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.
| Code | Code system | Status in this policy |
|---|---|---|
| J9264 | HCPCS | Covered |
| J9267 | HCPCS | Covered |
| C00.0 | ICD10CM | Covered |
| C00.1 | ICD10CM | Covered |
| C00.2 | ICD10CM | Covered |
| C00.3 | ICD10CM | Covered |
| C00.4 | ICD10CM | Covered |
| C00.5 | ICD10CM | Covered |
| C00.6 | ICD10CM | Covered |
| C00.8 | ICD10CM | Covered |
| C00.9 | ICD10CM | Covered |
| C01 | ICD10CM | Covered |
| C02.0 | ICD10CM | Covered |
| C02.1 | ICD10CM | Covered |
| C02.2 | ICD10CM | Covered |
| C02.3 | ICD10CM | Covered |
| C02.4 | ICD10CM | Covered |
| C02.8 | ICD10CM | Covered |
| C02.9 | ICD10CM | Covered |
| C03.0 | ICD10CM | Covered |
| C03.1 | ICD10CM | Covered |
| C03.9 | ICD10CM | Covered |
| C04.0 | ICD10CM | Covered |
| C04.1 | ICD10CM | Covered |
| C04.8 | ICD10CM | Covered |
| C04.9 | ICD10CM | Covered |
| C05.0 | ICD10CM | Covered |
| C05.1 | ICD10CM | Covered |
| C05.2 | ICD10CM | Covered |
| C05.8 | ICD10CM | Covered |
| C05.9 | ICD10CM | Covered |
| C06.0 | ICD10CM | Covered |
| C06.1 | ICD10CM | Covered |
| C06.2 | ICD10CM | Covered |
| C06.80 | ICD10CM | Covered |
| C06.89 | ICD10CM | Covered |
| C06.9 | ICD10CM | Covered |
| C07 | ICD10CM | Covered |
| C08.0 | ICD10CM | Covered |
| C08.1 | ICD10CM | Covered |
| C08.9 | ICD10CM | Covered |
| C09.0 | ICD10CM | Covered |
| C09.1 | ICD10CM | Covered |
| C09.8 | ICD10CM | Covered |
| C09.9 | ICD10CM | Covered |
| C10.0 | ICD10CM | Covered |
| C10.1 | ICD10CM | Covered |
| C10.2 | ICD10CM | Covered |
| C10.3 | ICD10CM | Covered |
| C10.4 | ICD10CM | Covered |
| C10.8 | ICD10CM | Covered |
| C10.9 | ICD10CM | Covered |
| C11.0 | ICD10CM | Covered |
| C11.1 | ICD10CM | Covered |
| C11.2 | ICD10CM | Covered |
| C11.3 | ICD10CM | Covered |
| C11.8 | ICD10CM | Covered |
| C11.9 | ICD10CM | Covered |
| C12 | ICD10CM | Covered |
| C13.0 | ICD10CM | Covered |
| C13.1 | ICD10CM | Covered |
| C13.2 | ICD10CM | Covered |
| C13.8 | ICD10CM | Covered |
| C13.9 | ICD10CM | Covered |
| C14.0 | ICD10CM | Covered |
| C14.2 | ICD10CM | Covered |
| C14.8 | ICD10CM | Covered |
| C15.3 | ICD10CM | Covered |
| C15.4 | ICD10CM | Covered |
| C15.5 | ICD10CM | Covered |
| C15.8 | ICD10CM | Covered |
| C15.9 | ICD10CM | Covered |
| C16.0 | ICD10CM | Covered |
| C16.1 | ICD10CM | Covered |
| C16.2 | ICD10CM | Covered |
| C16.3 | ICD10CM | Covered |
| C16.4 | ICD10CM | Covered |
| C16.5 | ICD10CM | Covered |
| C16.6 | ICD10CM | Covered |
| C16.8 | ICD10CM | Covered |
| C16.9 | ICD10CM | Covered |
| C17.0 | ICD10CM | Covered |
| C17.1 | ICD10CM | Covered |
| C17.2 | ICD10CM | Covered |
| C17.3 | ICD10CM | Covered |
| C17.8 | ICD10CM | Covered |
| C17.9 | ICD10CM | Covered |
| C21.0 | ICD10CM | Covered |
| C21.1 | ICD10CM | Covered |
| C21.2 | ICD10CM | Covered |
| C21.8 | ICD10CM | Covered |
| C22.1 | ICD10CM | Covered |
