Policy source
The recorded policy does not contain a public text excerpt. Read the official source for details.
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.
Showing the first 1,000 of 1,639 codes. The source has the full list.
| Code | Code system | Status in this policy |
|---|---|---|
| 90702 | HCPCS | Covered |
| 90714 | HCPCS | Covered |
| J1670 | HCPCS | Covered |
| S00.01XA | ICD10CM | Covered |
| S00.02XA | ICD10CM | Covered |
| S00.04XA | ICD10CM | Covered |
| S00.05XA | ICD10CM | Covered |
| S00.06XA | ICD10CM | Covered |
| S00.07XA | ICD10CM | Covered |
| S00.31XA | ICD10CM | Covered |
| S00.32XA | ICD10CM | Covered |
| S00.34XA | ICD10CM | Covered |
| S00.35XA | ICD10CM | Covered |
| S00.36XA | ICD10CM | Covered |
| S00.37XA | ICD10CM | Covered |
| S00.411A | ICD10CM | Covered |
| S00.412A | ICD10CM | Covered |
| S00.421A | ICD10CM | Covered |
| S00.422A | ICD10CM | Covered |
| S00.441A | ICD10CM | Covered |
| S00.442A | ICD10CM | Covered |
| S00.451A | ICD10CM | Covered |
| S00.452A | ICD10CM | Covered |
| S00.461A | ICD10CM | Covered |
| S00.462A | ICD10CM | Covered |
| S00.471A | ICD10CM | Covered |
| S00.472A | ICD10CM | Covered |
| S00.511A | ICD10CM | Covered |
| S00.512A | ICD10CM | Covered |
| S00.521A | ICD10CM | Covered |
| S00.522A | ICD10CM | Covered |
| S00.541A | ICD10CM | Covered |
| S00.542A | ICD10CM | Covered |
| S00.551A | ICD10CM | Covered |
| S00.552A | ICD10CM | Covered |
| S00.561A | ICD10CM | Covered |
| S00.562A | ICD10CM | Covered |
| S00.571A | ICD10CM | Covered |
| S00.572A | ICD10CM | Covered |
| S00.81XA | ICD10CM | Covered |
| S00.82XA | ICD10CM | Covered |
| S00.84XA | ICD10CM | Covered |
| S00.85XA | ICD10CM | Covered |
| S00.86XA | ICD10CM | Covered |
| S00.87XA | ICD10CM | Covered |
| S00.94XA | ICD10CM | Covered |
| S00.97XA | ICD10CM | Covered |
| S01.01XA | ICD10CM | Covered |
| S01.02XA | ICD10CM | Covered |
| S01.03XA | ICD10CM | Covered |
| S01.04XA | ICD10CM | Covered |
| S01.05XA | ICD10CM | Covered |
| S01.101A | ICD10CM | Covered |
| S01.102A | ICD10CM | Covered |
| S01.111A | ICD10CM | Covered |
| S01.112A | ICD10CM | Covered |
| S01.119A | ICD10CM | Covered |
| S01.121A | ICD10CM | Covered |
| S01.122A | ICD10CM | Covered |
| S01.129A | ICD10CM | Covered |
| S01.131A | ICD10CM | Covered |
| S01.132A | ICD10CM | Covered |
| S01.139A | ICD10CM | Covered |
| S01.141A | ICD10CM | Covered |
| S01.142A | ICD10CM | Covered |
| S01.149A | ICD10CM | Covered |
| S01.151A | ICD10CM | Covered |
| S01.152A | ICD10CM | Covered |
| S01.159A | ICD10CM | Covered |
| S01.21XA | ICD10CM | Covered |
| S01.22XA | ICD10CM | Covered |
| S01.23XA | ICD10CM | Covered |
| S01.24XA | ICD10CM | Covered |
| S01.25XA | ICD10CM | Covered |
| S01.301A | ICD10CM | Covered |
| S01.302A | ICD10CM | Covered |
| S01.311A | ICD10CM | Covered |
| S01.312A | ICD10CM | Covered |
| S01.321A | ICD10CM | Covered |
| S01.322A | ICD10CM | Covered |
| S01.329A | ICD10CM | Covered |
| S01.331A | ICD10CM | Covered |
| S01.332A | ICD10CM | Covered |
| S01.341A | ICD10CM | Covered |
| S01.342A | ICD10CM | Covered |
| S01.351A | ICD10CM | Covered |
| S01.352A | ICD10CM | Covered |
| S01.401A | ICD10CM | Covered |
| S01.402A | ICD10CM | Covered |
| S01.411A | ICD10CM | Covered |
| S01.412A | ICD10CM | Covered |
| S01.421A | ICD10CM | Covered |
| S01.422A | ICD10CM | Covered |
| S01.431A | ICD10CM | Covered |
| S01.432A | ICD10CM | Covered |
| S01.441A | ICD10CM | Covered |
| S01.442A | ICD10CM | Covered |
| S01.451A | ICD10CM | Covered |
| S01.452A | ICD10CM | Covered |
| S01.511A | ICD10CM | Covered |
| S01.512A | ICD10CM | Covered |
| S01.521A | ICD10CM | Covered |
| S01.522A | ICD10CM | Covered |
| S01.531A | ICD10CM | Covered |
| S01.532A | ICD10CM | Covered |
| S01.541A | ICD10CM | Covered |
| S01.542A | ICD10CM | Covered |
| S01.551A | ICD10CM | Covered |
| S01.552A | ICD10CM | Covered |
| S01.81XA | ICD10CM | Covered |
| S01.82XA | ICD10CM | Covered |
| S01.83XA | ICD10CM | Covered |
| S01.84XA | ICD10CM | Covered |
| S01.85XA | ICD10CM | Covered |
| S01.91XA | ICD10CM | Covered |
| S01.92XA | ICD10CM | Covered |
| S01.93XA | ICD10CM | Covered |
