S52.092R

S52.101A

S52.101B

S52.101C

S52.101D

S52.101E

S52.101F

S52.101G

S52.101H

S52.101J

S52.101K

S52.101M

S52.101N

S52.101P

S52.101Q

S52.101R

552.102A

S52.102B

S52.102C

S52.102D

S52.102E

S52.102F

S52.102G

S52.102H

552.102J

S52.102K

S52.102M

S52.102N

S52.102P

S52.102Q

S52.102R

S52.111A

S52.111D

S52.111G

S52.111K

S52.111P

S52.112A

S52.112D

S52.112G

S52.112K

S52.112P

S52.121A

S52.121B

S52.121C

S52.121D

552.121E

S52.121F

S52.121G

S52.121H

S52.121J

S52.121K

S52.121M

S52.121N

S52.121P

S52.121Q

S52.121R

S52.122A

S52.122B

S52.122C

S52.122D

S52.122E

S52.122F

S52.122G

S52.122H

S52.122J

S52.122K

S52.122M

S52.122N

S52.122P

S52.122Q

S52.122R

S52.124A

S52.124B

S52.124C

S52.124D

S52.124E

S52.124F

S52.124G

S52.124H

S52.124J

S52.124K

S52.124M

S52.124N

S52.124P

S52.124Q

S52.124R

S52.125A

S52.125B

S52.125C

S52.125D

S52.125E

S52.125F

S52.125G

S52.125H

S52.125J

S52.125K

S52.125M

S52.125N

552.125P

S52.125Q

S52.125R

S52.131A

S52.131B

S52.131C

S52.131D

S52.131E

S52.131F

S52.131G

S52.131H

S52.131J

S52.131K

S52.131M

S52.131N

S52.131P

S52.131Q

S52.131R

S52.132A

S52.132B

S52.132C

S52.132D

S52.132E

S52.132F

S52.132G

S52.132H

S52.132J

S52.132K

S52.132M

S52.132N

S52.132P

S52.132Q

S52.132R

S52.134A

S52.134B

S52.134C

S52.134D

S52.134E

S52.134F

S52.134G

S52.134H

S52.134J

S52.134K

S52.134M

S52.134N

S52.134P

S52.134Q

S52.134R

S52.135A

S52.135B

S52.135C

S52.135D

S52.135E

S52.135F

S52.135G

S52.135H

S52.135J

S52.135K

S52.135M

S52.135N

S52.135P

S52.135Q

S52.135R

S52.181A

S52.181B

S52.181C

S52.181D

S52.181E

S52.181F

S52.181G

S52.181H

S52.181J

852.181K

S52.181M

S52.181N

S52.181P

S52.181Q

S52.181R

S52.182A

S52.182B

S52.182C

S52.182D

S52.182E

S52.182F

S52.182G

S52.182H

S52.182J

S52.182K

S52.182M

S52.182N

S52.182P

S52.182Q

S52.182R

S52.201A

S52.201B

S52.201C

S52.201D

S52.201E

S52.201F

S52.201G

S52.201H

S52.201J

S52.201K

S52.201M

S52.201N

S52.201P

S52.201Q

S52.201R

S52.202A

S52.202B

S52.202C

S52.202D

552.202E

S52.202F

S52.202G

S52.202H

S52.202J

S52.202K

S52.202M

S52.202N

S52.202P

S52.202Q

552.202R

S52.211A

S52.211D

S52.211G

S52.211K

S52.211P

S52.212A

S52.212D

S52.212G

S52.212K

S52.212P

S52.221A

S52.221B

S52.221C

S52.221D

S52.221E

S52.221F

S52.221G

S52.221H

S52.221J

S52.221K

S52.221M

S52.221N

S52.221P

S52.221Q

S52.221R

S52.222A

S52.222B

S52.222C

S52.222D

S52.222E

S52.222F

S52.222G

S52.222H

S52.222J

S52.222K

S52.222M

S52.222N

S52.222P

S52.222Q

S52.222R

S52.224A

S52.224B

S52.224C

S52.224D

S52.224E

S52.224F

S52.224G

S52.224H

S52.224J

S52.224K

S52.224M

S52.224N

S52.224P

S52.224Q

S52.224R

S52.225A

S52.225B

S52.225C

S52.225D

S52.225E

S52.225F

S52.225G

S52.225H

S52.225J

852.225K

S52.225M

S52.225N

S52.225P

S52.225Q

S52.225R

S52.231A

S52.231B

S52.231C

S52.231D

S52.231E

S52.231F

S52.231G

S52.231H

S52.231J

S52.231K

S52.231M

S52.231N

S52.231P

S52.231Q

S52.231R

S52.232A

S52.232B

S52.232C

S52.232D

S52.232E

S52.232F

S52.232G

S52.232H

S52.232J

S52.232K

S52.232M

S52.232N

S52.232P

S52.232Q

S52.232R

S52.234A

S52.234B

S52.234C

S52.234D

S52.234E

S52.234F

S52.234G

S52.234H

S52.234J

S52.234K

552.234M

S52.234N

S52.234P

S52.234Q

S52.234R

S52.235A

S52.235B

S52.235C

S52.235D

S52.235E

552.235F

S52.235G

S52.235H

S52.235J

S52.235K

S52.235M

S52.235N

552.235P

S52.235Q

S52.235R

S52.241A

S52.241B

S52.241C

S52.241D

S52.241E

S52.241F

S52.241G

S52.241H

S52.241J

S52.241K

S52.241M

S52.241N

S52.241P

S52.241Q

S52.241R

S52.242A

S52.242B

S52.242C

552.242D

S52.242E

552.242F

S52.242G

S52.242H

S52.242J

S52.242K

S52.242M

S52.242N

S52.242P

S52.242Q

S52.242R

S52.244A

S52.244B

S52.244C

S52.244D

S52.244E

S52.244F

S52.244G

S52.244H

S52.244J

S52.244K

S52.244M

S52.244N

S52.244P

S52.244Q

S52.244R

S52.245A

S52.245B

S52.245C

S52.245D

S52.245E

S52.245F

S52.245G

S52.245H

S52.245J

S52.245K

S52.245M

S52.245N

S52.245P

S52.245Q

S52.245R

S52.251A

S52.251B

S52.251C

S52.251D

S52.251E

S52.251F

S52.251G

S52.251H

S52.251J

S52.251K

S52.251M

S52.251N

S52.251P

S52.251Q

S52.251R

S52.252A

S52.252B

S52.252C

S52.252D

S52.252E

S52.252F

S52.252G

S52.252H

S52.252J

852.252K

S52.252M

S52.252N

S52.252P

S52.252Q

S52.252R

S52.254A

552.254B

S52.254C

S52.254D

S52.254E

S52.254F

S52.254G

S52.254H

S52.254J

S52.254K

S52.254M

S52.254N

552.254P

S52.254Q

S52.254R

S52.255A

552.255B

S52.255C

S52.255D

552.255E

S52.255F

S52.255G

S52.255H

552.255J

S52.255K

S52.255M

552.255N

S52.255P

S52.255Q

S52.255R

S52.261A

552.261B

S52.261C

S52.261D

S52.261E

S52.261F

S52.261G

S52.261H

S52.261J

S52.261K

S52.261M

S52.261N

S52.261P

S52.261Q

S52.261R

S52.262A

S52.262B

S52.262C

S52.262D

S52.262E

S52.262F

S52.262G

S52.262H

S52.262J

S52.262K

S52.262M

S52.262N

S52.262P

S52.262Q

S52.262R

S52.264A

S52.264B

S52.264C

S52.264D

S52.264E

S52.264F

S52.264G

S52.264H

S52.264J

S52.264K

S52.264M

S52.264N

S52.264P

S52.264Q

S52.264R

S52.265A

S52.264B

S52.265C

S52.264D

S52.265E

S52.264F

S52.265G

S52.264H

S52.265J

S52.264K

S52.265M

S52.264N

S52.265P

S52.264Q

S52.265R

S52.271A

S52.271B

S52.271C

S52.271D

S52.271E

S52.271F

S52.271G

S52.271H

S52.271J

S52.271K

S52.271M

S52.271N

S52.271P

S52.271Q

S52.271R

S52.272A

S52.272B

S52.272C

S52.272D

S52.272E

S52.272F

S52.272G

S52.272H

S52.272J

852.272K

S52.272M

S52.272N

S52.272P

S52.272Q

S52.272R

S52.281A

S52.281B

S52.281C

S52.281D

S52.281E

S52.281F

S52.281G

S52.281H

S52.281J

S52.281K

S52.281M

S52.281N

S52.281P

S52.281Q

S52.281R

S52.282A

S52.282B

S52.282C

S52.282D

S52.282E

S52.282F

S52.282G

S52.282H

S52.282J

S52.282K

S52.282M

S52.282N

S52.282P

S52.282Q

S52.282R

S52.291A

S52.291B

S52.291C

S52.291D

S52.291E

S52.291F

S52.291G

S52.291H

S52.291J

S52.291K

S52.291M

S52.291N

S52.291P

S52.291Q

S52.291R

S52.292A

S52.292B

S52.292C

S52.292D

S52.292E

S52.292F

S52.292G

S52.292H

552.292J

S52.292K

S52.292M

S52.292N

S52.292P

S52.292Q

S52.292R

S52.301A

S52.301B

S52.301C

S52.301D

S52.301E

S52.301F

S52.301G

S52.301H

S52.301J

S52.301K

S52.301M

S52.301N

S52.301P

S52.301Q

S52.301R

S52.302A

S52.302B

S52.302C

S52.302D

S52.302E

S52.302F

S52.302G

S52.302H

S52.302J

S52.302K

S52.302M

S52.302N

S52.302P

S52.302Q

S52.302R

S52.311A

S52.311D

S52.311G

S52.311K

S52.311P

S52.312A

S52.312D

S52.312G

S52.312K

S52.312P

S52.321A

S52.321B

S52.321C

S52.321D

S52.321E

S52.321F

S52.321G

S52.321H

S52.321J

852.321K

S52.321M

S52.321N

S52.321P

S52.321Q

S52.321R

S52.322A

S52.322B

S52.322C

S52.322D

S52.322E

S52.322F

S52.322G

S52.322H

S52.322J

S52.322K

S52.322M

S52.322N

S52.322P

S52.322Q

S52.322R

S52.324A

S52.324B

S52.324C

S52.324D

S52.324E

S52.324F

S52.324G

S52.324H

S52.324J

S52.324K

S52.324M

S52.324N

S52.324P

S52.324Q

S52.324R

552.325A

S52.325B

S52.325C

S52.325D

S52.325E

S52.325F

S52.325G

S52.325H

S52.325J

S52.325K

S52.325M

S52.325N

S52.325P

S52.325Q

S52.325R

S52.331A

S52.331B

S52.331C

S52.331D

S52.331E

S52.331F

S52.331G

S52.331H

S52.331J

S52.331K

S52.331M

S52.331N

S52.331P

S52.331Q

S52.331R

S52.332A

S52.332B

S52.332C

S52.332D

S52.332E

S52.332F

S52.332G

S52.332H

S52.332J

S52.332K

S52.332M

S52.332N

S52.332P

S52.332Q

S52.332R

S52.334A

S52.334B

S52.334C

S52.334D

S52.334E

S52.334F

S52.334G

S52.334H

S52.334J

852.334K

S52.334M

S52.334N

S52.334P

S52.334Q

S52.334R

S52.335A

552.335B

S52.335C

S52.335D

S52.335E

S52.335F

S52.335G

S52.335H

S52.335J

S52.335K

S52.335M

S52.335N

S52.335P

S52.335Q

S52.335R

S52.341A

S52.341B

S52.341C

S52.341D

S52.341E

S52.341F

S52.341G

S52.341H

S52.341J

S52.341K

552.341M

S52.341N

S52.341P

S52.341Q

S52.341R

S52.342A

S52.342B

S52.342C

S52.342D

S52.342E

S52.342F

S52.342G

S52.342H

S52.342J

S52.342K

S52.342M

S52.342N

S52.342P

S52.342Q

S52.342R

S52.344A

S52.344B

S52.344C

S52.344D

S52.344E

S52.344F

S52.344G

S52.344H

S52.344J

S52.344K

S52.344M

S52.344N

S52.344P

S52.344Q

S52.344R

S52.345A

S52.345B

S52.345C

S52.345D

S52.345E

S52.345F

S52.345G

S52.345H

S52.345J

S52.345K

S52.345M

S52.345N

S52.345P

S52.345Q

S52.345R

S52.351A

S52.351B

S52.351C

S52.351D

S52.351E

S52.351F

S52.351G

S52.351H

S52.351J

S52.351K

S52.351M

S52.351N

S52.351P

S52.351Q

S52.351R

S52.352A

S52.352B

S52.352C

S52.352D

S52.352E

S52.352F

S52.352G

S52.352H

S52.352J

S52.352K

S52.352M

S52.352N

S52.352P

S52.352Q

S52.352R

S52.354A

S52.354B

S52.354C

S52.354D

S52.354E

S52.354F

S52.354G

S52.354H

S52.354J

S52.354K

S52.354M

S52.354N

S52.354P

S52.354Q

S52.354R

S52.355A

S52.355B

S52.355C

S52.355D

552.355E

S52.355F

S52.355G

552.355H

S52.355J

S52.355K

S52.355M

552.355N

S52.355P

S52.355Q

552.355R

S52.361A

S52.361B

S52.361C

S52.361D

S52.361E

S52.361F

552.361G

S52.361H

S52.361J

S52.361K

S52.361M

S52.361N

S52.361P

S52.361Q

S52.361R

S52.362A

S52.362B

S52.362C

S52.362D

S52.362E

S52.362F

S52.362G

S52.362H

552.362J

852.362K

S52.362M

S52.362N

S52.362P

S52.362Q

S52.362R

S52.364A

S52.364B

S52.364C

S52.364D

S52.364E

S52.364F

S52.364G

S52.364H

S52.364J

S52.364K

S52.364M

S52.364N

S52.364P

S52.364Q

S52.364R

S52.365A

S52.365B

S52.365C

S52.365D

S52.365E

S52.365F

S52.365G

S52.365H

S52.365J

S52.365K

S52.365M

S52.365N

S52.365P

S52.365Q

S52.365R

S52.371A

S52.371B

S52.371C

S52.371D

S52.371E

S52.371F

S52.371G

S52.371H

S52.371J

S52.371K

552.371M

S52.371N

S52.371P

552.371Q

S52.371R

S52.372A

S52.372B

S52.372C

S52.372D

S52.372E

S52.372F

552.372G

S52.372H

S52.372J

S52.372K

S52.372M

S52.372N

S52.372P

S52.372Q

S52.372R

S52.381A

S52.381B

S52.381C

S52.381D

S52.381E

S52.381F

S52.381G

S52.381H

S52.381J

S52.381K

S52.381M

S52.381N

S52.381P

S52.381Q

S52.381R

S52.382A

S52.382B

S52.382C

S52.382D

S52.382E

S52.382F

S52.382G

S52.382H

S52.382J

852.382K

S52.382M

S52.382N

552.382P

S52.382Q

S52.382R

S52.391A

552.391B

S52.391C

S52.391D

S52.391E

S52.391F

S52.391G

S52.391H

S52.391J

S52.391K

S52.391M

S52.391N

S52.391P

S52.391Q

S52.391R

S52.392A

S52.392B

S52.392C

S52.392D

S52.392E

S52.392F

S52.392G

S52.392H

S52.392J

S52.392K

S52.392M

S52.392N

S52.392P

S52.392Q

S52.392R

S52.91XA

S52.91X6

S52.91XC

S52.91XD

S52.91XE

S52.91XF

S52.91XG

S52.91XH

S52.91XJ

S52.91XK

S52.91XM

S52.91XN

S52.91XP

S52.91XQ

S52.91XR

552.92XA

S52.92XB

S52.92XC

S52.92XD

552.92XE

S52.92XF

S52.92XG

S52.92XH

S52.92XJ

S52.92XK

S52.92XM

552.92XN

S52.92XP

S52.92XQ

S52.92XR

S53.001A

S53.001D

553.001S

S53.002A

S53.002D

S53.0025

S53.004A

S53.004D

S53.004S

S53.005A

S53.005D

553.005S

S53.011A

S53.011D