| C22.3 | ICD10CM | Covered |
| C23 | ICD10CM | Covered |
| C24.0 | ICD10CM | Covered |
| C24.1 | ICD10CM | Covered |
| C24.8 | ICD10CM | Covered |
| C25.0 | ICD10CM | Covered |
| C25.1 | ICD10CM | Covered |
| C25.2 | ICD10CM | Covered |
| C25.3 | ICD10CM | Covered |
| C25.7 | ICD10CM | Covered |
| C25.8 | ICD10CM | Covered |
| C25.9 | ICD10CM | Covered |
| C30.0 | ICD10CM | Covered |
| C30.1 | ICD10CM | Covered |
| C31.0 | ICD10CM | Covered |
| C31.1 | ICD10CM | Covered |
| C31.2 | ICD10CM | Covered |
| C31.3 | ICD10CM | Covered |
| C31.8 | ICD10CM | Covered |
| C31.9 | ICD10CM | Covered |
| C32.0 | ICD10CM | Covered |
| C32.1 | ICD10CM | Covered |
| C32.2 | ICD10CM | Covered |
| C32.3 | ICD10CM | Covered |
| C32.8 | ICD10CM | Covered |
| C32.9 | ICD10CM | Covered |
| C33 | ICD10CM | Covered |
| C34.00 | ICD10CM | Covered |
| C34.01 | ICD10CM | Covered |
| C34.02 | ICD10CM | Covered |
| C34.10 | ICD10CM | Covered |
| C34.11 | ICD10CM | Covered |
| C34.12 | ICD10CM | Covered |
| C34.2 | ICD10CM | Covered |
| C34.30 | ICD10CM | Covered |
| C34.31 | ICD10CM | Covered |
| C34.32 | ICD10CM | Covered |
| C34.80 | ICD10CM | Covered |
| C34.81 | ICD10CM | Covered |
| C34.82 | ICD10CM | Covered |
| C34.90 | ICD10CM | Covered |
| C34.91 | ICD10CM | Covered |
| C34.92 | ICD10CM | Covered |
| C37 | ICD10CM | Covered |
| C43.0 | ICD10CM | Covered |
| C43.10 | ICD10CM | Covered |
| C43.111 | ICD10CM | Covered |
| C43.112 | ICD10CM | Covered |
| C43.121 | ICD10CM | Covered |
| C43.122 | ICD10CM | Covered |
| C43.20 | ICD10CM | Covered |
| C43.21 | ICD10CM | Covered |
| C43.22 | ICD10CM | Covered |
| C43.30 | ICD10CM | Covered |
| C43.31 | ICD10CM | Covered |
| C43.39 | ICD10CM | Covered |
| C43.4 | ICD10CM | Covered |
| C43.51 | ICD10CM | Covered |
| C43.52 | ICD10CM | Covered |
| C43.59 | ICD10CM | Covered |
| C43.60 | ICD10CM | Covered |
| C43.61 | ICD10CM | Covered |
| C43.62 | ICD10CM | Covered |
| C43.70 | ICD10CM | Covered |
| C43.71 | ICD10CM | Covered |
| C43.72 | ICD10CM | Covered |
| C43.8 | ICD10CM | Covered |
| C43.9 | ICD10CM | Covered |
| C44.00 | ICD10CM | Covered |
| C44.01 | ICD10CM | Covered |
| C44.02 | ICD10CM | Covered |
| C44.09 | ICD10CM | Covered |
| C44.101 | ICD10CM | Covered |
| C44.1021 | ICD10CM | Covered |
| C44.1022 | ICD10CM | Covered |
| C44.1091 | ICD10CM | Covered |
| C44.1092 | ICD10CM | Covered |
| C44.111 | ICD10CM | Covered |
| C44.1121 | ICD10CM | Covered |
| C44.1122 | ICD10CM | Covered |
| C44.1191 | ICD10CM | Covered |
| C44.1192 | ICD10CM | Covered |
| C44.121 | ICD10CM | Covered |
| C44.1221 | ICD10CM | Covered |
| C44.1222 | ICD10CM | Covered |
| C44.1291 | ICD10CM | Covered |
| C44.1292 | ICD10CM | Covered |
| C44.1321 | ICD10CM | Covered |
| C44.1322 | ICD10CM | Covered |
| C44.1391 | ICD10CM | Covered |
| C44.1392 | ICD10CM | Covered |
| C44.191 | ICD10CM | Covered |