| S01.94XA | ICD10CM | Covered |
| S01.95XA | ICD10CM | Covered |
| S02.5XXA | ICD10CM | Covered |
| S02.5XXB | ICD10CM | Covered |
| S03.2XXA | ICD10CM | Covered |
| S05.21XA | ICD10CM | Covered |
| S05.22XA | ICD10CM | Covered |
| S05.30XA | ICD10CM | Covered |
| S05.31XA | ICD10CM | Covered |
| S05.32XA | ICD10CM | Covered |
| S05.41XA | ICD10CM | Covered |
| S05.42XA | ICD10CM | Covered |
| S05.51XA | ICD10CM | Covered |
| S05.52XA | ICD10CM | Covered |
| S05.61XA | ICD10CM | Covered |
| S05.62XA | ICD10CM | Covered |
| S05.71XA | ICD10CM | Covered |
| S05.72XA | ICD10CM | Covered |
| S05.8X1A | ICD10CM | Covered |
| S05.8X2A | ICD10CM | Covered |
| S05.90XA | ICD10CM | Covered |
| S05.91XA | ICD10CM | Covered |
| S05.92XA | ICD10CM | Covered |
| S08.0XXA | ICD10CM | Covered |
| S08.111A | ICD10CM | Covered |
| S08.112A | ICD10CM | Covered |
| S08.121A | ICD10CM | Covered |
| S08.122A | ICD10CM | Covered |
| S08.811A | ICD10CM | Covered |
| S08.812A | ICD10CM | Covered |
| S08.89XA | ICD10CM | Covered |
| S09.12XA | ICD10CM | Covered |
| S09.21XA | ICD10CM | Covered |
| S09.22XA | ICD10CM | Covered |
| S09.301A | ICD10CM | Covered |
| S09.302A | ICD10CM | Covered |
| S09.311A | ICD10CM | Covered |
| S09.312A | ICD10CM | Covered |
| S09.313A | ICD10CM | Covered |
| S09.391A | ICD10CM | Covered |
| S09.392A | ICD10CM | Covered |
| S09.8XXA | ICD10CM | Covered |
| S09.91XA | ICD10CM | Covered |
| S09.93XA | ICD10CM | Covered |
| S10.11XA | ICD10CM | Covered |
| S10.12XA | ICD10CM | Covered |
| S10.14XA | ICD10CM | Covered |
| S10.15XA | ICD10CM | Covered |
| S10.16XA | ICD10CM | Covered |
| S10.17XA | ICD10CM | Covered |
| S10.81XA | ICD10CM | Covered |
| S10.82XA | ICD10CM | Covered |
| S10.84XA | ICD10CM | Covered |
| S10.85XA | ICD10CM | Covered |
| S10.86XA | ICD10CM | Covered |
| S10.87XA | ICD10CM | Covered |
| S10.94XA | ICD10CM | Covered |
| S10.97XA | ICD10CM | Covered |
| S11.011A | ICD10CM | Covered |
| S11.012A | ICD10CM | Covered |
| S11.013A | ICD10CM | Covered |
| S11.014A | ICD10CM | Covered |
| S11.015A | ICD10CM | Covered |
| S11.021A | ICD10CM | Covered |
| S11.022A | ICD10CM | Covered |
| S11.023A | ICD10CM | Covered |
| S11.024A | ICD10CM | Covered |
| S11.025A | ICD10CM | Covered |
| S11.031A | ICD10CM | Covered |
| S11.032A | ICD10CM | Covered |
| S11.033A | ICD10CM | Covered |
| S11.034A | ICD10CM | Covered |
| S11.035A | ICD10CM | Covered |
| S11.11XA | ICD10CM | Covered |
| S11.12XA | ICD10CM | Covered |
| S11.13XA | ICD10CM | Covered |
| S11.14XA | ICD10CM | Covered |
| S11.15XA | ICD10CM | Covered |
| S11.21XA | ICD10CM | Covered |
| S11.22XA | ICD10CM | Covered |
| S11.23XA | ICD10CM | Covered |
| S11.24XA | ICD10CM | Covered |
| S11.25XA | ICD10CM | Covered |
| S11.81XA | ICD10CM | Covered |
| S11.82XA | ICD10CM | Covered |
| S11.83XA | ICD10CM | Covered |
| S11.84XA | ICD10CM | Covered |
| S11.85XA | ICD10CM | Covered |
| S11.89XA | ICD10CM | Covered |
| S11.91XA | ICD10CM | Covered |
| S11.92XA | ICD10CM | Covered |
| S11.93XA | ICD10CM | Covered |
| S11.94XA | ICD10CM | Covered |
| S11.95XA | ICD10CM | Covered |
| S16.2XXA | ICD10CM | Covered |
| S20.111A | ICD10CM | Covered |
| S20.112A | ICD10CM | Covered |
| S20.121A | ICD10CM | Covered |
| S20.122A | ICD10CM | Covered |
| S20.141A | ICD10CM | Covered |
| S20.142A | ICD10CM | Covered |
| S20.151A | ICD10CM | Covered |
| S20.152A | ICD10CM | Covered |
| S20.161A | ICD10CM | Covered |
| S20.162A | ICD10CM | Covered |
| S20.171A | ICD10CM | Covered |
| S20.172A | ICD10CM | Covered |
| S20.303A | ICD10CM | Covered |
| S20.303D | ICD10CM | Covered |
| S20.303S | ICD10CM | Covered |
| S20.304A | ICD10CM | Covered |
| S20.304D | ICD10CM | Covered |
| S20.304S | ICD10CM | Covered |
| S20.311A | ICD10CM | Covered |
| S20.312A | ICD10CM | Covered |
| S20.313A | ICD10CM | Covered |
| S20.313D | ICD10CM | Covered |
| S20.313S | ICD10CM | Covered |
| S20.314A | ICD10CM | Covered |
| S20.314D | ICD10CM | Covered |
| S20.314S | ICD10CM | Covered |
| S20.321A | ICD10CM | Covered |
| S20.322A | ICD10CM | Covered |
| S20.323A | ICD10CM | Covered |
| S20.323D | ICD10CM | Covered |
| S20.323S | ICD10CM | Covered |
| S20.324A | ICD10CM | Covered |