S53.011S

S53.012A

S53.012D

S53.012S

S53.014A

S53.014D

S53.014S

553.015A

S53.015D

S53.0155

S53.021A

S53.021D

S53.021S

S53.022A

S53.022D

S53.022S

553.024A

S53.024D

S53.0245

S53.025A

S53.025D

S53.025S

S53.031A

S53.031D

S53.031S

S53.032A

S53.032S

S53.091A

S53.091D

S53.091S

S53.092A

S53.092D

S53.092S

S53.094A

S53.094D

S53.094S

S53.095A

S53.095D

S53.095S

S53.101A

S53.101D

S53.101S

S53.102A

S53.102D

S53.102S

S53.104A

S53.104D

S53.104S

S53.105A

S53.105D

S53.105S

S53.111A

S53.111D

S53.111S

S53.112A

S53.112D

S53.112S

S53.114A

S53.114D

S53.114S

S53.115A

S53.115D

S53.115S

S53.121A

S53.121D

S53.1215

S53.122A

S53.122D

S53.122S

S53.124A

S53.124D

S53.124S

553.125A

S53.125D

S53.125S

S53.131A

S53.131D

S53.131S

S53.132A

S53.132D

S53.132S

553.134A

553.134D

S53.134S

S53.135A

S53.135D

S53.135S

S53.141A

S53.141D

S53.141S

553.142A

553.142D

S53.142S

S53.144A

S53.144D

S53.144S

S53.145A

S53.145D

S53.145S

553.191A

S53.191D

S53.191S

S53.192A

S53.192D

S53.192S

S53.194A

S53.194D

S53.194S

S53.195A

S53.195D

S53.195S

S53.21XA

S53.21XD

S53.21XS

S53.22XA

S53.22XD

S53.22XS

S53.31XA

S53.31XD

S53.31XS

S53.32XA

S53.32XD

S53.32XS

S53.401A

S53.401D

S53.401S

S53.402A

S53.402D

S53.402S

S53.411A

S53.411D

S53.411S

S53.412A

S53.412D

S53.412S

S53.421A

S53.421D

S53.421S

S53.422A

S53.422D

S53.422S

S53.431A

S53.431D

S53.431S

S53.432A

S53.432D

S53.432S

S53.441A

S53.441D

S53.441S

S53.442A

S53.442D

S53.442S

S53.491A

S53.491D

S53.491S

S53.492A

S53.492D

S53.492S

S56.001D

S56.001S

S56.002D

S56.002S

S56.011A

S56.011D

S56.011S

S56.012A

S56.012D

S56.012S

S56.021A

S56.021D

S56.021S

S56.022A

S56.022D

S56.022S

S56.091D

S56.091S

S56.092D

S56.092S

S56.101D

S56.101S

S56.102D

S56.102S

S56.103D

556.103S

S56.104D

S56.104S

S56.105D

S56.105S

S56.106D

S56.106S

556.107D

S56.107S

S56.108D

S56.108S

S56.109D

S56.1095

S56.111A

S56.111D

S56.111S

S56.112A

S56.112D

S56.112S

S56.113A

S56.113D

S56.113S

S56.114A

S56.114D

S56.114S

S56.115A

556.115D

S56.115S

S56.116A

S56.116D

S56.116S

S56.117A

S56.117D

S56.117S

S56.118A

S56.118D

S56.118S

S56.121A

S56.121D

S56.121S

S56.122A

S56.122D

S56.122S

S56.123A

S56.123D

S56.123S

S56.124A

S56.124D

S56.124S

S56.125A

S56.125D

S56.125S

S56.126A

S56.126D

S56.126S

S56.127A

S56.127D

S56.127S

S56.128A

S56.128D

S56.128S

S56.191D

S56.191S

S56.192D

S56.1925

S56.193D

S56.193S

S56.194D

S56.194S

S56.195D

S56.195S

S56.196D

S56.196S

S56.197D

S56.197S

S56.198D

S56.198S

S56.201D

S56.201S

S56.202D

S56.202S

S56.211A

S56.211D

S56.211S

S56.212A

S56.212D

S56.212S

S56.221A

S56.221D

S56.221S

S56.222A

S56.222D

S56.222S

S56.291D

S56.291S

S56.292D

S56.292S

S56.301D

S56.301S

S56.302D

S56.302S

S56.311A

S56.311D

S56.311S

S56.312A

S56.312D

S56.312S

S56.321A

S56.321D

S56.321S

S56.322A

S56.322D

S56.322S

S56.391D

S56.391S

S56.392D

S56.392S

S56.401D

S56.401S

S56.402D

S56.402S

S56.403D

S56.403S

S56.404D

S56.404S

S56.405D

S56.405S

S56.406D

S56.406S

S56.407D

S56.407S

556.408D

S56.408S

S56.411A

S56.411D

S56.411S

S56.412A

556.412D

S56.412S

S56.413A

S56.413D

S56.4135

S56.414A

S56.414D

S56.4145

S56.415A

S56.415D

S56.4155

S56.416A

S56.416D

556.416S

S56.417A

S56.417D

S56.417S

S56.418A

S56.418D

S56.418S

S56.421A

S56.421D

S56.421S

S56.422A

S56.422D

S56.422S

S56.423A

S56.423D

S56.423S

S56.424A

S56.424D

S56.424S

S56.425A

S56.425D

556.425S

S56.426A

S56.426D

S56.426S

S56.427A

S56.427D

S56.427S

S56.428A

S56.428D

S56.428S

S56.491D

S56.491S

S56.492D

S56.492S

S56.493D

S56.493S

S56.494D

S56.494S

S56.495D

S56.495S

S56.496D

S56.496S

S56.497D

S56.497S

S56.498D

S56.498S

S56.501D

S56.501S

S56.502D

S56.502S

S56.511A

S56.511D

S56.511S

S56.512A

S56.512D

S56.512S

S56.521A

S56.521D

S56.521S

S56.522A

S56.522D

S56.522S

S56.591D

S56.591S

S56.592D

S56.592S

S56.801D

S56.801S

S56.802D

S56.802S

S56.811A

S56.811D

S56.811S

S56.812A

S56.812D

S56.812S

S56.821A

S56.821D

S56.821S

S56.822A

S56.822D

S56.822S

S56.891D

S56.891S

S56.892D

S56.892S

S56.901D

S56.901S

S56.902D

S56.9025

S56.911A

S56.911D

S56.9115

S56.912A

S56.912D

556.912S

S56.921A

S56.921D

S56.9215

S56.922A

S56.922D

S56.922S

S56.991D

S56.991S

S56.992D

S56.992S

COVERED DIAGNOSIS CODES FOR E1805 AND E1820

M12.531

M12.532

M12.541

M12.542

M24.131

M24.132

M24.141

M24.142

M24.231

M24.232

M24.241

M24.242

M24.331

M24.332

M24.341

M24.342

M24.431

M24.432

M24.441

M24.442

M24.531

M24.532

M24.541

M24.542

M24.831

M24.832

M24.841

M24.842

M25.641

M25.642

S52.371S

S52.372S

S52.501A

S52.501B

S52.501C

S52.501D

S52.501E

S52.501F

S52.501G

S52.501H

S52.501J

S52.501K

S52.501M

S52.501N

S52.501P

S52.501Q

S52.501R

S52.502A

S52.502B

S52.502C

S52.502D

S52.502E

552.502F

S52.502G

S52.502H

S52.502J

S52.502K

S52.502M

S52.502N

S52.502P

S52.502Q

S52.502R

S52.511A

S52.511B

S52.511C

S52.511D

S52.511E

S52.511F

S52.511G

S52.511H

S52.511J

S52.511K

S52.511M

S52.511N

S52.511P

S52.511Q

S52.511R

S52.512A

S52.512B

S52.512C

S52.512D

S52.512E

S52.512F

S52.512G

S52.512H

S52.512J

S52.512K

S52.512M

S52.512N

S52.512P

S52.512Q

S52.512R

S52.514A

S52.514B

S52.514C

S52.514D

S52.514E

S52.514F

S52.514G

S52.514H

S52.514J

S52.514K

S52.514M

S52.514N

S52.514P

S52.514Q

S52.514R

S52.515A

S52.515B

S52.515C

S52.515D

S52.515E

S52.515F

S52.515G

S52.515H

S52.515J

S52.515K

S52.515M

S52.515N

S52.515P

S52.515Q

S52.515R

S52.521A

S52.521D

S52.521G

S52.521K

S52.521P

S52.521S

S52.522A

S52.522D

S52.522G

S52.522K

S52.522P

S52.522S

S52.531A

S52.531B

S52.531C

S52.531D

S52.531E

S52.531F

S52.531G

S52.531H

S52.531J

S52.531K

S52.531M

S52.531N

S52.531P

S52.531Q

S52.531R

S52.531S

S52.532A

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S66.1105

S66.111A

S66.111D

S66.111S

566.112A

S66.112D

S66.112S

S66.113A

S66.113D

S66.113S

S66.114A

S66.114D

S66.114S

S66.115A

S66.115D

S66.115S

S66.116A

S66.116D

S66.116S

S66.117A

S66.117D

S66.117S

S66.120A

S66.120D

S66.120S

S66.121A

S66.121D

S66.121S

S66.122A

S66.122D

S66.122S

S66.123A

S66.123D

S66.123S

S66.124A

S66.124D

S66.124S

S66.125A

S66.125D

S66.125S

S66.126A

S66.126D

S66.126S

S66.127A

S66.127D

S66.1275

566.190D

S66.190S

S66.191D

S66.191S

S66.192D

S66.192S

S66.193D

S66.193S

S66.194D

S66.194S

S66.195D

S66.195S

S66.196D

S66.196S

S66.197D

S66.197S

S66.201D

S66.201S

S66.202D

S66.202S

S66.211A

S66.211D

S66.211S

S66.212A

S66.212D

S66.212S

S66.221A

S66.221D

S66.221S

S66.222A

S66.222D

S66.222S

S66.291D

S66.291S

S66.292D

S66.292S

S66.300D

S66.300S

S66.301D

S66.301S

S66.302D

S66.302S

S66.303D

S66.303S

S66.304D

S66.304S

S66.305D

S66.305S

S66.306D

S66.3065

S66.307D

S66.307S

S66.310A

S66.310D

S66.310S

S66.311A

S66.311D

S66.311S

S66.312A

S66.312D

S66.3125

S66.313A

S66.313D

S66.3135

S66.314A

S66.314D

S66.314S

S66.315A

S66.315D

S66.315S

S66.316A

S66.316D

S66.316S

S66.317A

S66.317D

S66.317S

S66.320A

S66.320D

S66.320S

S66.321A

S66.321D

S66.321S

S66.322A

S66.322D

S66.322S

S66.323A

S66.323D

S66.323S

S66.324A

S66.324D

S66.324S

S66.325A

S66.325D

S66.325S

S66.326A

S66.326D

S66.326S

S66.327A

S66.327D

S66.327S

S66.390D

S66.390S

S66.391D

S66.391S

S66.392D

S66.392S

S66.393D

S66.393S

S66.394D

S66.394S

S66.395D

S66.395S

S66.396D

S66.396S

S66.397D

S66.397S

S66.401D

S66.401S

S66.402D

S66.402S

S66.411A

S66.411D

S66.411S

S66.412A

S66.412D

S66.412S

S66.421A

S66.421D

S66.4215

S66.422A

S66.422D

S66.422S

S66.491D

S66.491S

S66.492D

S66.4925

S66.500D

S66.500S

S66.501D

S66.501S

S66.502D

S66.502S

S66.503D

S66.503S

S66.504D

S66.504S

S66.505D

S66.505S

S66.506D

S66.506S

S66.507D

S66.507S

S66.510A

S66.510D

S66.510S

S66.511A

S66.511D

S66.511S

S66.512A

S66.512D

S66.5125

S66.513A

S66.513D

S66.513S

S66.514A

S66.514D

S66.514S

S66.515A

S66.515D

S66.515S

S66.516A

S66.516D

S66.516S

S66.517A

S66.517D

S66.517S

S66.520A

S66.520D

S66.520S

S66.521A

S66.521D

S66.521S

S66.522A

S66.522D

S66.522S

S66.523A

S66.523D

S66.523S

S66.524A

S66.524D

S66.524S

S66.525A

S66.525D

S66.525S

S66.526A

S66.526D

S66.526S

S66.527A

S66.527D

S66.527S

S66.590D

S66.590S

S66.591D

S66.591S

S66.592D

S66.592S

S66.593D

S66.593S

S66.594D

S66.594S

S66.595D

S66.595S

S66.596D

S66.596S

S66.597D

S66.597S

S66.801D

S66.801S

S66.802D

S66.802S

S66.811A

S66.811D

S66.811S

S66.812A

S66.812D

S66.812S

S66.821A

S66.821D

S66.821S

S66.822A

S66.822D

S66.822S

S66.891D

S66.891S

S66.892D

S66.892S

S66.901D

S66.901S

S66.902D

S66.902S

S66.911A

S66.911D

S66.911S

S66.912A

S66.912D

S66.912S

S66.921A

S66.921D

S66.921S

S66.922A

S66.922D

S66.922S

S66.991D

S66.991S

S66.992D

S66.992S

S69.81XD

S69.81XS

S69.82XD

S69.82XS

S69.91XD

S69.91XS

S69.92XD

S69.92XS

Covered Diagnosis Codes for E1820 & E1825

M12.561

M12.562

M22.01

M22.02

M22.11

M22.12

M22.2X1

M22.2X2

M22.3X1

M22.3X2

M22.8X1

M22.8X2

M22.91

M22.92

M23.200

M23.201

M23.203

M23.204

M23.206

M23.207

M23.211

M23.212

M23.221

M23.222

M23.231

M23.232

M23.241

M23.242

M23.251

M23.252

M23.261

M23.262

M23.300

M23.301

M23.303

M23.304

M23.306

M23.307

M23.311

M23.312

M23.321

M23.322

M23.331

M23.332

M23.341

M23.342

M23.351

M23.352

M23.361

M23.362

M23.51

M23.52

M23.601

M23.602

M23.611

M23.612

M23.621

M23.622

M23.631

M23.632

M23.641

M23.642

M23.671

M23.672

M23.8X1

M23.8X2

M23.91

M23.92

M24.361

M24.362

M24.444

M24.445

M24.461

M24.462

S62.501D

S62.501G

S62.501K

S62.501P

S62.501S

S62.502D

S62.502G

S62.502K

S62.502P

S62.502S

S62.511D

S62.511G

S62.511K

S62.511P

S62.511S

S62.512D

S62.512G

S62.512K

S62.512P

S62.512S

S62.514D

S62.514G

S62.514K

S62.514P

S62.514S

S62.515D

S62.515G

S62.515K

S62.515P

S62.515S

S62.521D

S62.521G

S62.521K

S62.521P

S62.521S

S62.522D

S62.522G

S62.522K

S62.522P

S62.522S

S62.524D

S62.524G

S62.524K

S62.524P

S62.524S

S62.525D

S62.525G

S62.525K

S62.525P

S62.5255

S62.600D

S62.600G

S62.600K

S62.600P

S62.6005

S62.601D

S62.601G

S62.601K

S62.601P

S62.601S

S62.602D

S62.602G

S62.602K

S62.602P

S62.602S

S62.603D

S62.603G

S62.603K

S62.603P

S62.6035

S62.604D

S62.604G

S62.604K

S62.604P

S62.6045

S62.605D

S62.605G

S62.605K

S62.605P

S62.6055

S62.606D

S62.606G

S62.606K

S62.606P

S62.606S

S62.607D

S62.607G

S62.607K

S62.607P

S62.607S

S62.610D

S62.610G

S62.610K

S62.610P

S62.610S

S62.611D

S62.611G

S62.611K

S62.611P

S62.611S

S62.612D

S62.612G

S62.612K

S62.612P

S62.612S

S62.613D

S62.613G

S62.613K

S62.613P

S62.613S

S62.614D

S62.614G

S62.614K

S62.614P

S62.614S