| C44.1921 | ICD10CM | Covered |
| C44.1922 | ICD10CM | Covered |
| C44.1991 | ICD10CM | Covered |
| C44.1992 | ICD10CM | Covered |
| C44.201 | ICD10CM | Covered |
| C44.202 | ICD10CM | Covered |
| C44.209 | ICD10CM | Covered |
| C44.211 | ICD10CM | Covered |
| C44.212 | ICD10CM | Covered |
| C44.219 | ICD10CM | Covered |
| C44.221 | ICD10CM | Covered |
| C44.222 | ICD10CM | Covered |
| C44.229 | ICD10CM | Covered |
| C44.291 | ICD10CM | Covered |
| C44.292 | ICD10CM | Covered |
| C44.299 | ICD10CM | Covered |
| C44.300 | ICD10CM | Covered |
| C44.301 | ICD10CM | Covered |
| C44.309 | ICD10CM | Covered |
| C44.310 | ICD10CM | Covered |
| C44.311 | ICD10CM | Covered |
| C44.319 | ICD10CM | Covered |
| C44.320 | ICD10CM | Covered |
| C44.321 | ICD10CM | Covered |
| C44.329 | ICD10CM | Covered |
| C44.390 | ICD10CM | Covered |
| C44.391 | ICD10CM | Covered |
| C44.399 | ICD10CM | Covered |
| C44.40 | ICD10CM | Covered |
| C44.41 | ICD10CM | Covered |
| C44.42 | ICD10CM | Covered |
| C44.49 | ICD10CM | Covered |
| C44.500 | ICD10CM | Covered |
| C44.501 | ICD10CM | Covered |
| C44.509 | ICD10CM | Covered |
| C44.510 | ICD10CM | Covered |
| C44.511 | ICD10CM | Covered |
| C44.519 | ICD10CM | Covered |
| C44.520 | ICD10CM | Covered |
| C44.521 | ICD10CM | Covered |
| C44.529 | ICD10CM | Covered |
| C44.590 | ICD10CM | Covered |
| C44.591 | ICD10CM | Covered |
| C44.599 | ICD10CM | Covered |
| C44.601 | ICD10CM | Covered |
| C44.602 | ICD10CM | Covered |
| C44.609 | ICD10CM | Covered |
| C44.611 | ICD10CM | Covered |
| C44.612 | ICD10CM | Covered |
| C44.619 | ICD10CM | Covered |
| C44.621 | ICD10CM | Covered |
| C44.622 | ICD10CM | Covered |
| C44.629 | ICD10CM | Covered |
| C44.691 | ICD10CM | Covered |
| C44.692 | ICD10CM | Covered |
| C44.699 | ICD10CM | Covered |
| C44.701 | ICD10CM | Covered |
| C44.702 | ICD10CM | Covered |
| C44.709 | ICD10CM | Covered |
| C44.711 | ICD10CM | Covered |
| C44.712 | ICD10CM | Covered |
| C44.719 | ICD10CM | Covered |
| C44.721 | ICD10CM | Covered |
| C44.722 | ICD10CM | Covered |
| C44.729 | ICD10CM | Covered |
| C44.791 | ICD10CM | Covered |
| C44.792 | ICD10CM | Covered |
| C44.799 | ICD10CM | Covered |
| C44.80 | ICD10CM | Covered |
| C44.81 | ICD10CM | Covered |
| C44.82 | ICD10CM | Covered |
| C44.89 | ICD10CM | Covered |
| C44.90 | ICD10CM | Covered |
| C44.91 | ICD10CM | Covered |
| C44.92 | ICD10CM | Covered |
| C44.99 | ICD10CM | Covered |
| C45.1 | ICD10CM | Covered |
| C45.9 | ICD10CM | Covered |
| C46.0 | ICD10CM | Covered |
| C46.1 | ICD10CM | Covered |
| C46.2 | ICD10CM | Covered |
| C46.3 | ICD10CM | Covered |
| C46.4 | ICD10CM | Covered |
| C46.50 | ICD10CM | Covered |
| C46.51 | ICD10CM | Covered |
| C46.52 | ICD10CM | Covered |
| C46.7 | ICD10CM | Covered |
| C46.9 | ICD10CM | Covered |
| C47.0 | ICD10CM | Covered |
| C47.10 | ICD10CM | Covered |