| S20.324D | ICD10CM | Covered |
| S20.324S | ICD10CM | Covered |
| S20.341A | ICD10CM | Covered |
| S20.342A | ICD10CM | Covered |
| S20.343A | ICD10CM | Covered |
| S20.343D | ICD10CM | Covered |
| S20.343S | ICD10CM | Covered |
| S20.344A | ICD10CM | Covered |
| S20.344D | ICD10CM | Covered |
| S20.344S | ICD10CM | Covered |
| S20.351A | ICD10CM | Covered |
| S20.352A | ICD10CM | Covered |
| S20.353A | ICD10CM | Covered |
| S20.353D | ICD10CM | Covered |
| S20.353S | ICD10CM | Covered |
| S20.354A | ICD10CM | Covered |
| S20.354D | ICD10CM | Covered |
| S20.354S | ICD10CM | Covered |
| S20.361A | ICD10CM | Covered |
| S20.362A | ICD10CM | Covered |
| S20.363A | ICD10CM | Covered |
| S20.363D | ICD10CM | Covered |
| S20.363S | ICD10CM | Covered |
| S20.364A | ICD10CM | Covered |
| S20.364D | ICD10CM | Covered |
| S20.364S | ICD10CM | Covered |
| S20.371A | ICD10CM | Covered |
| S20.372A | ICD10CM | Covered |
| S20.373A | ICD10CM | Covered |
| S20.373D | ICD10CM | Covered |
| S20.373S | ICD10CM | Covered |
| S20.374A | ICD10CM | Covered |
| S20.374D | ICD10CM | Covered |
| S20.374S | ICD10CM | Covered |
| S20.411A | ICD10CM | Covered |
| S20.412A | ICD10CM | Covered |
| S20.421A | ICD10CM | Covered |
| S20.422A | ICD10CM | Covered |
| S20.441A | ICD10CM | Covered |
| S20.442A | ICD10CM | Covered |
| S20.451A | ICD10CM | Covered |
| S20.452A | ICD10CM | Covered |
| S20.461A | ICD10CM | Covered |
| S20.462A | ICD10CM | Covered |
| S20.471A | ICD10CM | Covered |
| S20.472A | ICD10CM | Covered |
| S21.011A | ICD10CM | Covered |
| S21.012A | ICD10CM | Covered |
| S21.021A | ICD10CM | Covered |
| S21.022A | ICD10CM | Covered |
| S21.031A | ICD10CM | Covered |
| S21.032A | ICD10CM | Covered |
| S21.041A | ICD10CM | Covered |
| S21.042A | ICD10CM | Covered |
| S21.051A | ICD10CM | Covered |
| S21.052A | ICD10CM | Covered |
| S21.101A | ICD10CM | Covered |
| S21.102A | ICD10CM | Covered |
| S21.111A | ICD10CM | Covered |
| S21.112A | ICD10CM | Covered |
| S21.121A | ICD10CM | Covered |
| S21.122A | ICD10CM | Covered |
| S21.131A | ICD10CM | Covered |
| S21.132A | ICD10CM | Covered |
| S21.141A | ICD10CM | Covered |
| S21.142A | ICD10CM | Covered |
| S21.151A | ICD10CM | Covered |
| S21.152A | ICD10CM | Covered |
| S21.201A | ICD10CM | Covered |
| S21.202A | ICD10CM | Covered |
| S21.211A | ICD10CM | Covered |
| S21.212A | ICD10CM | Covered |
| S21.221A | ICD10CM | Covered |
| S21.222A | ICD10CM | Covered |
| S21.231A | ICD10CM | Covered |
| S21.232A | ICD10CM | Covered |
| S21.241A | ICD10CM | Covered |
| S21.242A | ICD10CM | Covered |
| S21.251A | ICD10CM | Covered |
| S21.252A | ICD10CM | Covered |
| S21.91XA | ICD10CM | Covered |
| S21.93XA | ICD10CM | Covered |
| S21.95XA | ICD10CM | Covered |
| S28.1XXA | ICD10CM | Covered |
| S28.211A | ICD10CM | Covered |
| S28.212A | ICD10CM | Covered |
| S28.221A | ICD10CM | Covered |
| S28.222A | ICD10CM | Covered |
| S29.021A | ICD10CM | Covered |
| S29.022A | ICD10CM | Covered |
| S30.810A | ICD10CM | Covered |
| S30.811A | ICD10CM | Covered |
| S30.812A | ICD10CM | Covered |
| S30.813A | ICD10CM | Covered |
| S30.814A | ICD10CM | Covered |
| S30.817A | ICD10CM | Covered |
| S30.81AA | ICD10CM | Covered |
| S30.81AD | ICD10CM | Covered |
| S30.81AS | ICD10CM | Covered |
| S30.820A | ICD10CM | Covered |
| S30.821A | ICD10CM | Covered |
| S30.822A | ICD10CM | Covered |
| S30.823A | ICD10CM | Covered |
| S30.824A | ICD10CM | Covered |
| S30.827A | ICD10CM | Covered |
| S30.82AA | ICD10CM | Covered |
| S30.82AD | ICD10CM | Covered |
| S30.82AS | ICD10CM | Covered |
| S30.840A | ICD10CM | Covered |
| S30.841A | ICD10CM | Covered |
| S30.842A | ICD10CM | Covered |
| S30.843A | ICD10CM | Covered |
| S30.844A | ICD10CM | Covered |
| S30.84AA | ICD10CM | Covered |
| S30.84AD | ICD10CM | Covered |
| S30.84AS | ICD10CM | Covered |
| S30.850A | ICD10CM | Covered |
| S30.851A | ICD10CM | Covered |
| S30.852A | ICD10CM | Covered |
| S30.853A | ICD10CM | Covered |
| S30.854A | ICD10CM | Covered |
| S30.857A | ICD10CM | Covered |
| S30.85AA | ICD10CM | Covered |
| S30.85AD | ICD10CM | Covered |
| S30.85AS | ICD10CM | Covered |
| S30.860A | ICD10CM | Covered |