S62.615D

S62.615G

S62.615K

S62.615P

S62.615S

S62.616D

S62.616G

S62.616K

S62.616P

S62.616S

S62.617D

S62.617G

S62.617K

S62.617P

S62.617S

S62.620D

S62.620G

S62.620K

S62.620P

S62.620S

S62.621D

S62.621G

S62.621K

S62.621P

S62.621S

S62.622D

S62.622G

S62.622K

S62.622P

S62.622S

S62.623D

S62.623G

S62.623K

S62.623P

S62.623S

S62.624D

S62.624G

S62.624K

S62.624P

S62.624S

S62.625D

S62.625G

S62.625K

S62.625P

S62.625S

S62.626D

S62.626G

S62.626K

S62.626P

S62.626S

S62.627D

S62.627G

S62.627K

S62.627P

S62.627S

S62.630D

S62.630G

S62.630K

S62.630P

S62.630S

S62.631D

S62.631G

S62.631K

S62.631P

S62.631S

S62.632D

S62.632G

S62.632K

S62.632P

S62.632S

S62.633D

S62.633G

S62.633K

S62.633P

S62.633S

S62.634D

S62.634G

S62.634K

S62.634P

S62.634S

S62.635D

S62.635G

S62.635K

S62.635P

S62.635S

S62.636D

S62.636G

S62.636K

S62.636P

S62.636S

S62.637D

S62.637G

S62.637K

S62.637P

S62.637S

S62.640D

S62.640G

S62.640K

S62.640P

S62.640S

S62.641D

S62.641G

S62.641K

S62.641P

S62.641S

S62.642D

S62.642G

S62.642K

S62.642P

S62.642S

S62.643D

S62.643G

S62.643K

S62.643P

S62.643S

S62.644D

S62.644G

S62.644K

S62.644P

S62.644S

S62.645D

S62.645G

S62.645K

S62.645P

S62.645S

S62.646D

S62.646G

S62.646K

S62.646P

S62.646S

S62.647D

S62.647G

S62.647K

S62.647P

S62.647S

S62.650D

S62.650G

S62.650K

S62.650P

S62.650S

S62.651D

S62.651G

S62.651K

S62.651P

S62.651S

S62.652D

S62.652G

S62.652K

562.652P

S62.652S

S62.653D

S62.653G

S62.653K

S62.653P

S62.653S

S62.654D

S62.654G

S62.654K

S62.654P

S62.654S

S62.655D

S62.655G

S62.655K

S62.655P

S62.655S

S62.656D

S62.656G

S62.656K

S62.656P

S62.656S

S62.657D

S62.657G

S62.657K

S62.657P

S62.657S

S62.660D

S62.660G

S62.660K

S62.660P

S62.660S

S62.661D

S62.661G

S62.661K

S62.661P

S62.661S

S62.662D

S62.662G

S62.662K

S62.662P

S62.664G

S62.664K

S62.664P

S62.664S

S62.665D

S62.663S

S62.664D

S62.665G

S62.665K

S62.665P

S62.665S

S62.666D

S62.666G

S62.666K

S62.666P

S62.666S

S62.667D

S62.667G

S62.667K

S62.667P

S62.667S

S63.101D

S63.101S

S63.102D

S63.102S

S63.104D

S63.104S

S63.105D

S63.105S

S63.111D

S63.111S

S63.112D

S63.112S

S63.114D

S63.114S

S63.115D

S63.115S

S63.121D

S63.121S

S63.122D

S63.122S

S63.124D

S63.124S

S63.125D

S63.125S

S63.200D

S63.200S

S63.201D

S63.201S

S63.202D

S63.202S

S63.203D

S63.203S

S63.204D

S63.204S

S63.205D

S63.205S

S63.206D

S63.206S

S63.207D

S63.207S

S63.210D

S63.210S

S63.211D

S63.211S

S63.212D

S63.212S

S63.213D

S63.213S

S63.214D

S63.214S

S63.215D

S63.215S

S63.216D

S63.216S

S63.217D

S63.217S

S63.220D

S63.220S

S63.221D

S63.221S

S63.222D

S63.222S

S63.223D

S63.223S

S63.224D

S63.224S

S63.225D

S63.225S

S63.226D

S63.226S

S63.227D

S63.227S

S63.230D

S63.230S

S63.231D

S63.231S

S63.232D

S63.232S

S63.233D

S63.233S

S63.234D

S63.234S

S63.235D

S63.235S

S63.236D

S63.236S

S63.237D

S63.237S

S63.240D

S63.240S

S63.241D

S63.241S

S63.242D

S63.242S

S63.243D

S63.243S

S63.244D

S63.244S

S63.245D

S63.245S

S63.246D

S63.246S

S63.247D

S63.247S

S63.250D

S63.250S

S63.251D

S63.251S

S63.252D

S63.252S

S63.253D

S63.253S

S63.254D

S63.254S

S63.255D

S63.255S

S63.256D

S63.256S

S63.257D

S63.257S

S63.260D

S63.260S

S63.261D

S63.261S

S63.262D

S63.262S

S63.263D

S63.263S

S63.264D

S63.264S

S63.265D

S63.265S

S63.266D

S63.266S

S63.267D

S63.267S

S63.270D

S63.270S

S63.271D

S63.271S

S63.272D

S63.272S

S63.273D

S63.273S

S63.274D

S63.274S

S63.275D

S63.275S

S63.276D

S63.276S

S63.277D

S63.277S

S63.280D

S63.280S

S63.281D

S63.281S

S63.282D

S63.282S

S63.283D

S63.283S

S63.284D

S63.284S

S63.285D

S63.285S

S63.286D

S63.286S

S63.287D

S63.287S

S63.290D

S63.290S

S63.291D

S63.291S

S63.292D

S63.292S

S63.293D

S63.293S

S63.294D

S63.294S

S63.295D

S63.295S

S63.296D

S63.296S

S63.297D

S63.297S

S63.400A

S63.400D

S63.400S

S63.401A

S63.401D

S63.401S

S63.402A

S63.402D

S63.402S

S63.403A

S63.403D

S63.403S

S63.404A

S63.404D

S63.404S

S63.405A

S63.405D

S63.405S

S63.406A

S63.406D

S63.406S

S63.407A

S63.407D

S63.407S

S63.410A

S63.410D

S63.410S

S63.411A

S63.411D

S63.411S

S63.412A

S63.412D

S63.412S

S63.413A

S63.413D

S63.413S

S63.414A

S63.414D

S63.414S

S63.415A

S63.415D

S63.415S

S63.416A

S63.416D

S63.416S

S63.417A

S63.417D

S63.417S

S63.420A

S63.420D

S63.420S

S63.421A

S63.421D

S63.421S

S63.422A

S63.422D

S63.422S

S63.423A

S63.423D

S63.423S

S63.424A

S63.424D

S63.424S

S63.425A

S63.425D

S63.425S

S63.426A

S63.426D

S63.426S

S63.427A

S63.427D

S63.427S

S63.430A

S63.430D

S63.430S

S63.431A

S63.431D

S63.431S

S63.432A

S63.432D

S63.432S

S63.433A

S63.433D

S63.433S

S63.434A

S63.434D

S63.434S

S63.435A

S63.435D

S63.435S

S63.436A

S63.436D

S63.436S

S63.437A

S63.437D

S63.437S

S63.490A

S63.490D

S63.490S

S63.491A

S63.491D

S63.491S

S63.492A

S63.492D

S63.492S

S63.493A

S63.493D

S63.493S

S63.494A

S63.494D

S63.494S

S63.495A

S63.495D

S63.495S

S63.496A

S63.496D

S63.496S

S63.497A

S63.497D

S63.497S

S63.601A

S63.601D

S63.601S

S63.602A

S63.602D

S63.602S

S63.610A

S63.610D

S63.610S

S63.611A

S63.611D

S63.611S

S63.612A

S63.612D

S63.612S

S63.613A

S63.613D

S63.613S

S63.614A

S63.614D

S63.614S

S63.615A

S63.615D

S63.615S

S63.616A

S63.616D

S63.616S

S63.617A

S63.617D

S63.617S

S63.621A

S63.621D

S63.6215

S63.622A

S63.622D

S63.622S

S63.630A

S63.630D

S63.630S

S63.631A

S63.631D

S63.6315

S63.632A

S63.632D

S63.632S

S63.633A

S63.633D

S63.633S

S63.634A

S63.634D

S63.6345

S63.635A

S63.635D

S63.635S

S63.636A

S63.636D

S63.636S

S63.637A

S63.637D

S63.637S

S63.641A

S63.641D

S63.641S

S63.642A

S63.642D

S63.642S

S63.650A

S63.650D

S63.650S

S63.651A

S63.651D

S63.651S

S63.652A

S63.652D

S63.652S

S63.653A

S63.653D

S63.653S

S63.654A

S63.654D

S63.654S

S63.655A

S63.655D

S63.655S

S63.656A

S63.656D

S63.656S

S63.657A

S63.657D

S63.657S

S63.681A

S63.681D

S63.681S

S63.682A

S63.682D

S63.682S

S63.690A

S63.690D

S63.690S

S63.691A

S63.691D

S63.6915

S63.692A

S63.692D

S63.692S

S63.693A

S63.693D

S63.693S

S63.694A

S63.694D

S63.694S

S63.695A

S63.695D

S63.695S

S63.696A

S63.696D

S63.696S

S63.697A

S63.697D

S63.697S

S69.81XD

S69.81XS

S69.82XD

S69.82XS

S69.91XD

S69.91XS

S69.92XD

S69.92XS

S82.001D

S82.001E

S82.001F

S82.001G

S82.001H

S82.001J

S82.001K

S82.001M

S82.001N

S82.001P

S82.001Q

S82.001R

S82.002D

S82.002E

S82.002F

S82.002G

S82.002H

S82.002J

S82.002K

S82.002M

S82.002N

S82.002P

S82.002Q

S82.002R

S82.011D

S82.011E

S82.011F

S82.011G

S82.011H

S82.011J

S82.011K

S82.011M

S82.011N

S82.011P

S82.011Q

S82.011R

S82.012D

S82.012E

S82.012F

S82.012G

S82.012H

S82.012J

S82.012K

S82.012M

S82.012N

S82.012P

S82.012Q

S82.012R

S82.014D

S82.014E

S82.014F

S82.014G

S82.014H

S82.014J

S82.014K

S82.014M

S82.014N

S82.014P

S82.014Q

S82.014R

S82.015D

S82.015E

S82.015F

S82.015G

S82.015H

S82.015J

S82.015K

S82.015M

S82.015N

S82.015P

S82.015Q

S82.015R

S82.021D

S82.021E

S82.021F

S82.021G

S82.021H

S82.021J

S82.021K

S82.021M

S82.021N

S82.021P

S82.021Q

S82.021R

S82.022D

S82.022E

S82.022F

S82.022G

S82.022H

S82.022J

S82.022K

S82.022M

S82.022N

S82.022P

S82.022Q

S82.022R

S82.024D

S82.024E

S82.024F

S82.024G

S82.024H

S82.024J

S82.024K

S82.024M

S82.032Q

S82.032R

S82.034D

S82.024R

S82.025D

S82.025E

S82.025F

S82.025G

S82.025H

S82.025J

S82.025K

S82.025M

S82.025N

S82.025P

S82.025Q

S82.025R

S82.031D

S82.031E

S82.031F

S82.031G

S82.031H

S82.031J

S82.031K

S82.031M

S82.031N

S82.031P

S82.031Q

S82.031R

S82.032D

S82.032E

S82.032F

S82.032G

S82.032H

S82.032J

S82.032K

S82.032M

S82.032N

S82.032P

S82.032Q

S82.032R

S82.034D

S82.034E

S82.034F

S82.034G

S82.034H

S82.034J

S82.034K

S82.034M

S82.034N

S82.034P

S82.034Q

S82.034R

S82.035D

S82.035E

S82.035F

S82.035G

S82.035H

S82.035J

S82.035K

S82.035M

S82.035N

S82.035P

S82.035Q

S82.035R

S82.041D

S82.041E

S82.041F

S82.041G

S82.041H

S82.041J

S82.041K

S82.041M

S82.041N

S82.041P

S82.041Q

S82.041R

S82.042D

S82.042E

S82.042F

S82.042G

S82.042H

S82.042J

S82.042K

S82.042M

S82.042N

S82.042P

S82.042Q

S82.042R

S82.044D

S82.044E

S82.044F

S82.044G

S82.044H

S82.044J

S82.044K

S82.044M

S82.044N

S82.044P

S82.044Q

S82.044R

S82.045D

S82.045E

S82.045F

S82.045G

S82.045H

S82.045J

S82.045K

S82.045M

S82.045N

S82.045P

S82.045Q

S82.045R

S82.091D

S82.091E

S82.091F

S82.091G

S82.091H

S82.091J

S82.091K

S82.091M

S82.091N

S82.091P

S82.091Q

S82.091R

S82.092D

S82.092E

S82.092F

S82.092G

S82.092H

S82.092J

S82.092K

S82.092M

S82.092N

S82.092P

S82.092Q

S82.092R

S82.101A

S82.101B

S82.101C

S82.101D

S82.101E

S82.101F

S82.101G

S82.101H

S82.101J

S82.101K

S82.101M

S82.101N

S82.101P

S82.101Q

S82.101R

S82.102A

S82.102B

S82.102C

S82.102D

S82.102E

S82.102F

S82.102G

S82.102H

S82.102J

S82.102K

S82.102M

S82.102N

S82.102P

S82.102Q

S82.102R

S82.111A

S82.111B

S82.111C

S82.111D

S82.111E

S82.111F

S82.111G

S82.111H

S82.111J

S82.111K

S82.111M

S82.111N

S82.111P

S82.111Q

S82.111R

S82.112A

S82.112B

S82.112C

S82.112D

S82.112E

S82.112F

882.112G

S82.112H

S82.112J

S82.112K

S82.112M

S82.112N

S82.112P

S82.112Q

S82.112R

S82.114A

S82.114B

S82.114C

S82.114D

S82.114E

S82.114F

S82.114G

S82.114H

S82.114J

S82.114K

S82.114M

S82.114N

S82.114P

S82.114Q

S82.114R

S82.115A

S82.115B

S82.115C

S82.115D

S82.115E

S82.115F

S82.115G

S82.115H

S82.115J

S82.115K

S82.115M

S82.115N

S82.115P

S82.115Q

S82.115R

S82.121A

S82.121B

S82.121C

S82.121D

S82.121E

S82.121F

S82.121G

S82.121H

S82.121J

S82.121K

S82.121M

S82.121N

S82.121P

S82.121Q

S82.121R

S82.122A

S82.122B

S82.122C

S82.122D

S82.122E

S82.122F

S82.122G

S82.122H

S82.122J

S82.122K

S82.122M

S82.122N

S82.122P

S82.122Q

S82.122R

S82.124A

S82.124B

S82.124C

S82.124D

S82.124E

S82.124F

S82.124G

S82.124H

S82.124J

S82.124K

S82.124M

S82.124N

S82.124P

S82.124Q

S82.124R

S82.125A

S82.125B

S82.125C

S82.125D

S82.125E

S82.125F

S82.125G

S82.125H

S82.125J

S82.125K

S82.125M

S82.125N

S82.125P

S82.125Q

S82.125R

S82.131A

S82.131B

S82.131C

S82.131D

S82.131E

S82.131F

S82.131G

S82.131H

S82.131J

S82.131K

S82.131M

S82.131N

S82.131P

S82.131Q

S82.131R

S82.132A

S82.132B

S82.132C

S82.132D

S82.132E

S82.132F

S82.132G

S82.132H

S82.132J

S82.132K

S82.132M

S82.132N

S82.132P

S82.132Q

S82.132R

S82.134A

S82.134B

S82.134C

S82.134D

S82.134E

S82.134F

S82.134G

S82.134H

S82.134J

S82.134K

S82.134M

S82.134N

S82.134P

S82.134Q

S82.134R

S82.135A

S82.135B

S82.135C

S82.135D

S82.135E

S82.135F

S82.135G

S82.135H

S82.135J

S82.135K

S82.135M

S82.135N

S82.135P

S82.135Q

S82.135R

S82.141A

S82.141B

S82.141C