| C47.11 | ICD10CM | Covered |
| C47.12 | ICD10CM | Covered |
| C47.20 | ICD10CM | Covered |
| C47.21 | ICD10CM | Covered |
| C47.22 | ICD10CM | Covered |
| C47.3 | ICD10CM | Covered |
| C47.4 | ICD10CM | Covered |
| C47.5 | ICD10CM | Covered |
| C47.6 | ICD10CM | Covered |
| C47.8 | ICD10CM | Covered |
| C47.9 | ICD10CM | Covered |
| C48.0 | ICD10CM | Covered |
| C48.1 | ICD10CM | Covered |
| C48.2 | ICD10CM | Covered |
| C48.8 | ICD10CM | Covered |
| C49.0 | ICD10CM | Covered |
| C49.10 | ICD10CM | Covered |
| C49.11 | ICD10CM | Covered |
| C49.12 | ICD10CM | Covered |
| C49.20 | ICD10CM | Covered |
| C49.21 | ICD10CM | Covered |
| C49.22 | ICD10CM | Covered |
| C49.3 | ICD10CM | Covered |
| C49.4 | ICD10CM | Covered |
| C49.5 | ICD10CM | Covered |
| C49.6 | ICD10CM | Covered |
| C49.8 | ICD10CM | Covered |
| C49.9 | ICD10CM | Covered |
| C50.011 | ICD10CM | Covered |
| C50.012 | ICD10CM | Covered |
| C50.019 | ICD10CM | Covered |
| C50.021 | ICD10CM | Covered |
| C50.022 | ICD10CM | Covered |
| C50.029 | ICD10CM | Covered |
| C50.111 | ICD10CM | Covered |
| C50.112 | ICD10CM | Covered |
| C50.119 | ICD10CM | Covered |
| C50.121 | ICD10CM | Covered |
| C50.122 | ICD10CM | Covered |
| C50.129 | ICD10CM | Covered |
| C50.211 | ICD10CM | Covered |
| C50.212 | ICD10CM | Covered |
| C50.219 | ICD10CM | Covered |
| C50.221 | ICD10CM | Covered |
| C50.222 | ICD10CM | Covered |
| C50.229 | ICD10CM | Covered |
| C50.311 | ICD10CM | Covered |
| C50.312 | ICD10CM | Covered |
| C50.319 | ICD10CM | Covered |
| C50.321 | ICD10CM | Covered |
| C50.322 | ICD10CM | Covered |
| C50.329 | ICD10CM | Covered |
| C50.411 | ICD10CM | Covered |
| C50.412 | ICD10CM | Covered |
| C50.419 | ICD10CM | Covered |
| C50.421 | ICD10CM | Covered |
| C50.422 | ICD10CM | Covered |
| C50.429 | ICD10CM | Covered |
| C50.511 | ICD10CM | Covered |
| C50.512 | ICD10CM | Covered |
| C50.519 | ICD10CM | Covered |
| C50.521 | ICD10CM | Covered |
| C50.522 | ICD10CM | Covered |
| C50.529 | ICD10CM | Covered |
| C50.611 | ICD10CM | Covered |
| C50.612 | ICD10CM | Covered |
| C50.619 | ICD10CM | Covered |
| C50.621 | ICD10CM | Covered |
| C50.622 | ICD10CM | Covered |
| C50.629 | ICD10CM | Covered |
| C50.811 | ICD10CM | Covered |
| C50.812 | ICD10CM | Covered |
| C50.819 | ICD10CM | Covered |
| C50.821 | ICD10CM | Covered |
| C50.822 | ICD10CM | Covered |
| C50.829 | ICD10CM | Covered |
| C50.911 | ICD10CM | Covered |
| C50.912 | ICD10CM | Covered |
| C50.919 | ICD10CM | Covered |
| C50.921 | ICD10CM | Covered |
| C50.922 | ICD10CM | Covered |
| C50.929 | ICD10CM | Covered |
| C50.A1 | ICD10CM | Covered |
| C50.A2 | ICD10CM | Covered |
| C51.0 | ICD10CM | Covered |
| C51.1 | ICD10CM | Covered |
| C51.2 | ICD10CM | Covered |
| C51.8 | ICD10CM | Covered |
| C51.9 | ICD10CM | Covered |
| C52 | ICD10CM | Covered |
| C53.0 | ICD10CM | Covered |
| C53.1 | ICD10CM | Covered |