| S30.861A | ICD10CM | Covered |
| S30.862A | ICD10CM | Covered |
| S30.863A | ICD10CM | Covered |
| S30.864A | ICD10CM | Covered |
| S30.867A | ICD10CM | Covered |
| S30.86AA | ICD10CM | Covered |
| S30.86AD | ICD10CM | Covered |
| S30.86AS | ICD10CM | Covered |
| S30.870A | ICD10CM | Covered |
| S30.871A | ICD10CM | Covered |
| S30.872A | ICD10CM | Covered |
| S30.873A | ICD10CM | Covered |
| S30.874A | ICD10CM | Covered |
| S30.875A | ICD10CM | Covered |
| S30.876A | ICD10CM | Covered |
| S30.877A | ICD10CM | Covered |
| S30.87AA | ICD10CM | Covered |
| S30.87AD | ICD10CM | Covered |
| S31.010A | ICD10CM | Covered |
| S31.020A | ICD10CM | Covered |
| S31.030A | ICD10CM | Covered |
| S31.040A | ICD10CM | Covered |
| S31.050A | ICD10CM | Covered |
| S31.106A | ICD10CM | Covered |
| S31.106D | ICD10CM | Covered |
| S31.106S | ICD10CM | Covered |
| S31.107A | ICD10CM | Covered |
| S31.107D | ICD10CM | Covered |
| S31.107S | ICD10CM | Covered |
| S31.10AA | ICD10CM | Covered |
| S31.10AD | ICD10CM | Covered |
| S31.10AS | ICD10CM | Covered |
| S31.110A | ICD10CM | Covered |
| S31.111A | ICD10CM | Covered |
| S31.112A | ICD10CM | Covered |
| S31.113A | ICD10CM | Covered |
| S31.114A | ICD10CM | Covered |
| S31.115A | ICD10CM | Covered |
| S31.116A | ICD10CM | Covered |
| S31.116D | ICD10CM | Covered |
| S31.116S | ICD10CM | Covered |
| S31.117A | ICD10CM | Covered |
| S31.117D | ICD10CM | Covered |
| S31.117S | ICD10CM | Covered |
| S31.120A | ICD10CM | Covered |
| S31.121A | ICD10CM | Covered |
| S31.122A | ICD10CM | Covered |
| S31.123A | ICD10CM | Covered |
| S31.124A | ICD10CM | Covered |
| S31.125A | ICD10CM | Covered |
| S31.126A | ICD10CM | Covered |
| S31.126D | ICD10CM | Covered |
| S31.126S | ICD10CM | Covered |
| S31.127A | ICD10CM | Covered |
| S31.127D | ICD10CM | Covered |
| S31.127S | ICD10CM | Covered |
| S31.130A | ICD10CM | Covered |
| S31.131A | ICD10CM | Covered |
| S31.132A | ICD10CM | Covered |
| S31.133A | ICD10CM | Covered |
| S31.134A | ICD10CM | Covered |
| S31.135A | ICD10CM | Covered |
| S31.136A | ICD10CM | Covered |
| S31.136D | ICD10CM | Covered |
| S31.136S | ICD10CM | Covered |
| S31.137A | ICD10CM | Covered |
| S31.137D | ICD10CM | Covered |
| S31.137S | ICD10CM | Covered |
| S31.13AA | ICD10CM | Covered |
| S31.140A | ICD10CM | Covered |
| S31.141A | ICD10CM | Covered |
| S31.142A | ICD10CM | Covered |
| S31.143A | ICD10CM | Covered |
| S31.144A | ICD10CM | Covered |
| S31.145A | ICD10CM | Covered |
| S31.146D | ICD10CM | Covered |
| S31.146S | ICD10CM | Covered |
| S31.147A | ICD10CM | Covered |
| S31.147D | ICD10CM | Covered |
| S31.147S | ICD10CM | Covered |
| S31.150A | ICD10CM | Covered |
| S31.151A | ICD10CM | Covered |
| S31.152A | ICD10CM | Covered |
| S31.153A | ICD10CM | Covered |
| S31.154A | ICD10CM | Covered |
| S31.155A | ICD10CM | Covered |
| S31.156A | ICD10CM | Covered |
| S31.156D | ICD10CM | Covered |
| S31.156S | ICD10CM | Covered |
| S31.157A | ICD10CM | Covered |
| S31.157D | ICD10CM | Covered |
| S31.157S | ICD10CM | Covered |
| S31.15AA | ICD10CM | Covered |
| S31.15AD | ICD10CM | Covered |
| S31.15AS | ICD10CM | Covered |
| S31.21XA | ICD10CM | Covered |
| S31.22XA | ICD10CM | Covered |
| S31.23XA | ICD10CM | Covered |
| S31.24XA | ICD10CM | Covered |
| S31.25XA | ICD10CM | Covered |
| S31.31XA | ICD10CM | Covered |
| S31.32XA | ICD10CM | Covered |
| S31.33XA | ICD10CM | Covered |
| S31.34XA | ICD10CM | Covered |
| S31.35XA | ICD10CM | Covered |
| S31.41XA | ICD10CM | Covered |
| S31.42XA | ICD10CM | Covered |
| S31.43XA | ICD10CM | Covered |
| S31.44XA | ICD10CM | Covered |
| S31.45XA | ICD10CM | Covered |
| S31.511A | ICD10CM | Covered |
| S31.512A | ICD10CM | Covered |
| S31.521A | ICD10CM | Covered |
| S31.522A | ICD10CM | Covered |
| S31.531A | ICD10CM | Covered |
| S31.532A | ICD10CM | Covered |
| S31.541A | ICD10CM | Covered |
| S31.542A | ICD10CM | Covered |
| S31.551A | ICD10CM | Covered |
| S31.552A | ICD10CM | Covered |
| S31.811A | ICD10CM | Covered |
| S31.812A | ICD10CM | Covered |
| S31.813A | ICD10CM | Covered |
| S31.814A | ICD10CM | Covered |
| S31.815A | ICD10CM | Covered |
| S31.821A | ICD10CM | Covered |