S82.141D

S82.141E

S82.141F

S82.141G

S82.141H

S82.141J

S82.141K

S82.141M

S82.141N

S82.141P

S82.141Q

S82.141R

S82.142A

S82.142B

S82.142C

S82.142D

S82.142E

S82.142F

S82.142G

S82.142H

S82.142J

882.142K

S82.142M

S82.142N

S82.142P

S82.142Q

S82.142R

S82.144A

S82.144B

S82.144C

S82.144D

S82.144E

S82.144F

S82.144G

S82.144H

S82.144J

S82.144K

S82.144M

S82.144N

S82.144P

S82.144Q

S82.144R

S82.145A

S82.145B

S82.145C

S82.145D

S82.145E

S82.145F

S82.145G

S82.145H

S82.145J

S82.145K

S82.145M

S82.145N

S82.145P

S82.145Q

S82.145R

S82.151A

S82.151B

S82.151C

S82.151D

S82.151E

S82.151F

S82.151G

S82.151H

S82.151J

S82.151K

S82.151M

S82.151N

S82.151P

S82.151Q

S82.151R

S82.152A

S82.152B

S82.152C

S82.152D

S82.152E

S82.152F

S82.152G

S82.152H

S82.152J

S82.152K

S82.152M

S82.152N

S82.152P

S82.152Q

S82.152R

S82.154A

S82.154B

S82.154C

S82.154D

S82.154E

S82.154F

S82.154G

S82.154H

S82.154J

S82.154K

S82.154M

S82.154N

S82.154P

S82.154Q

S82.154R

S82.155A

S82.155B

S82.155C

S82.155D

S82.155E

S82.155F

S82.155G

S82.155H

S82.155J

S82.155K

S82.155M

S82.155N

S82.155P

S82.155Q

S82.155R

S82.161A

S82.161D

S82.161G

S82.161K

S82.161P

S82.162A

S82.162D

S82.162G

S82.162K

S82.162P

S82.191A

S82.191B

S82.191C

S82.191D

S82.191E

S82.191F

S82.191G

S82.191H

S82.191J

S82.191K

S82.191M

S82.191N

S82.191P

S82.191Q

S82.191R

S82.192A

S82.192B

S82.192C

S82.192D

S82.192E

S82.192F

S82.192G

S82.192H

S82.192J

S82.192K

S82.192M

S82.192N

S82.192P

S82.192Q

S82.192R

S83.001D

S83.001S

S83.002D

S83.002S

S83.004D

S83.004S

S83.005D

S83.005S

S83.011D

S83.011S

S83.012D

S83.012S

S83.014D

S83.014S

S83.015D

S83.015S

S83.091D

S83.091S

S83.092D

S83.092S

S83.094D

S83.094S

S83.095D

S83.095S

S83.101D

S83.101S

S83.102D

S83.102S

S83.103D

S83.103S

S83.104D

S83.104S

S83.105D

S83.105S

S83.111D

S83.111S

S83.112D

S83.112S

S83.114D

S83.114S

S83.115D

S83.115S

S83.121D

S83.121S

S83.122D

S83.122S

S83.124D

S83.124S

S83.125D

S83.125S

S83.131D

S83.131S

S83.132D

S83.132S

S83.134D

S83.134S

S83.135D

S83.135S

S83.141D

S83.141S

S83.142D

S83.142S

S83.144D

S83.144S

S83.145D

S83.145S

S83.191D

S83.191S

S83.192D

S83.192S

S83.194D

S83.194S

S83.195D

S83.195S

S83.200D

S83.200S

S83.201D

S83.201S

S83.203D

S83.203S

S83.204D

S83.204S

S83.206D

S83.206S

S83.207D

S83.207S

S83.211D

S83.211S

S83.212D

S83.212S

S83.221D

S83.221S

S83.222D

S83.222S

S83.231D

S83.231S

S83.232D

S83.232S

S83.241D

S83.241S

S83.242D

S83.242S

S83.251D

S83.251S

S83.252D

S83.252S

S83.261D

S83.261S

S83.262D

S83.262S

S83.271D

S83.271S

S83.272D

S83.272S

S83.281D

S83.281S

S83.282D

S83.282S

S83.31XD

S83.31XS

S83.32XD

S83.32XS

S83.401A

S83.401D

S83.401S

S83.402A

S83.402D

S83.402S

S83.411A

S83.411D

S83.411S

S83.412A

S83.412D

S83.412S

S83.421A

S83.421D

S83.421S

S83.422A

S83.422D

S83.422S

S83.501A

S83.501D

S83.501S

S83.502A

S83.502D

S83.502S

S83.511A

S83.511D

S83.511S

S83.512A

S83.512D

S83.512S

S83.521A

S83.521D

S83.521S

S83.522A

S83.522D

S83.522S

S83.61XA

S83.61XD

S83.61XS

S83.62XA

S83.62XD

S83.62XS

S83.8X1A

S83.8X1D

S83.8X1S

S83.8X2A

S83.8X2D

S83.8X2S

S83.91XA

S83.91XD

S83.91XS

S83.92XA

S83.92XD

S83.92XS

COVERED DIAGNOSIS CODES FOR PROCEDURE CODES E1820 AND E1830

M20.11

M20.12

M20.21

M20.22

M20.31

M20.32

M20.41

M20.42

M20.5X1

M20.5X2

M20.61

M20.62

M24.477

M24.478

S92.401

S92.401B

S92.401D

S92.401G

S92.401K

S92.401P

S92.402A

S92.402B

S92.402D

S92.402G

S92.402K

S92.402P

S92.404A

S92.404B

S92.404D

S92.404G

S92.404K

S92.404P

S92.405A

S92.405B

S92.405D

S92.405G

S92.405K

S92.405P

S92.411A

S92.411B

S92.411D

S92.411G

S92.411K

S92.411P

S92.412A

S92.412B

S92.412D

S92.412G

S92.412K

S92.412P

S92.414A

S92.414B

S92.414D

S92.414G

S92.414K

S92.414P

S92.415A

S92.415B

S92.415D

S92.415G

S92.415K

S92.415P

S92.421A

S92.421B

S92.421D

S92.421G

S92.421K

S92.421P

S92.422A

S92.422B

S92.422D

S92.422G

S92.422K

S92.422P

S92.424A

S92.424B

S92.424D

S92.424G

S92.424K

S92.424P

S92.425A

S92.425B

S92.425D

S92.425G

S92.425K

S92.425P

S92.491A

S92.491B

S92.491D

S92.491G

S92.491K

S92.491P

S92.492A

S92.492B

S92.492D

S92.492G

S92.492K

S92.492P

S92.501A

S92.501B

S92.501D

S92.501G

S92.501K

S92.501P

S92.502A

S92.502B

S92.502D

S92.502G

S92.502K

S92.502P

S92.504A

S92.504B

S92.504D

S92.504G

S92.504K

S92.504P

S92.504A

S92.504B

S92.504D

S92.504G

S92.504K

S92.504P

S92.511A

S92.511B

S92.511D

S92.511G

S92.512P

S92.514A

S92.514B

S92.514D

S92.514G

S92.514K

S92.514P

S92.515A

S92.515B

S92.515D

S92.515G

S92.515K

S92.515P

S92.521A

S92.521B

S92.521D

S92.521G

S92.521K

S92.521P

S92.522A

S92.522B

S92.522D

S92.522G

S92.522K

S92.522P

S92.524A

S92.524B

S92.524D

S92.524G

S92.524K

S92.524P

S92.525A

S92.525B

S92.525D

S92.525G

S92.525K

S92.525P

S92.531A

S92.531B

S92.531D

S92.531G

S92.531K

S92.531P

S92.532A

S92.532B

S92.532D

S92.532G

S92.532K

S92.532P

S92.534A

S92.534B

S92.534D

S92.534G

S92.534K

S92.534P

S92.535A

S92.535B

S92.535D

S92.535G

S92.535K

S92.535P

S92.591A

S92.591B

S92.591D

S92.591G

S92.591K

S92.591P

S92.592A

S92.592B

S92.592D

S92.592G

S92.592K

S92.592P

S92.911A

S92.911B

S92.911D

S92.911G

S92.911K

S92.911P

S92.912A

S92.912B

S92.912D

S92.912G

S92.912K

S92.912P

S93.101A

S93.101D

S93.101S

S93.102A

S93.102D

S93.102S

S93.104A

S93.104D

S93.104S

S93.105A

S93.105D

S93.105S

S93.111A

S93.111D

S93.111S

S93.112A

S93.112D

S93.112S

S93.114A

S93.114D

S93.114S

S93.115A

S93.115D

S93.115S

S93.121A

S93.121D

S93.121S

S93.122A

S93.122D

S93.122S

S93.124A

S93.124D

S93.124S

S93.125A

S93.125D

S93.125S

S93.131A

S93.131D

S93.131S

S93.132A

S93.132D

S93.132S

S93.134A

S93.134D

S93.134S

S93.135A

S93.135D

S93.135S

S93.141A

S93.141D

S93.141S

S93.142A

S93.142D

S93.142S

S93.144A

S93.144D

S93.144S

S93.145A

S93.145D

S93.145S

S93.501A

S93.501D

S93.501S

S93.502A

S93.502D

S93.502S

S93.504A

S93.504D

S93.504S

S93.505A

S93.505D

S93.505S

S93.511A

S93.511D

S93.511S

S93.512A

S93.512D

S93.512S

S93.514A

S93.514D

S93.514S

S93.515A

S93.515D

S93.515S

S93.521A

S93.521D

S93.521S

S93.522A

S93.522D

S93.522S

S93.524A

S93.524D

S93.524S

S93.525A

S93.525D

S93.525S

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 5-19-2020

Internal Medical Policy Committee 9-21-2020 Annual Review-No changes in criteria

Internal Medical Policy Committee 3-17-2021 Annual Review-No changes in criteria

Internal Medical Policy Committee 3-23-2022 Revision

Revised language; and
Updated Diagnosis coding placing it within policy verses as an attachment

Internal Medical Policy Committee 3-23-2023 Annual Review - No changes in criteria

Internal Medical Policy Committee 5-14-2024 Annual Review - No changes in criteria

Added Policy Application

Internal Medical Policy Committee 9-17-2024 Revision - Effective November 04, 2024

Removed duplicate diagnosis codes; and
Updated language

Internal Medical Policy Committee 1-14-2025 Coding update - Effective January 01, 2025

Added procedure codes E1803; E1804; E1807; E1808; E1813; E1814; E1822; E1823; E1826; E1827; E1828; and E1829.

Internal Medical Policy Committee 5-13-2025 Coding update - Effective April 01, 2025

Added procedure code E1832

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: O-10-019

Section: Orthotic & Prosthetic Devices

Effective Date: July 01, 2018

Revised Date: December 17, 2024

Revision Effective Date: January 01, 2025

Last Reviewed: January 14, 2025

Archived Date: March 31, 2025

Applies To: Commercial and Medicaid Expansion

Description

Bi-directional static progressive (SP) stretch devices are used for multiple short treatment sessions per day with the joint angle progressively advanced at each session.

Individual-actuated serial stretch (PASS) devices provide a low-to-high level load to the joint using pneumatic or hydraulic systems that are adjusted by the individual.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

*See below to determine whether the policy rules apply to initial and adjustment claims based on date of processing (DOP) or Date of Service (DOS).

Criteria

Dynamic Low-Load Prolonged-duration Stretch (LLPS)

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Dynamic low-load prolonged-duration stretch (LLPS) devices for the toe, knee, elbow, wrist, or finger may be considered medically necessary when ONE or more of the following are met:

The individual is in the subacute injury or post-operative period (greater than or equal to three (3) weeks but less than or equal to four (4) months after injury or operation) and ONE or more of the following
- LLPS is being used in addition to physical therapy for an individual with signs and symptoms of persistent joint stiffness or contracture
- LLPS is being used for an individual whose limited range of motion poses a meaningful (as judged by the physician) functional limitation, and who has not responded to other therapy (including physical therapy)
The individual is in the acute post-operative period following an additional procedure to improve range of motion of a previously affected joint
The individual is unable to benefit from standard physical therapy modalities due to an inability to exercise

NOTE:

LLPS meeting medical necessity criteria will be approved for an initial period of up to four (4) months.
LLPS meeting medical necessity criteria and utilized beyond four (4) months will be approved if the individual shows significant improvement after the initial period and improvement continues to be demonstrated.

Replacement of soft interface material for dynamic adjustable extension/flexion devices may be considered medically necessary per coverage criteria.

Dynamic low-load prolonged-duration stretch (LLPS) devices used for all other conditions are considered not medically necessary.

Procedure Codes

E1800

E1802

E1803

E1804

E1805

E1807

E1808

E1810

E1812

E1813

E1814

E1820

E1825

E1826

E1827

E1828

E1829

E1830

Experimental/Investigational

All claims submitted under this policy's section will be processed according to t he policy effective date and associated revision effective dates in effect on the date of service.

Dynamic (LLPS) devices which are specific to the ankle and shoulder
SaeboFlex
Bi-directional static progressive (SP) stretch devices
Replacement of soft interface material for bi-directional static progressive (SP) stretch devices
Patient-actuated serial stretch (PASS) devices

Carpal tunnel syndrome
Cerebral palsy
Foot-drop associated with neuromuscular diseases
Head and spinal cord injuries
Injuries of the ankle and shoulder
Multiple sclerosis
Muscular dystrophy
Plantar fasciitis
Rheumatoid arthritis
Stroke
Trismus

Procedure Codes

E1399

E1801

E1806

E1811

E1815

E1816

E1818

E1821

E1822

E1823

E1831

E1840

E1841

L3999

Diagnosis Codes

Covered Diagnosis Codes for E1800; E1802

M12.521

M12.522

M24.121

M24.122

M24.221

M24.222

M24.321

M24.322

M24.421

M24.422

M24.521

M24.522

M24.821

M24.822

S42.401B

S42.401D

S42.401G

S42.401K

S42.401P

S42.402B

S42.402D

S42.402G

S42.402K

S42.402P

S42.411A

S42.411B

S42.411D

S42.411G

S42.411K

S42.411P

S42.412A

S42.412B

S42.412D

S42.412G

S42.412K

S42.412P

S42.414A

S42.414B

S42.414D

S42.414G

S42.414K

S42.414P

S42.415A

S42.415B

S42.415D

S42.415G

S42.415K

S42.415P

S42.421A

S42.421B

S42.421D

S42.421G

S42.421K

S42.421P

S42.422A

S42.422B

S42.422D

S42.422G

S42.422K

S42.422P

S42.424A

S42.424B

S42.424D

S42.424G

S42.424K

S42.424P

S42.425A

S42.425B

S42.425D

S42.425G

S42.425K

S42.425P

S42.431A

S42.431B

S42.431D

S42.431G

S42.431K

S42.431P

S42.432A

S42.432B

S42.432D

S42.432G

S42.432K

S42.432P

S42.434A

S42.434B

S42.434D

S42.434G

S42.434K

S42.434P

S42.435A

S42.435B

S42.435D

S42.435G

S42.435K

S42.435P

S42.441A

S42.441B

S42.441D

S42.441G

S42.441K

S42.441P

S42.442A

S42.442B

S42.442D

S42.442G

S42.442K

S42.442P

S42.444A

S42.444B

S42.444D

S42.444G

S42.444K

S42.444P

S42.445A

S42.445B

S42.445D

S42.445G

S42.445K

S42.445P

S42.447A

S42.447B

S42.447D

S42.447G

S42.447K

S42.447P

S42.448A

S42.448B

S42.448D

S42.448G

S42.448K

S42.448P

S42.451A

S42.451B

S42.451D

S42.451G

S42.451K

S42.451P

S42.452A

S42.452B

S42.452D

S42.452G

S42.452K

S42.452P

S42.454A

S42.454B

S42.454D

S42.454G

S42.454K

S42.454P

S42.455A

S42.455B

S42.455D

S42.455G

S42.455K

S42.455P

S42.461A

S42.461B

S42.461D

S42.461G

S42.461K

S42.461P

S42.462A

S42.462B

S42.462D

S42.462G

S42.462K

S42.462P

S42.464A

S42.464B

S42.464D

S42.464G

S42.464K

S42.464P

S42.465A

S42.465B

S42.465D

S42.465G

S42.465K

S42.465P

S42.471A

S42.471B

S42.471D

S42.471G

S42.471K

S42.471P

S42.472A

S42.472B

S42.472D

S42.472G

S42.472K

S42.472P

S42.474A

S42.474B

S42.474D

S42.474G

S42.474K

S42.474P

S42.475A

S42.475B

S42.475D

S42.475G

S42.475K

S42.475P

S42.481A

S42.481D

S42.481G

S42.481K

S42.481P

S42.482A

S42.482D

S42.482G

S42.482K

S42.482P

S42.491A

S42.491B

S42.491D

S42.491G

S42.491K

S42.491P

S42.492A

S42.492B

S42.492D

S42.492G

S42.492K

S42.492P

S42.494A

S42.494B

S42.494D

S42.494G

S42.494K

S42.494P

S42.495A

S42.495B

S42.495D

S42.495G

S42.495K

S42.495P

S52.001A

S52.001B

S52.001C

S52.001D

S52.001E

S52.001F

S52.001G

S52.001H

S52.001J

S52.001K

S52.001M

S52.001N

S52.001P

S52.001Q

S52.001R

S52.001S

S52.002A

S52.002B

S52.002C

S52.002D

S52.002E

S52.002F

S52.002G

S52.002H

S52.002J

S52.002K

S52.002M

S52.002N

S52.002P

S52.002Q

S52.002R

S52.011A

S52.011D

S52.011G

S52.011K

S52.011P

S52.012A

S52.012D

S52.012G

S52.012K

S52.012P

S52.021A

S52.021B

S52.021C

S52.021D

S52.021E

S52.021F

S52.021G

S52.021H

S52.021J

S52.021K

S52.021M

S52.021N

S52.021P

S52.021Q

S52.021R

S52.022A

S52.022B

S52.022C

S52.022D

S52.022E

S52.022F

S52.022G

S52.022H

S52.022J

S52.022K

S52.022M

S52.022N

S52.022P

S52.022Q

S52.022R

S52.024A

S52.024B

S52.024C

S52.024D

S52.024E

S52.024F

S52.024G

S52.024H

S52.024J

S52.024K

S52.024M

S52.024N

S52.024P

S52.024Q

S52.024R

S52.025A

S52.025B

S52.025C

S52.025D

S52.025E

S52.025F

S52.025G

S52.025H

S52.025J

S52.025K

S52.025M

S52.025N

S52.025P

S52.025Q

S52.025R

S52.031A

S52.031B

S52.031C

S52.031D

S52.031E

S52.031F

S52.031G

S52.031H

S52.031J

S52.031K

S52.031M

S52.031N

S52.031P

S52.031Q

S52.031R

S52.032A

S52.032B

S52.032C

S52.032D

S52.032E

S52.032F

S52.032G

S52.032H

S52.032J

S52.032K

S52.032M

S52.032N

S52.032P

S52.032Q

S52.032R

S52.034A

S52.034B

S52.034C

S52.034D

S52.034E

S52.034F

S52.034G

S52.034H

S52.034J

S52.034K

S52.034M

S52.034N

S52.034P

S52.034Q

S52.034R

S52.035A

S52.035B

S52.035C

S52.035D

S52.035E

S52.035F

S52.035G

S52.035H

S52.035J

S52.035K

S52.035M

S52.035N

S52.035P

S52.035Q

S52.035R

S52.041A

S52.041B

S52.041C

S52.041D

S52.041E

S52.041F

S52.041G

S52.041H

S52.041J

S52.041K

S52.041M

S52.041N

S52.041P

S52.041Q

S52.041R

S52.042A

S52.042B

S52.042C

S52.042D

S52.042E

S52.042F

S52.042G

S52.042H

S52.042J

S52.042K

S52.042M

S52.042N

S52.042P

S52.042Q

S52.042R

S52.044A

S52.044B

S52.044C

S52.044D

S52.044E

S52.044F

S52.044G

S52.044H

S52.044J

S52.044K

S52.044M

S52.044N

S52.044P

S52.044Q

S52.044R

S52.045A

S52.045B

S52.045C

S52.045D

S52.045E

S52.045F

S52.045G

S52.045H

S52.045J

S52.045K

S52.045M

S52.045N

S52.045P

S52.045Q

S52.045R

S52.091A

S52.091B

S52.091C

S52.091D

S52.091E

S52.091F

S52.091G

S52.091H

S52.091J

S52.091K

S52.091M

S52.091N

S52.091P

S52.091Q

S52.091R

S52.092A

S52.092B

S52.092C

S52.092D

S52.092E

S52.092F

S52.092G

S52.092H

S52.092J

S52.092K

S52.092M

S52.092N

S52.092P

S52.092Q

S52.092R

S52.101A

S52.101B

S52.101C

S52.101D

S52.101E

S52.101F

S52.101G

S52.101H

S52.101J

S52.101K

S52.101M

S52.101N

S52.101P

S52.101Q

S52.101R

S52.102A

S52.102B

S52.102C

S52.102D

S52.102E

S52.102F

S52.102G

S52.102H

S52.102J

S52.102K

S52.102M

S52.102N

S52.102P

S52.102Q

S52.102R

S52.111A

S52.111D

S52.111G

S52.111K

S52.111P

S52.112A

S52.112D

S52.112G

S52.112K

S52.112P

S52.121A

S52.121B

S52.121C

S52.121D

S52.121E

S52.121F

S52.121G

S52.121H

S52.121J

S52.121K

S52.121M

S52.121N

S52.121P

S52.121Q

S52.121R

S52.122A

S52.122B

S52.122C

S52.122D

S52.122E

S52.122F

S52.122G

S52.122H

S52.122J

S52.122K

S52.122M

S52.122N

S52.122P

S52.122Q

S52.122R

S52.124A

S52.124B

S52.124C

S52.124D

S52.124E

S52.124F

S52.124G

S52.124H

S52.124J

S52.124K

S52.124M

S52.124N

S52.124P

S52.124Q

S52.124R

S52.125A

S52.125B

S52.125C

S52.125D

S52.125E

S52.125F

S52.125G

S52.125H

S52.125J

S52.125K

S52.125M

S52.125N

S52.125P

S52.125Q

S52.125R

S52.131A

S52.131B

S52.131C

S52.131D

S52.131E

S52.131F

S52.131G

S52.131H

S52.131J

S52.131K

S52.131M

S52.131N

S52.131P

S52.131Q

S52.131R

S52.132A

S52.132B

S52.132C

S52.132D

S52.132E

S52.132F

S52.132G

S52.132H

S52.132J

S52.132K

S52.132M

S52.132N

S52.132P

S52.132Q

S52.132R

S52.134A

S52.134B

S52.134C

S52.134D

S52.134E

S52.134F

S52.134G

S52.134H

S52.134J

S52.134K

S52.134M

S52.134N

S52.134P

S52.134Q

S52.134R

S52.135A

S52.135B

S52.135C

S52.135D

S52.135E

S52.135F

S52.135G

S52.135H

S52.135J

S52.135K

S52.135M

S52.135N

S52.135P

S52.135Q

S52.135R

S52.181A

S52.181B

S52.181C

S52.181D

S52.181E

S52.181F

S52.181G

S52.181H

S52.181J

S52.181K

S52.181M

S52.181N

S52.181P

S52.181Q

S52.181R

S52.182A

S52.182B

S52.182C

S52.182D

S52.182E

S52.182F

S52.182G

S52.182H

S52.182J

S52.182K

S52.182M

S52.182N

S52.182P

S52.182Q

S52.182R

S53.001A

S53.001D

S53.001S

S53.002A

S53.002D

S53.002S

S53.004A

S53.004D

S53.004S

S53.005A

S53.005D

S53.005S

S53.011A

S53.011D

S53.011S

S53.012A

S53.012D

S53.012S

S53.014A

S53.014D

S53.014S

S53.015A

S53.015D

S53.015S

S53.021A

S53.021D

S53.021S

S53.022A

S53.022D

S53.022S

S53.024A

S53.024D

S53.024S

S53.025A

S53.025D

S53.025S

S53.031A

S53.031D

S53.031S

S53.032A

S53.032S

S53.091A

S53.091D

S53.091S

S53.092A

S53.092D

S53.092S

S53.094A

S53.094D

S53.094S

S53.095A

S53.095D

S53.095S

S53.101A

S53.101D

S53.101S

S53.102A

S53.102D

S53.102S

S53.104A

S53.104S

S53.105A

S53.105D

S53.105S

S53.111A

S53.111D

S53.111S

S53.112A

S53.112D

S53.112S

S53.114A

S53.114D

S53.114S

S53.115A

S53.115D

S53.115S

S53.121A

S53.121D

S53.121S

S53.122A

S53.122D

S53.122S

S53.124A

S53.124D

S53.124S

S53.125A

S53.125D

S53.125S

S53.131A

S53.131D

S53.131S

S53.132A

S53.132D

S53.132S

S53.134A

S53.134D

S53.134S

S53.135A

S53.135D

S53.135S

S53.141A

S53.141D

S53.141S

S53.142A

S53.142D

S53.142S

S53.144A

S53.144D

S53.144S

S53.145A

S53.145D

S53.145S

S53.191A

S53.191D

S53.191S

S53.192A

S53.192D

S53.192S

S53.194A

S53.194D

S53.194S

S53.195A

S53.195D

S53.195S

S53.21XA

S53.21XD

S53.21XS

S53.22XA

S53.22XS

S53.31XA

S53.31XD

S53.31XS

S53.32XA

S53.32XD

S53.32XS

S53.401A

S53.401D

S53.401S

S53.402A

S53.402D

S53.402S

S53.411A

S53.411D

S53.411S

S53.412A

S53.412D

S53.412S

S53.421A

S53.421D

S53.421S

S53.422A

S53.422D

S53.422S

S53.431A

S53.431D

S53.431S

S53.432A

S53.432D