| S31.822A | ICD10CM | Covered |
| S31.823A | ICD10CM | Covered |
| S31.824A | ICD10CM | Covered |
| S31.825A | ICD10CM | Covered |
| S31.831A | ICD10CM | Covered |
| S31.832A | ICD10CM | Covered |
| S31.833A | ICD10CM | Covered |
| S31.834A | ICD10CM | Covered |
| S31.835A | ICD10CM | Covered |
| S38.211A | ICD10CM | Covered |
| S38.212A | ICD10CM | Covered |
| S38.221A | ICD10CM | Covered |
| S38.222A | ICD10CM | Covered |
| S38.231A | ICD10CM | Covered |
| S38.232A | ICD10CM | Covered |
| S38.3XXA | ICD10CM | Covered |
| S39.021A | ICD10CM | Covered |
| S39.022A | ICD10CM | Covered |
| S39.023A | ICD10CM | Covered |
| S40.211A | ICD10CM | Covered |
| S40.212A | ICD10CM | Covered |
| S40.221A | ICD10CM | Covered |
| S40.222A | ICD10CM | Covered |
| S40.241A | ICD10CM | Covered |
| S40.242A | ICD10CM | Covered |
| S40.251A | ICD10CM | Covered |
| S40.252A | ICD10CM | Covered |
| S40.261A | ICD10CM | Covered |
| S40.262A | ICD10CM | Covered |
| S40.271A | ICD10CM | Covered |
| S40.272A | ICD10CM | Covered |
| S40.811A | ICD10CM | Covered |
| S40.812A | ICD10CM | Covered |
| S40.821A | ICD10CM | Covered |
| S40.822A | ICD10CM | Covered |
| S40.841A | ICD10CM | Covered |
| S40.842A | ICD10CM | Covered |
| S40.851A | ICD10CM | Covered |
| S40.852A | ICD10CM | Covered |
| S40.861A | ICD10CM | Covered |
| S40.862A | ICD10CM | Covered |
| S40.871A | ICD10CM | Covered |
| S40.872A | ICD10CM | Covered |
| S41.009A | ICD10CM | Covered |
| S41.011A | ICD10CM | Covered |
| S41.012A | ICD10CM | Covered |
| S41.021A | ICD10CM | Covered |
| S41.022A | ICD10CM | Covered |
| S41.029A | ICD10CM | Covered |
| S41.031A | ICD10CM | Covered |
| S41.032A | ICD10CM | Covered |
| S41.041A | ICD10CM | Covered |
| S41.042A | ICD10CM | Covered |
| S41.051A | ICD10CM | Covered |
| S41.052A | ICD10CM | Covered |
| S41.111A | ICD10CM | Covered |
| S41.112A | ICD10CM | Covered |
| S41.121A | ICD10CM | Covered |
| S41.122A | ICD10CM | Covered |
| S41.131A | ICD10CM | Covered |
| S41.132A | ICD10CM | Covered |
| S41.141A | ICD10CM | Covered |
| S41.142A | ICD10CM | Covered |
| S41.151A | ICD10CM | Covered |
| S41.152A | ICD10CM | Covered |
| S46.021A | ICD10CM | Covered |
| S46.022A | ICD10CM | Covered |
| S46.121A | ICD10CM | Covered |
| S46.122A | ICD10CM | Covered |
| S46.221A | ICD10CM | Covered |
| S46.222A | ICD10CM | Covered |
| S46.321A | ICD10CM | Covered |
| S46.322A | ICD10CM | Covered |
| S46.821A | ICD10CM | Covered |
| S46.822A | ICD10CM | Covered |
| S46.921A | ICD10CM | Covered |
| S46.922A | ICD10CM | Covered |
| S48.011A | ICD10CM | Covered |
| S48.012A | ICD10CM | Covered |
| S48.021A | ICD10CM | Covered |
| S48.022A | ICD10CM | Covered |
| S48.111A | ICD10CM | Covered |
| S48.112A | ICD10CM | Covered |
| S48.121A | ICD10CM | Covered |
| S48.122A | ICD10CM | Covered |
| S48.911A | ICD10CM | Covered |
| S48.912A | ICD10CM | Covered |
| S48.919A | ICD10CM | Covered |
| S48.921A | ICD10CM | Covered |
| S48.922A | ICD10CM | Covered |
| S48.929A | ICD10CM | Covered |
| S50.311A | ICD10CM | Covered |
| S50.312A | ICD10CM | Covered |
| S50.321A | ICD10CM | Covered |
| S50.322A | ICD10CM | Covered |
| S50.341A | ICD10CM | Covered |
| S50.342A | ICD10CM | Covered |
| S50.351A | ICD10CM | Covered |
| S50.352A | ICD10CM | Covered |
| S50.361A | ICD10CM | Covered |
| S50.362A | ICD10CM | Covered |
| S50.371A | ICD10CM | Covered |
| S50.372A | ICD10CM | Covered |
| S50.811A | ICD10CM | Covered |
| S50.812A | ICD10CM | Covered |
| S50.821A | ICD10CM | Covered |
| S50.822A | ICD10CM | Covered |
| S50.841A | ICD10CM | Covered |
| S50.842A | ICD10CM | Covered |
| S50.851A | ICD10CM | Covered |
| S50.852A | ICD10CM | Covered |
| S50.861A | ICD10CM | Covered |
| S50.862A | ICD10CM | Covered |
| S50.871A | ICD10CM | Covered |
| S50.872A | ICD10CM | Covered |
| S51.011A | ICD10CM | Covered |
| S51.012A | ICD10CM | Covered |
| S51.021A | ICD10CM | Covered |
| S51.022A | ICD10CM | Covered |
| S51.031A | ICD10CM | Covered |
| S51.032A | ICD10CM | Covered |
| S51.041A | ICD10CM | Covered |
| S51.042A | ICD10CM | Covered |
| S51.051A | ICD10CM | Covered |
| S51.052A | ICD10CM | Covered |
| S51.811A | ICD10CM | Covered |