S53.432S

S53.441A

S53.441D

S53.441S

S53.442A

S53.442D

S53.442S

S53.491A

S53.491D

S53.491S

S53.492A

S53.492D

S53.492S

S56.001D

S56.001S

S56.002D

S56.002S

S56.011A

S56.011D

S56.011S

S56.012A

S56.012D

S56.012S

S56.021A

S56.021D

S56.021S

S56.022A

S56.022D

S56.022S

S56.091D

S56.091S

S56.092D

S56.092S

S56.101D

S56.101S

S56.102D

S56.102S

S56.103D

S56.103S

S56.104D

S56.104S

S56.105D

S56.105S

S56.106D

S56.106S

S56.107D

S56.107S

S56.108D

S56.108S

S56.109D

S56.109S

S56.111A

S56.111D

S56.111S

S56.112A

S56.112D

S56.112S

S56.113A

S56.113D

S56.113S

S56.114A

S56.114D

S56.114S

S56.115A

S56.115D

S56.115S

S56.116A

S56.116D

S56.116S

S56.117A

S56.117D

S56.117S

S56.118A

S56.118D

S56.118S

S56.121A

S56.121D

S56.121S

S56.122A

S56.122D

S56.122S

S56.123A

S56.123D

S56.123S

S56.124A

S56.124D

S56.124S

S56.125A

S56.125D

S56.125S

S56.126A

S56.126D

S56.126S

S56.127A

S56.127D

S56.127S

S56.128A

S56.128D

S56.128S

S56.191D

S56.191S

S56.192D

S56.192S

S56.193D

S56.193S

S56.194D

S56.194S

S56.195D

S56.195S

S56.196D

S56.196S

S56.197D

S56.197S

S56.198D

S56.198S

S56.301D

S56.301S

S56.302D

S56.302S

S56.311A

S56.311D

S56.311S

S56.312A

S56.312D

S56.312S

S56.321A

S56.321D

S56.321S

S56.322A

S56.322D

S56.322S

S56.391D

S56.391S

S56.392D

S56.392S

S56.401D

S56.401S

S56.402D

S56.402S

S56.404D

S56.404S

S56.405D

S56.405S

S56.406D

S56.406S

S56.407D

S56.407S

S56.408D

S56.408S

S56.411A

S56.411S

S56.412D

S56.413A

S56.413S

S56.414D

S56.415A

S56.415S

S56.416D

S56.422A

S56.422D

S56.422S

S56.423A

S56.423D

S56.423S

S56.424A

S56.424D

S56.424S

S56.425A

S56.425D

S56.425S

S56.426A

S56.426D

S56.426S

S56.427A

S56.427D

S56.427S

S56.428A

S56.428D

S56.428S

S56.491D

S56.491S

S56.492D

S56.493S

S56.494D

S56.494S

S56.495D

S56.495S

S56.496D

S56.496S

S56.497D

S56.497S

S56.498D

S56.498S

COVERED DIAGNOSIS CODES FOR E1805

M12.531

M12.532

M24.131

M24.132

M24.231

M24.232

M24.331

M24.332

M24.431

M24.432

M24.531

M24.532

M24.831

M24.832

S52.501A

S52.501B

S52.501C

S52.501D

S52.501E

S52.501F

S52.501G

S52.501H

S52.501J

S52.501K

S52.501M

S52.501N

S52.501P

S52.501Q

S52.501R

S52.502A

S52.502B

S52.502C

S52.502D

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S63.092S

S63.094D

S63.094S

S63.095D

S63.095S

S63.301A

S63.301D

S63.301S

S63.302A

S63.302D

S63.302S

S63.321A

S63.321D

S63.321S

S63.322A

S63.322D

S63.322S

S63.331A

S63.331D

S63.331S

S63.332A

S63.332D

S63.332S

S63.391A

S63.391D

S63.391S

S63.392A

S63.392D

S63.392S

S63.501A

S63.501D

S63.501S

S63.502A

S63.502D

S63.502S

S63.511A

S63.511D

S63.511S

S63.512A

S63.512D

S63.512S

S63.521A

S63.521D

S63.521S

S63.522A

S63.522D

S63.522S

S63.591A

S63.591D

S63.591S

S63.592A

S63.592D

S63.592S

S63.8X1A

S63.8X1D

S63.8X1S

S63.8X2A

S63.8X2D

S63.8X2S

S63.91XA

S63.91XD

S63.91XS

S63.92XA

S63.92XD

S63.92XS

S66.001D

S66.001S

S66.002D

S66.002S

S66.011D

S66.011S

S66.012D

S66.012S

S66.021D

S66.021S

S66.022D

S66.022S

S66.091A

S66.091D

S66.091S

S66.092D

S66.092S

S66.100D

S66.100S

S66.101D

S66.101S

S66.102D

S66.102S

S66.103D

S66.103S

S66.104D

S66.104S

S66.105D

S66.105S

S66.106D

S66.106S

S66.107D

S66.107S

S66.110A

S66.110D

S66.110S

S66.111A

S66.111D

S66.111S

S66.112A

S66.112D

S66.112S

S66.113A

S66.113D

S66.113S

S66.114A

S66.114D

S66.114S

S66.115A

S66.115D

S66.115S

S66.116A

S66.116D

S66.116S

S66.117A

S66.117D

S66.117S

S66.120A

S66.120D

S66.120S

S66.121A

S66.121D

S66.121S

S66.122A

S66.122D

S66.122S

S66.123A

S66.123D

S66.123S

S66.124A

S66.124D

S66.124S

S66.125A

S66.125D

S66.125S

S66.126A

S66.126D

S66.126S

S66.127A

S66.127D

S66.127S

S66.190D

S66.190S

S66.191D

S66.191S

S66.192D

S66.192S

S66.193D

S66.193S

S66.194D

S66.194S

S66.195D

S66.195S

S66.196D

S66.196S

S66.197D

S66.197S

S66.201D

S66.201S

S66.202D

S66.202S

S66.211A

S66.211D

S66.211S

S66.212A

S66.212D

S66.212S

S66.221A

S66.221D

S66.221S

S66.222A

S66.222D

S66.222S

S66.291D

S66.291S

S66.292D

S66.292S

S66.300D

S66.300S

S66.301D

S66.301S

S66.302D

S66.302S

S66.303D

S66.303S

S66.304D

S66.304S

S66.305D

S66.305S

S66.306D

S66.306S

S66.307D

S66.307S

S66.310A

S66.310D

S66.310S

S66.311A

S66.311D

S66.311S

S66.312A

S66.312D

S66.312S

S66.313A

S66.313D

S66.313S

S66.314A

S66.314D

S66.314S

S66.315A

S66.315D

S66.315S

S66.316A

S66.316D

S66.316S

S66.317A

S66.317D

S66.317S

S66.320A

S66.320D

S66.320S

S66.321A

S66.321D

S66.321S

S66.322A

S66.322D

S66.322S

S66.323A

S66.323D

S66.323S

S66.324A

S66.324D

S66.324S

S66.325A

S66.325D

S66.325S

S66.326A

S66.326D

S66.326S

S66.327A

S66.327D

S66.327S

S66.390D

S66.390S

S66.391D

S66.391S

S66.392D

S66.392S

S66.393D

S66.393S

S66.394D

S66.394S

S66.395D

S66.395S

S66.396D

S66.396S

S66.397D

S66.397S

S66.401D

S66.401S

S66.402D

S66.402S

S66.411A

S66.411D

S66.411S

S66.412A

S66.412D

S66.412S

S66.421A

S66.421D

S66.421S

S66.422A

S66.422D

S66.422S

S66.491D

S66.491S

S66.492D

S66.492S

S66.500D

S66.500S

S66.501D

S66.501S

S66.502D

S66.502S

S66.503D

S66.503S

S66.504D

S66.504S

S66.505D

S66.505S

S66.506D

S66.506S

S66.507D

S66.507S

S66.510A

S66.510D

S66.510S

S66.511A

S66.511D

S66.511S

S66.512A

S66.512D

S66.512S

S66.513A

S66.513D

S66.513S

S66.514A

S66.514D

S66.514S

S66.515A

S66.515D

S66.515S

S66.516A

S66.516D

S66.516S

S66.517A

S66.517D

S66.517S

S66.520A

S66.520D

S66.520S

S66.521A

S66.521D

S66.521S

S66.522A

S66.522D

S66.522S

S66.523A

S66.523D

S66.523S

S66.524A

S66.524D

S66.524S

S66.525A

S66.525D

S66.525S

S66.526A

S66.526D

S66.526S

S66.527A

S66.527D

S66.527S

S66.590D

S66.590S

S66.591D

S66.591S

S66.592D

S66.592S

S66.593D

S66.593S

S66.594D

S66.594S

S66.595D

S66.595S

S66.596D

S66.596S

S66.597D

S66.597S

S66.801D

S66.801S

S66.802D

S66.802S

S66.811A

S66.811D

S66.811S

S66.812A

S66.812D

S66.812S

S66.821A

S66.821D

S66.821S

S66.822A

S66.822D

S66.822S

S66.891D

S66.891S

S66.892D

S66.892S

S66.901D

S66.901S

S66.902D

S66.902S

S66.911A

S66.911D

S66.911S

S66.912A

S66.912D

S66.912S

S66.921A

S66.921D

S66.921S

S66.922A

S66.922D

S66.922S

S66.991D

S66.991S

S66.992D

S66.992S

S69.81XD

S69.81XS

S69.82XD

S69.82XS

S69.91XD

S69.91XS

S69.92XD

S69.92XS

COVERED DIAGNOSIS CODES FOR E1825

M24.444

M24.445

S62.501D

S62.501G

S62.501K

S62.501P

S62.501S

S62.502D

S62.502G

S62.502K

S62.502P

S62.502S

S62.511D

S62.511G

S62.511K

S62.511P

S62.511S

S62.512D

S62.512G

S62.512K

S62.512P

S62.512S

S62.514D

S62.514G

S62.514K

S62.514P

S62.514S

S62.515D

S62.515G

S62.515K

S62.515P

S62.515S

S62.521D

S62.521G

S62.521K

S62.521P

S62.521S

S62.522D

S62.522G

S62.522K

S62.522P

S62.522S

S62.524D

S62.524G

S62.524K

S62.524P

S62.524S

S62.525D

S62.525G

S62.525K

S62.525P

S62.525S

S62.600D

S62.600G

S62.600K

S62.600P

S62.600S

S62.601D

S62.601G

S62.601K

S62.601P

S62.601S

S62.602D

S62.602G

S62.602K

S62.602P

S62.602S

S62.603D

S62.603G

S62.603K

S62.603P

S62.603S

S62.604D

S62.604G

S62.604K

S62.604P

S62.604S

S62.605D

S62.605G

S62.605K

S62.605P

S62.605S

S62.606D

S62.606G

S62.606K

S62.606P

S62.606S

S62.607D

S62.607G

S62.607K

S62.607P

S62.607S

S62.610D

S62.610G

S62.610K

S62.610P

S62.610S

S62.611D

S62.611G

S62.611K

S62.611P

S62.611S

S62.612D

S62.612G

S62.612K

S62.612P

S62.612S

S62.613D

S62.613G

S62.613K

S62.613P

S62.613S

S62.614D

S62.614G

S62.614K

S62.614P

S62.614S

S62.615D

S62.615G

S62.615K

S62.615P

S62.615S

S62.616D

S62.616G

S62.616K

S62.616P

S62.616S

S62.617D

S62.617G

S62.617K

S62.617P

S62.617S

S62.620D

S62.620G

S62.620K

S62.620P

S62.620S

S62.621D

S62.621G

S62.621K

S62.621P

S62.621S

S62.622D

S62.622G

S62.622K

S62.622P

S62.622S

S62.623D

S62.623G

S62.623K

S62.623P

S62.623S

S62.624D

S62.624G

S62.624K

S62.624P

S62.624S

S62.625D

S62.625G

S62.625K

S62.625P

S62.625S

S62.626D

S62.626G

S62.626K

S62.626P

S62.626S

S62.627D

S62.627G

S62.627K

S62.627P

S62.627S

S62.630D

S62.630G

S62.630K

S62.630P

S62.630S

S62.631D

S62.631G

S62.631K

S62.631P

S62.631S

S62.632D

S62.632G

S62.632K

S62.632P

S62.632S

S62.633D

S62.633G

S62.633K

S62.633P

S62.633S

S62.634D

S62.634G

S62.634K

S62.634P

S62.634S

S62.635D

S62.635G

S62.635K

S62.635P

S62.635S

S62.636D

S62.636G

S62.636K

S62.636P

S62.636S

S62.637D

S62.637G

S62.637K

S62.637P

S62.637S

S62.640D

S62.640G

S62.640K

S62.640P

S62.640S

S62.641D

S62.641G

S62.641K

S62.641P

S62.641S

S62.642D

S62.642G

S62.642K

S62.642P

S62.642S

S62.643D

S62.643G

S62.643K

S62.643P

S62.643S

S62.644D

S62.644G

S62.644K

S62.644P

S62.644S

S62.645D

S62.645G

S62.645K

S62.645P

S62.645S

S62.646D

S62.646G

S62.646K

S62.646P

S62.646S

S62.647D

S62.647G

S62.647K

S62.647P

S62.647S

S62.650D

S62.650G

S62.650K

S62.650P

S62.650S

S62.651D

S62.651G

S62.651K

S62.651P

S62.651S

S62.652D

S62.652G

S62.652K

S62.652P

S62.652S

S62.653D

S62.653G

S62.653K

S62.653P

S62.653S

S62.654D

S62.654G

S62.654K

S62.654P

S62.654S

S62.655D

S62.655G

S62.655K

S62.655P

S62.655S

S62.656D

S62.656G

S62.656K

S62.656P

S62.656S

S62.657D

S62.657G

S62.657K

S62.657P

S62.657S

S62.660D

S62.660G

S62.660K

S62.660P

S62.660S

S62.661D

S62.661G

S62.661K

S62.661P

S62.661S

S62.662D

S62.662G

S62.662K

S62.662P

S62.662S

S62.663D

S62.663G

S62.663K

S62.663P

S62.663S

S62.664D

S62.664G

S62.664K

S62.664P

S62.664S

S62.665D

S62.665G

S62.665K

S62.665P

S62.665S

S62.666D

S62.666G

S62.666K

S62.666P

S62.666S

S62.667D

S62.667G

S62.667K

S62.667P

S62.667S

S63.101D

S63.101S

S63.102D

S63.102S

S63.104D

S63.104S

S63.105D

S63.105S

S63.111D

S63.111S

S63.112D

S63.112S

S63.114D

S63.114S

S63.115D

S63.115S

S63.121D

S63.121S

S63.122D

S63.122S

S63.124D

S63.124S

S63.125D

S63.125S

S63.200D

S63.200S

S63.201D

S63.201S

S63.202D

S63.202S

S63.203D

S63.203S

S63.204D

S63.204S

S63.205D

S63.205S

S63.206D

S63.206S

S63.207D

S63.207S

S63.210D

S63.210S

S63.211D

S63.211S

S63.212D

S63.212S

S63.213D

S63.213S

S63.214D

S63.214S

S63.215D

S63.215S

S63.216D

S63.216S

S63.217D

S63.217S

S63.220D

S63.220S

S63.221D

S63.221S

S63.222S

S63.223D

S63.223S

S63.224D

S63.224S

S63.225D

S63.225S

S63.226D

S63.226S

S63.227D

S63.227S

S63.230D

S63.230S

S63.231D

S63.231S

S63.232D

S63.232S

S63.233D

S63.233S

S63.234D

S63.234S

S63.235D

S63.235S

S63.236D

S63.236S

S63.237D

S63.237S

S63.240D

S63.240S

S63.241D

S63.241S

S63.242D

S63.242S

S63.243D

S63.243S

S63.244D

S63.244S

S63.245D

S63.245S

S63.246D

S63.246S

S63.247D

S63.247S

S63.250D

S63.250S

S63.251D

S63.251S

S63.252D

S63.252S

S63.253D

S63.253S

S63.254D

S63.254S

S63.255D

S63.255S

S63.256D

S63.256S

S63.257D

S63.257S

S63.260D

S63.260S

S63.261D

S63.261S

S63.262D

S63.262S

S63.263D

S63.263S

S63.264D

S63.264S

S63.265D

S63.265S

S63.266D

S63.266S

S63.267D

S63.267S

S63.270D

S63.270S

S63.271D

S63.271S

S63.272D

S63.272S

S63.273D

S63.273S

S63.274D

S63.274S

S63.275D

S63.275S

S63.276D

S63.276S

S63.277D

S63.277S

S63.280D

S63.280S

S63.281D

S63.281S

S63.282D

S63.282S

S63.283D

S63.283S

S63.284D

S63.284S

S63.285D

S63.285S

S63.286D

S63.286S

S63.287D

S63.287S

S63.290D

S63.290S

S63.291D

S63.291S

S63.292D

S63.292S

S63.293D

S63.293S

S63.294D

S63.294S

S63.295D

S63.295S

S63.296D

S63.296S

S63.297D

S63.297S

S63.400A

S63.400D

S63.400S

S63.401A

S63.401D

S63.401S

S63.402A

S63.402D

S63.402S

S63.403A

S63.403D

S63.403S

S63.404A

S63.404D

S63.404S

S63.405A

S63.405D

S63.405S

S63.406A

S63.406D

S63.406S

S63.407A

S63.407D

S63.407S

S63.410A

S63.410D

S63.410S

S63.411A

S63.411D

S63.411S

S63.412A

S63.412D

S63.412S

S63.413A

S63.413D

S63.413S

S63.414A

S63.414D

S63.414S

S63.415A

S63.415D

S63.415S

S63.416A

S63.416D

S63.416S

S63.417A

S63.417D

S63.417S

S63.420A

S63.420D

S63.420S

S63.421A

S63.421D

S63.421S

S63.422A

S63.422D

S63.422S

S63.423A

S63.423D

S63.423S

S63.424A

S63.424D

S63.424S

S63.425A

S63.425D

S63.425S

S63.426A

S63.426D

S63.426S

S63.427A

S63.427D

S63.427S

S63.430A

S63.430D

S63.430S

S63.431A

S63.431D

S63.431S

S63.432A

S63.432D

S63.432S

S63.433A

S63.433D

S63.433S

S63.434A

S63.434D

S63.434S

S63.435A

S63.435D

S63.435S

S63.436A

S63.436D

S63.436S

S63.437A

S63.437D

S63.437S

S63.490A

S63.490D

S63.490S

S63.491A

S63.491D

S63.491S

S63.492A

S63.492D

S63.492S

S63.493A

S63.493D

S63.493S

S63.494A

S63.494D

S63.494S

S63.495A

S63.495D

S63.495S

S63.496A

S63.496D

S63.496S

S63.497A

S63.497D

S63.497S

S63.601A

S63.601D

S63.601S

S63.602A

S63.602D

S63.602S

S63.610A

S63.610D

S63.610S

S63.611A

S63.611D

S63.611S

S63.612A

S63.612D

S63.612S

S63.613A

S63.613D

S63.613S

S63.614A

S63.614D

S63.614S

S63.615A

S63.615D

S63.615S

S63.616A

S63.616D

S63.616S

S63.617A

S63.617D

S63.617S

S63.621A

S63.621D

S63.621S

S63.622A

S63.622D

S63.622S

S63.630A

S63.630D

S63.630S

S63.631A

S63.631D

S63.631S

S63.632A

S63.632D

S63.632S

S63.633A

S63.633D

S63.633S

S63.634A

S63.634D

S63.634S

S63.635A

S63.635D

S63.635S

S63.636A

S63.636D

S63.636S

S63.637A

S63.637D

S63.637S

S63.641A

S63.641D

S63.641S

S63.642A

S63.642D

S63.642S

S63.650A

S63.650D

S63.650S

S63.651A

S63.651D

S63.651S

S63.652A

S63.652D

S63.652S

S63.653A

S63.653D

S63.653S

S63.654A

S63.654D

S63.654S

S63.655D

S63.655S

S63.656A

S63.656D

S63.656S

S63.657A

S63.657D

S63.657S

S63.681A

S63.681D

S63.681S

S63.682A

S63.682D

S63.682S

S63.690A

S63.690D

S63.690S

S63.691A

S63.691D

S63.691S

S63.692A

S63.692D

S63.692S

S63.693A

S63.693D

S63.693S

S63.694A

S63.694D

S63.694S

S63.695A

S63.695D

S63.695S

S63.696A

S63.696D

S63.696S

S63.697A

S63.697D

S63.697S

S69.81XD

S69.81XS

S69.82XD

S69.82XS

S69.91XD

S69.91XS

S69.92XD

S69.92XS

COVERED DIAGNOSIS CODES FOR PROCEDURE CODES E1810 AND E1812

M12.561

M12.562

M22.01

M22.02

M22.11

M22.12

M22.2X1

M22.2X2

M22.3X1

M22.3X2

M22.8X1

M22.8X2

M22.91

M22.92

M23.200

M23.201

M23.203

M23.204

M23.206

M23.207

M23.211

M23.212

M23.221

M23.222

M23.231

M23.232

M23.241

M23.242

M23.251

M23.252

M23.261

M23.262

M23.300

M23.301

M23.303

M23.304

M23.306

M23.307

M23.311

M23.312

M23.321

M23.322

M23.331

M23.332

M23.341

M23.342

M23.351

M23.352

M23.361

M23.362

M23.51

M23.52

M23.601

M23.602

M23.611

M23.612

M23.621

M23.622

M23.631

M23.632

M23.641

M23.642

M23.671

M23.672

M23.8X1

M23.8X2

M23.91

M23.92

M24.361

M24.362

M24.461

M24.462

S82.001D

S82.001E

S82.001F

S82.001G

S82.001H

S82.001J

S82.001K

S82.001M

S82.001N

S82.001P

S82.001Q

S82.001R

S82.002D

S82.002E

S82.002F

S82.002G

S82.002H

S82.002J

S82.002K

S82.002M

S82.002N

S82.002P

S82.002Q

S82.002R

S82.011D

S82.011E

S82.011F

S82.011G

S82.011H

S82.011J

S82.011K

S82.011M

S82.011N

S82.011P

S82.011Q

S82.011R

S82.012D

S82.012E

S82.012F

S82.012G

S82.012H

S82.012J

S82.012K

S82.012M

S82.012N

S82.012P

S82.012Q

S82.012R

S82.014D

S82.014E

S82.014F

S82.014G

S82.014H

S82.014J

S82.014K

S82.014M

S82.014N

S82.014P

S82.014Q

S82.014R

S82.015D

S82.015E

S82.015F

S82.015G

S82.015H

S82.015J

S82.015K

S82.015M

S82.015N

S82.015P

S82.015Q

S82.015R

S82.021D

S82.021E

S82.021F

S82.021G

S82.021H

S82.021J

S82.021K

S82.021M

S82.021N

S82.021P

S82.021Q

S82.021R

S82.022D

S82.022E

S82.022F

S82.022G

S82.022H

S82.022J

S82.022K

S82.022M

S82.022N

S82.022P

S82.022Q

S82.022R

S82.024D

S82.024E

S82.024F

S82.024G

S82.024H

S82.024J

S82.024K

S82.024M

S82.024N

S82.024P

S82.024Q

S82.024R

S82.025D

S82.025E

S82.025F

S82.025G

S82.025H

S82.025J

S82.025K

S82.025M

S82.025N

S82.025P

S82.025Q

S82.025R

S82.031D

S82.031E

S82.031F

S82.031G

S82.031H

S82.031J

S82.031K

S82.031M

S82.031N

S82.031P

S82.031Q

S82.031R

S82.032D

S82.032E

S82.032F

S82.032G

S82.032H

S82.032J

S82.032K

S82.032M

S82.032N

S82.032P

S82.032Q

S82.032R

S82.034D

S82.034E

S82.034F

S82.034G

S82.034H

S82.034J

S82.034K

S82.034M

S82.034N

S82.034P

S82.034Q

S82.034R

S82.035D

S82.035E

S82.035F

S82.035G

S82.035H

S82.035J

S82.035K

S82.035M

S82.035N

S82.035P

S82.035Q

S82.035R

S82.041E

S82.041F

S82.041G

S82.041H

S82.041J

S82.041K

S82.041M

S82.041N

S82.041P

S82.041Q

S82.041R

S82.042D

S82.042E

S82.042F

S82.042G

S82.042H

S82.042J

S82.042K

S82.042M

S82.042N

S82.042P

S82.042Q

S82.042R

S82.044D

S82.044E

S82.044F

S82.044G

S82.044H

S82.044J

S82.044K

S82.044M

S82.044N

S82.044P

S82.044Q

S82.044R

S82.045D

S82.045E

S82.045F

S82.045G

S82.045H

S82.045J

S82.045M

S82.045N

S82.045P

S82.045Q

S82.045R

S82.091D

S82.091E

S82.091F

S82.091G

S82.091H

S82.091J

S82.091M

S82.091N

S82.091P

S82.091Q

S82.091R

S82.092D

S82.092E

S82.092F