| S51.812A | ICD10CM | Covered |
| S51.821A | ICD10CM | Covered |
| S51.822A | ICD10CM | Covered |
| S51.831A | ICD10CM | Covered |
| S51.832A | ICD10CM | Covered |
| S51.841A | ICD10CM | Covered |
| S51.842A | ICD10CM | Covered |
| S51.851A | ICD10CM | Covered |
| S51.852A | ICD10CM | Covered |
| S56.021A | ICD10CM | Covered |
| S56.022A | ICD10CM | Covered |
| S56.121A | ICD10CM | Covered |
| S56.122A | ICD10CM | Covered |
| S56.123A | ICD10CM | Covered |
| S56.124A | ICD10CM | Covered |
| S56.125A | ICD10CM | Covered |
| S56.126A | ICD10CM | Covered |
| S56.127A | ICD10CM | Covered |
| S56.128A | ICD10CM | Covered |
| S56.221A | ICD10CM | Covered |
| S56.222A | ICD10CM | Covered |
| S56.321A | ICD10CM | Covered |
| S56.322A | ICD10CM | Covered |
| S56.421A | ICD10CM | Covered |
| S56.422A | ICD10CM | Covered |
| S56.423A | ICD10CM | Covered |
| S56.424A | ICD10CM | Covered |
| S56.425A | ICD10CM | Covered |
| S56.426A | ICD10CM | Covered |
| S56.427A | ICD10CM | Covered |
| S56.428A | ICD10CM | Covered |
| S56.521A | ICD10CM | Covered |
| S56.522A | ICD10CM | Covered |
| S56.821A | ICD10CM | Covered |
| S56.822A | ICD10CM | Covered |
| S56.921A | ICD10CM | Covered |
| S56.922A | ICD10CM | Covered |
| S58.011A | ICD10CM | Covered |
| S58.012A | ICD10CM | Covered |
| S58.021A | ICD10CM | Covered |
| S58.022A | ICD10CM | Covered |
| S58.111A | ICD10CM | Covered |
| S58.112A | ICD10CM | Covered |
| S58.121A | ICD10CM | Covered |
| S58.122A | ICD10CM | Covered |
| S58.911A | ICD10CM | Covered |
| S58.912A | ICD10CM | Covered |
| S58.921A | ICD10CM | Covered |
| S58.922A | ICD10CM | Covered |
| S60.311A | ICD10CM | Covered |
| S60.312A | ICD10CM | Covered |
| S60.321A | ICD10CM | Covered |
| S60.322A | ICD10CM | Covered |
| S60.341A | ICD10CM | Covered |
| S60.342A | ICD10CM | Covered |
| S60.351A | ICD10CM | Covered |
| S60.352A | ICD10CM | Covered |
| S60.361A | ICD10CM | Covered |
| S60.362A | ICD10CM | Covered |
| S60.371A | ICD10CM | Covered |
| S60.372A | ICD10CM | Covered |
| S60.391A | ICD10CM | Covered |
| S60.392A | ICD10CM | Covered |
| S60.410A | ICD10CM | Covered |
| S60.411A | ICD10CM | Covered |
| S60.412A | ICD10CM | Covered |
| S60.413A | ICD10CM | Covered |
| S60.414A | ICD10CM | Covered |
| S60.415A | ICD10CM | Covered |
| S60.416A | ICD10CM | Covered |
| S60.417A | ICD10CM | Covered |
| S60.420A | ICD10CM | Covered |
| S60.421A | ICD10CM | Covered |
| S60.422A | ICD10CM | Covered |
| S60.423A | ICD10CM | Covered |
| S60.424A | ICD10CM | Covered |
| S60.425A | ICD10CM | Covered |
| S60.426A | ICD10CM | Covered |
| S60.427A | ICD10CM | Covered |
| S60.440A | ICD10CM | Covered |
| S60.441A | ICD10CM | Covered |
| S60.442A | ICD10CM | Covered |
| S60.443A | ICD10CM | Covered |
| S60.444A | ICD10CM | Covered |
| S60.445A | ICD10CM | Covered |
| S60.446A | ICD10CM | Covered |
| S60.447A | ICD10CM | Covered |
| S60.450A | ICD10CM | Covered |
| S60.451A | ICD10CM | Covered |
| S60.452A | ICD10CM | Covered |
| S60.453A | ICD10CM | Covered |
| S60.454A | ICD10CM | Covered |
| S60.455A | ICD10CM | Covered |
| S60.456A | ICD10CM | Covered |
| S60.457A | ICD10CM | Covered |
| S60.460A | ICD10CM | Covered |
| S60.461A | ICD10CM | Covered |
| S60.462A | ICD10CM | Covered |
| S60.463A | ICD10CM | Covered |
| S60.464A | ICD10CM | Covered |
| S60.465A | ICD10CM | Covered |
| S60.466A | ICD10CM | Covered |
| S60.467A | ICD10CM | Covered |
| S60.470A | ICD10CM | Covered |
| S60.471A | ICD10CM | Covered |
| S60.472A | ICD10CM | Covered |
| S60.473A | ICD10CM | Covered |
| S60.474A | ICD10CM | Covered |
| S60.475A | ICD10CM | Covered |
| S60.476A | ICD10CM | Covered |
| S60.477A | ICD10CM | Covered |
| S60.511A | ICD10CM | Covered |
| S60.512A | ICD10CM | Covered |
| S60.521A | ICD10CM | Covered |
| S60.522A | ICD10CM | Covered |
| S60.541A | ICD10CM | Covered |
| S60.542A | ICD10CM | Covered |
| S60.551A | ICD10CM | Covered |
| S60.552A | ICD10CM | Covered |
| S60.561A | ICD10CM | Covered |
| S60.562A | ICD10CM | Covered |
| S60.571A | ICD10CM | Covered |
| S60.572A | ICD10CM | Covered |
| S60.811A | ICD10CM | Covered |
| S60.812A | ICD10CM | Covered |
| S60.821A | ICD10CM | Covered |
| S60.822A | ICD10CM | Covered |
| S60.841A | ICD10CM | Covered |
| S60.842A | ICD10CM | Covered |
| S60.851A | ICD10CM | Covered |
| S60.852A | ICD10CM | Covered |
| S60.861A | ICD10CM | Covered |
| S60.862A | ICD10CM | Covered |
| S60.871A | ICD10CM | Covered |
| S60.872A | ICD10CM | Covered |
| S61.011A | ICD10CM | Covered |
| S61.012A | ICD10CM | Covered |
| S61.021A | ICD10CM | Covered |
| S61.022A | ICD10CM | Covered |
| S61.031A | ICD10CM | Covered |
| S61.032A | ICD10CM | Covered |
| S61.041A | ICD10CM | Covered |
| S61.042A | ICD10CM | Covered |
| S61.051A | ICD10CM | Covered |
| S61.052A | ICD10CM | Covered |
| S61.111A | ICD10CM | Covered |
| S61.112A | ICD10CM | Covered |
| S61.121A | ICD10CM | Covered |
| S61.122A | ICD10CM | Covered |
| S61.131A | ICD10CM | Covered |
| S61.132A | ICD10CM | Covered |
| S61.141A | ICD10CM | Covered |
| S61.142A | ICD10CM | Covered |
| S61.151A | ICD10CM | Covered |
| S61.152A | ICD10CM | Covered |
| S61.210A | ICD10CM | Covered |
| S61.211A | ICD10CM | Covered |
| S61.212A | ICD10CM | Covered |
| S61.213A | ICD10CM | Covered |
| S61.214A | ICD10CM | Covered |
| S61.215A | ICD10CM | Covered |
| S61.216A | ICD10CM | Covered |
| S61.217A | ICD10CM | Covered |
| S61.220A | ICD10CM | Covered |
| S61.221A | ICD10CM | Covered |
| S61.222A | ICD10CM | Covered |
| S61.223A | ICD10CM | Covered |
| S61.224A | ICD10CM | Covered |
| S61.225A | ICD10CM | Covered |
| S61.226A | ICD10CM | Covered |
| S61.227A | ICD10CM | Covered |
| S61.230A | ICD10CM | Covered |
| S61.231A | ICD10CM | Covered |
| S61.232A | ICD10CM | Covered |
| S61.233A | ICD10CM | Covered |
| S61.234A | ICD10CM | Covered |
| S61.235A | ICD10CM | Covered |
| S61.236A | ICD10CM | Covered |
| S61.237A | ICD10CM | Covered |
| S61.240A | ICD10CM | Covered |
| S61.241A | ICD10CM | Covered |
| S61.242A | ICD10CM | Covered |
| S61.243A | ICD10CM | Covered |
| S61.244A | ICD10CM | Covered |
| S61.245A | ICD10CM | Covered |
| S61.246A | ICD10CM | Covered |
| S61.247A | ICD10CM | Covered |
| S61.250A | ICD10CM | Covered |
| S61.251A | ICD10CM | Covered |
| S61.252A | ICD10CM | Covered |
| S61.253A | ICD10CM | Covered |
| S61.254A | ICD10CM | Covered |
| S61.255A | ICD10CM | Covered |
| S61.256A | ICD10CM | Covered |
| S61.257A | ICD10CM | Covered |
| S61.310A | ICD10CM | Covered |
| S61.311A | ICD10CM | Covered |
| S61.312A | ICD10CM | Covered |
| S61.313A | ICD10CM | Covered |
| S61.314A | ICD10CM | Covered |
| S61.315A | ICD10CM | Covered |
| S61.316A | ICD10CM | Covered |
| S61.317A | ICD10CM | Covered |
| S61.320A | ICD10CM | Covered |
| S61.321A | ICD10CM | Covered |
| S61.322A | ICD10CM | Covered |
| S61.323A | ICD10CM | Covered |
| S61.324A | ICD10CM | Covered |
| S61.325A | ICD10CM | Covered |
| S61.326A | ICD10CM | Covered |
| S61.327A | ICD10CM | Covered |
| S61.330A | ICD10CM | Covered |
| S61.331A | ICD10CM | Covered |
| S61.332A | ICD10CM | Covered |
| S61.333A | ICD10CM | Covered |
| S61.334A | ICD10CM | Covered |
| S61.335A | ICD10CM | Covered |
| S61.336A | ICD10CM | Covered |
| S61.337A | ICD10CM | Covered |
| S61.340A | ICD10CM | Covered |
| S61.341A | ICD10CM | Covered |
| S61.342A | ICD10CM | Covered |
| S61.343A | ICD10CM | Covered |
| S61.344A | ICD10CM | Covered |
| S61.345A | ICD10CM | Covered |
| S61.346A | ICD10CM | Covered |
| S61.347A | ICD10CM | Covered |
| S61.350A | ICD10CM | Covered |
| S61.351A | ICD10CM | Covered |
| S61.352A | ICD10CM | Covered |
| S61.353A | ICD10CM | Covered |
| S61.354A | ICD10CM | Covered |
| S61.355A | ICD10CM | Covered |
| S61.356A | ICD10CM | Covered |
| S61.357A | ICD10CM | Covered |
| S61.411A | ICD10CM | Covered |
| S61.412A | ICD10CM | Covered |
| S61.421A | ICD10CM | Covered |
| S61.422A | ICD10CM | Covered |
| S61.431A | ICD10CM | Covered |
| S61.432A | ICD10CM | Covered |
| S61.441A | ICD10CM | Covered |
| S61.442A | ICD10CM | Covered |
| S61.451A | ICD10CM | Covered |
| S61.452A | ICD10CM | Covered |
| S61.511A | ICD10CM | Covered |
| S61.512A | ICD10CM | Covered |
| S61.521A | ICD10CM | Covered |
| S61.522A | ICD10CM | Covered |
| S61.531A | ICD10CM | Covered |
| S61.532A | ICD10CM | Covered |
| S61.541A | ICD10CM | Covered |