S82.092G

S82.092H

S82.092J

S82.092K

S82.092M

S82.092N

S82.092P

S82.092Q

S82.092R

S82.101A

S82.101B

S82.101C

S82.101D

S82.101E

S82.101F

S82.101G

S82.101H

S82.101J

S82.101K

S82.101M

S82.101N

S82.101P

S82.101Q

S82.101R

S82.102A

S82.102B

S82.102C

S82.102D

S82.102E

S82.102F

S82.102G

S82.102H

S82.102J

S82.102K

S82.102M

S82.102N

S82.102P

S82.102Q

S82.102R

S82.121A

S82.121B

S82.121C

S82.121D

S82.121E

S82.121F

S82.121G

S82.121H

S82.121J

S82.121K

S82.121M

S82.121N

S82.121P

S82.121Q

S82.121R

S82.122A

S82.122B

S82.122C

S82.122D

S82.122E

S82.122F

S82.122G

S82.122H

S82.122J

S82.122K

S82.122M

S82.122N

S82.122P

S82.122Q

S82.122R

S82.124A

S82.124B

S82.124C

S82.124D

S82.124E

S82.124F

S82.124G

S82.124H

S82.124J

S82.124K

S82.124M

S82.124N

S82.124P

S82.124Q

S82.124R

S82.125A

S82.125B

S82.125C

S82.125D

S82.125E

S82.125F

S82.125G

S82.125H

S82.125J

S82.125K

S82.125M

S82.125N

S82.125P

S82.125Q

S82.125R

S82.131A

S82.131B

S82.131C

S82.131D

S82.131E

S82.131F

S82.131G

S82.131H

S82.131J

S82.131K

S82.131M

S82.131N

S82.131P

S82.131Q

S82.131R

S82.132A

S82.132B

S82.132C

S82.132D

S82.132E

S82.132F

S82.132G

S82.132H

S82.132J

S82.132K

S82.132M

S82.132N

S82.132P

S82.132Q

S82.132R

S82.134A

S82.134B

S82.134C

S82.134D

S82.134E

S82.134F

S82.134G

S82.134H

S82.134J

S82.134K

S82.134M

S82.134N

S82.134P

S82.134Q

S82.134R

S82.135A

S82.135B

S82.135C

S82.135D

S82.135E

S82.135F

S82.135G

S82.135H

S82.135J

S82.135K

S82.135M

S82.135N

S82.135P

S82.135Q

S82.141A

S82.141B

S82.141C

S82.141D

S82.141E

S82.141F

S82.141G

S82.141H

S82.141J

S82.141K

S82.141M

S82.141N

S82.141P

S82.141Q

S82.141R

S82.142A

S82.142B

S82.142C

S82.142D

S82.142E

S82.142F

S82.142G

S82.142H

S82.142J

S82.142K

S82.142M

S82.142P

S82.142Q

S82.142R

S82.144A

S82.144B

S82.144C

S82.144D

S82.144E

S82.144F

S82.144G

S82.144H

S82.144J

S82.144K

S82.144M

S82.144N

S82.144P

S82.144Q

S82.144R

S82.145A

S82.145B

S82.145C

S82.145D

S82.145E

S82.145F

S82.145G

S82.145H

S82.145J

S82.145K

S82.145M

S82.145N

S82.145P

S82.145Q

S82.145R

S82.151A

S82.151B

S82.151C

S82.151D

S82.151E

S82.151F

S82.151G

S82.151H

S82.151J

S82.151K

S82.151M

S82.151N

S82.151P

S82.151Q

S82.151R

S82.152A

S82.152B

S82.152C

S82.152D

S82.152E

S82.152F

S82.152G

S82.152H

S82.152J

S82.152K

S82.152M

S82.152N

S82.152P

S82.152Q

S82.152R

S82.154A

S82.154B

S82.154C

S82.154D

S82.154E

S82.154F

S82.154G

S82.154H

S82.154J

S82.154K

S82.154M

S82.154N

S82.154P

S82.154Q

S82.154R

S82.155A

S82.155B

S82.155C

S82.155D

S82.155E

S82.155F

S82.155G

S82.155H

S82.155J

S82.155K

S82.155M

S82.155N

S82.155P

S82.155Q

S82.155R

S82.161A

S82.161D

S82.161G

S82.161K

S82.161P

S82.162A

S82.162D

S82.162G

S82.162K

S82.162P

S82.191A

S82.191B

S82.191C

S82.191D

S82.191E

S82.191F

S82.191G

S82.191H

S82.191J

S82.191K

S82.191M

S82.191N

S82.191P

S82.191Q

S82.191R

S82.192A

S82.192B

S82.192C

S82.192D

S82.192E

S82.192F

S82.192G

S82.192H

S82.192J

S82.192K

S82.192M

S82.192N

S82.192P

S82.192Q

S82.192R

S83.001S

S83.002S

S83.004S

S83.005S

S83.011D

S83.011S

S83.012D

S83.014S

S83.015D

S83.091D

S83.092D

S83.094D

S83.095S

S83.101S

S83.102S

S83.103S

S83.104S

S83.105S

S83.112S

S83.114D

S83.115D

S83.121D

S83.121S

S83.122S

S83.124D

S83.125S

S83.132D

S83.134D

S83.135D

S83.144D

S83.145D

S83.191S

S83.194D

S83.195D

S83.200D

S83.201S

S83.203S

S83.204D

S83.206S

S83.207D

S83.207S

S83.211D

S83.212S

S83.221D

S83.221S

S83.222D

S83.222S

S83.231D

S83.231S

S83.232D

S83.232S

S83.241D

S83.241S

S83.242D

S83.242S

S83.251D

S83.251S

S83.252D

S83.252S

S83.261D

S83.261S

S83.262D

S83.262S

S83.271D

S83.271S

S83.272D

S83.272S

S83.281D

S83.281S

S83.282D

S83.282S

S83.31XD

S83.31XS

S83.32XD

S83.32XS

S83.401A

S83.401D

S83.401S

S83.402A

S83.402D

S83.402S

S83.411A

S83.411D

S83.411S

S83.412A

S83.412D

S83.412S

S83.421A

S83.421D

S83.421S

S83.422A

S83.422D

S83.422S

S83.501A

S83.501D

S83.501S

S83.502A

S83.502D

S83.502S

S83.511A

S83.511D

S83.511S

S83.512A

S83.512D

S83.512S

S83.521A

S83.521D

S83.521S

S83.522A

S83.522D

S83.522S

S83.61XA

S83.61XD

S83.61XS

S83.62XA

S83.62XD

S83.62XS

S83.8X1A

S83.8X1D

S83.8X1S

S83.8X2A

S83.8X2D

S83.8X2S

S83.91XA

S83.91XD

S83.91XS

S83.92XA

S83.92XD

S83.92XS

COVERED DIAGNOSIS CODES FOR PROCEDURE CODE E1830

M20.11

M20.12

M20.21

M20.22

M20.31

M20.32

M20.41

M20.42

M20.5X1

M20.5X2

M20.61

M20.62

M24.477

M24.478

S92.401A

S92.401B

S92.401D

S92.401G

S92.401K

S92.402A

S92.402B

S92.402D

S92.402G

S92.402K

S92.402P

S92.404A

S92.404B

S92.404D

S92.404G

S92.404K

S92.404P

S92.405A

S92.405B

S92.405D

S92.405G

S92.405K

S92.405P

S92.411A

S92.411B

S92.411D

S92.411G

S92.411K

S92.411P

S92.412A

S92.412B

S92.412D

S92.412G

S92.412K

S92.412P

S92.414A

S92.414B

S92.414D

S92.414G

S92.414K

S92.414P

S92.415A

S92.415B

S92.415D

S92.415G

S92.415K

S92.415P

S92.421A

S92.421B

S92.421D

S92.421G

S92.421K

S92.421P

S92.422A

S92.422B

S92.422D

S92.422G

S92.422K

S92.422P

S92.424A

S92.424B

S92.424D

S92.424G

S92.424K

S92.424P

S92.425A

S92.425B

S92.425D

S92.425G

S92.425K

S92.425P

S92.491A

S92.491B

S92.491D

S92.491G

S92.491K

S92.491P

S92.492A

S92.492B

S92.492D

S92.492G

S92.492K

S92.492P

S92.501A

S92.501B

S92.501D

S92.501G

S92.501K

S92.501P

S92.502A

S92.502B

S92.502D

S92.502G

S92.502K

S92.502P

S92.504A

S92.504B

S92.504D

S92.504G

S92.504K

S92.504P

S92.504A

S92.511A

S92.511B

S92.511D

S92.511G

S92.511K

S92.511P

S92.512A

S92.512B

S92.512D

S92.512G

S92.512K

S92.512P

S92.514A

S92.514B

S92.514D

S92.514G

S92.514K

S92.514P

S92.515A

S92.515B

S92.515D

S92.515G

S92.515K

S92.515P

S92.521A

S92.521B

S92.521D

S92.521G

S92.521K

S92.521P

S92.522A

S92.522B

S92.522D

S92.522G

S92.522K

S92.522P

S92.524A

S92.524B

S92.524D

S92.524G

S92.524K

S92.524P

S92.525A

S92.525B

S92.525D

S92.525G

S92.525K

S92.525P

S92.531A

S92.531B

S92.531D

S92.531G

S92.531K

S92.531P

S92.532A

S92.532B

S92.532D

S92.532G

S92.532K

S92.532P

S92.534A

S92.534B

S92.534D

S92.534G

S92.534K

S92.534P

S92.535A

S92.535B

S92.535D

S92.535G

S92.535K

S92.535P

S92.591A

S92.591B

S92.591D

S92.591G

S92.591K

S92.591P

S92.592A

S92.592B

S92.592D

S92.592G

S92.592K

S92.592P

S92.911A

S92.911B

S92.911D

S92.911G

S92.911K

S92.911P

S92.912A

S92.912B

S92.912D

S92.912G

S92.912K

S92.912P

S93.101A

S93.101D

S93.101S

S93.102A

S93.102D

S93.102S

S93.104A

S93.104D

S93.104S

S93.105A

S93.105D

S93.105S

S93.111A

S93.111D

S93.111S

S93.112A

S93.112D

S93.112S

S93.114A

S93.114D

S93.114S

S93.115A

S93.115D

S93.115S

S93.121A

S93.121D

S93.121S

S93.122A

S93.122D

S93.122S

S93.124A

S93.124D

S93.124S

S93.125A

S93.125D

S93.125S

S93.131A

S93.131D

S93.131S

S93.132A

S93.132D

S93.132S

S93.134A

S93.134D

S93.134S

S93.135A

S93.135D

S93.135S

S93.141A

S93.141D

S93.141S

S93.142A

S93.142D

S93.142S

S93.144A

S93.144D

S93.144S

S93.145A

S93.145D

S93.145S

S93.501A

S93.501D

S93.501S

S93.502A

S93.502D

S93.502S

S93.504A

S93.504D

S93.504S

S93.505A

S93.505D

S93.505S

S93.511A

S93.511D

S93.511S

S93.512A

S93.512D

S93.512S

S93.514A

S93.514D

S93.514S

S93.515A

S93.515D

S93.515S

S93.521A

S93.521D

S93.521S

S93.522A

S93.522D

S93.522S

S93.524A

S93.524D

S93.524S

S93.525A

S93.525D

S93.525S

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 5-19-2020

Internal Medical Policy Committee 9-21-2020 Annual Review-No changes in criteria

Internal Medical Policy Committee 3-17-2021 Annual Review-No changes in criteria

Internal Medical Policy Committee 3-23-2022 Revision

Revised language; and
Updated Diagnosis Coding placing it within policy verses as an attachment

Internal Medical Policy Committee 3-23-2023 Annual Review - No changes in criteria

Internal Medical Policy Committee 5-14-2024 Annual Review - No changes in criteria

Added Policy Application

Internal Medical Policy Committee 9-17-2024 Revision - Effective November 04, 2024

Removed duplicate Diagnosis Codes; and
Updated language

Internal Medical Policy Committee 1-14-2025 Coding update - Effective January 01, 2025

Added Procedure Codes E1803; E1804; E1807; E1808; E1813; E1814; E1822; E1823; E1826; E1827; E1828; and E1829.

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