| S61.542A | ICD10CM | Covered |
| S61.551A | ICD10CM | Covered |
| S61.552A | ICD10CM | Covered |
| S66.021A | ICD10CM | Covered |
| S66.022A | ICD10CM | Covered |
| S66.120A | ICD10CM | Covered |
| S66.121A | ICD10CM | Covered |
| S66.122A | ICD10CM | Covered |
| S66.123A | ICD10CM | Covered |
| S66.124A | ICD10CM | Covered |
| S66.125A | ICD10CM | Covered |
| S66.126A | ICD10CM | Covered |
| S66.127A | ICD10CM | Covered |
| S66.221A | ICD10CM | Covered |
| S66.222A | ICD10CM | Covered |
| S66.320A | ICD10CM | Covered |
| S66.321A | ICD10CM | Covered |
| S66.322A | ICD10CM | Covered |
| S66.323A | ICD10CM | Covered |
| S66.324A | ICD10CM | Covered |
| S66.325A | ICD10CM | Covered |
| S66.326A | ICD10CM | Covered |
| S66.327A | ICD10CM | Covered |
| S66.421A | ICD10CM | Covered |
| S66.422A | ICD10CM | Covered |
| S66.520A | ICD10CM | Covered |
| S66.521A | ICD10CM | Covered |
| S66.522A | ICD10CM | Covered |
| S66.523A | ICD10CM | Covered |
| S66.524A | ICD10CM | Covered |
| S66.525A | ICD10CM | Covered |
| S66.526A | ICD10CM | Covered |
| S66.527A | ICD10CM | Covered |
| S66.821A | ICD10CM | Covered |
| S66.822A | ICD10CM | Covered |
| S66.921A | ICD10CM | Covered |
| S66.922A | ICD10CM | Covered |
| S68.011A | ICD10CM | Covered |
| S68.012A | ICD10CM | Covered |
| S68.021A | ICD10CM | Covered |
| S68.022A | ICD10CM | Covered |
| S68.110A | ICD10CM | Covered |
| S68.111A | ICD10CM | Covered |
| S68.112A | ICD10CM | Covered |
| S68.113A | ICD10CM | Covered |
| S68.114A | ICD10CM | Covered |
| S68.115A | ICD10CM | Covered |
| S68.116A | ICD10CM | Covered |
| S68.117A | ICD10CM | Covered |
| S68.120A | ICD10CM | Covered |
| S68.121A | ICD10CM | Covered |
| S68.122A | ICD10CM | Covered |
| S68.123A | ICD10CM | Covered |
| S68.124A | ICD10CM | Covered |
| S68.125A | ICD10CM | Covered |
| S68.126A | ICD10CM | Covered |
| S68.127A | ICD10CM | Covered |
| S68.411A | ICD10CM | Covered |
| S68.412A | ICD10CM | Covered |
| S68.421A | ICD10CM | Covered |
| S68.422A | ICD10CM | Covered |
| S68.511A | ICD10CM | Covered |
| S68.512A | ICD10CM | Covered |
| S68.521A | ICD10CM | Covered |
| S68.522A | ICD10CM | Covered |
| S68.610A | ICD10CM | Covered |
| S68.611A | ICD10CM | Covered |
| S68.612A | ICD10CM | Covered |
| S68.613A | ICD10CM | Covered |
| S68.614A | ICD10CM | Covered |
| S68.615A | ICD10CM | Covered |
| S68.616A | ICD10CM | Covered |
| S68.617A | ICD10CM | Covered |
| S68.620A | ICD10CM | Covered |
| S68.621A | ICD10CM | Covered |
| S68.622A | ICD10CM | Covered |
| S68.623A | ICD10CM | Covered |
| S68.624A | ICD10CM | Covered |
| S68.625A | ICD10CM | Covered |
| S68.626A | ICD10CM | Covered |
| S68.627A | ICD10CM | Covered |
| S68.711A | ICD10CM | Covered |
| S68.712A | ICD10CM | Covered |
| S68.721A | ICD10CM | Covered |
| S68.722A | ICD10CM | Covered |
| S70.211A | ICD10CM | Covered |
| S70.212A | ICD10CM | Covered |
| S70.221A | ICD10CM | Covered |
| S70.222A | ICD10CM | Covered |
| S70.241A | ICD10CM | Covered |
| S70.242A | ICD10CM | Covered |
| S70.251A | ICD10CM | Covered |
| S70.252A | ICD10CM | Covered |
| S70.261A | ICD10CM | Covered |
| S70.262A | ICD10CM | Covered |
| S70.271A | ICD10CM | Covered |
| S70.272A | ICD10CM | Covered |
| S70.311A | ICD10CM | Covered |
| S70.312A | ICD10CM | Covered |
| S70.321A | ICD10CM | Covered |
| S70.322A | ICD10CM | Covered |
| S70.341A | ICD10CM | Covered |
| S70.342A | ICD10CM | Covered |
| S70.351A | ICD10CM | Covered |
| S70.352A | ICD10CM | Covered |
| S70.361A | ICD10CM | Covered |
| S70.362A | ICD10CM | Covered |
| S70.371A | ICD10CM | Covered |
| S70.372A | ICD10CM | Covered |
| S71.009A | ICD10CM | Covered |
| S71.011A | ICD10CM | Covered |
| S71.012A | ICD10CM | Covered |
| S71.021A | ICD10CM | Covered |
| S71.022A | ICD10CM | Covered |
| S71.029A | ICD10CM | Covered |
| S71.031A | ICD10CM | Covered |
| S71.032A | ICD10CM | Covered |
| S71.041A | ICD10CM | Covered |
| S71.042A | ICD10CM | Covered |
| S71.051A | ICD10CM | Covered |
| S71.052A | ICD10CM | Covered |
| S71.111A | ICD10CM | Covered |
| S71.112A | ICD10CM | Covered |
| S71.121A | ICD10CM | Covered |
| S71.122A | ICD10CM | Covered |
| S71.131A | ICD10CM | Covered |