| C53.8 | ICD10CM | Covered |
| C53.9 | ICD10CM | Covered |
| C54.0 | ICD10CM | Covered |
| C54.1 | ICD10CM | Covered |
| C54.2 | ICD10CM | Covered |
| C54.3 | ICD10CM | Covered |
| C54.8 | ICD10CM | Covered |
| C54.9 | ICD10CM | Covered |
| C55 | ICD10CM | Covered |
| C56.1 | ICD10CM | Covered |
| C56.2 | ICD10CM | Covered |
| C56.3 | ICD10CM | Covered |
| C56.9 | ICD10CM | Covered |
| C57.00 | ICD10CM | Covered |
| C57.01 | ICD10CM | Covered |
| C57.02 | ICD10CM | Covered |
| C57.10 | ICD10CM | Covered |
| C57.11 | ICD10CM | Covered |
| C57.12 | ICD10CM | Covered |
| C57.20 | ICD10CM | Covered |
| C57.21 | ICD10CM | Covered |
| C57.22 | ICD10CM | Covered |
| C57.3 | ICD10CM | Covered |
| C57.4 | ICD10CM | Covered |
| C57.7 | ICD10CM | Covered |
| C57.8 | ICD10CM | Covered |
| C58 | ICD10CM | Covered |
| C60.0 | ICD10CM | Covered |
| C60.1 | ICD10CM | Covered |
| C60.2 | ICD10CM | Covered |
| C60.8 | ICD10CM | Covered |
| C60.9 | ICD10CM | Covered |
| C61 | ICD10CM | Covered |
| C62.00 | ICD10CM | Covered |
| C62.01 | ICD10CM | Covered |
| C62.02 | ICD10CM | Covered |
| C62.10 | ICD10CM | Covered |
| C62.11 | ICD10CM | Covered |
| C62.12 | ICD10CM | Covered |
| C62.90 | ICD10CM | Covered |
| C62.91 | ICD10CM | Covered |
| C62.92 | ICD10CM | Covered |
| C63.7 | ICD10CM | Covered |
| C63.8 | ICD10CM | Covered |
| C63.9 | ICD10CM | Covered |
| C64.1 | ICD10CM | Covered |
| C64.2 | ICD10CM | Covered |
| C64.9 | ICD10CM | Covered |
| C65.1 | ICD10CM | Covered |
| C65.2 | ICD10CM | Covered |
| C65.9 | ICD10CM | Covered |
| C66.1 | ICD10CM | Covered |
| C66.2 | ICD10CM | Covered |
| C66.9 | ICD10CM | Covered |
| C67.0 | ICD10CM | Covered |
| C67.1 | ICD10CM | Covered |
| C67.2 | ICD10CM | Covered |
| C67.3 | ICD10CM | Covered |
| C67.4 | ICD10CM | Covered |
| C67.5 | ICD10CM | Covered |
| C67.6 | ICD10CM | Covered |
| C67.7 | ICD10CM | Covered |
| C67.8 | ICD10CM | Covered |
| C67.9 | ICD10CM | Covered |
| C68.0 | ICD10CM | Covered |
| C69.31 | ICD10CM | Covered |
| C69.32 | ICD10CM | Covered |
| C69.41 | ICD10CM | Covered |
| C69.42 | ICD10CM | Covered |
| C69.61 | ICD10CM | Covered |
| C69.62 | ICD10CM | Covered |
| C71.0 | ICD10CM | Covered |
| C71.1 | ICD10CM | Covered |
| C71.2 | ICD10CM | Covered |
| C71.3 | ICD10CM | Covered |
| C71.4 | ICD10CM | Covered |
| C71.5 | ICD10CM | Covered |
| C71.6 | ICD10CM | Covered |
| C71.7 | ICD10CM | Covered |
| C71.8 | ICD10CM | Covered |
| C71.9 | ICD10CM | Covered |
| C73 | ICD10CM | Covered |
| C76.0 | ICD10CM | Covered |
| C7A.1 | ICD10CM | Covered |
| C7A.8 | ICD10CM | Covered |
| C80.0 | ICD10CM | Covered |
| C80.1 | ICD10CM | Covered |
| C82.50 | ICD10CM | Covered |
| C82.51 | ICD10CM | Covered |
| C82.52 | ICD10CM | Covered |
| C82.53 | ICD10CM | Covered |
| C82.54 | ICD10CM | Covered |
| C82.55 | ICD10CM | Covered |
| C82.56 | ICD10CM | Covered |
| C82.57 | ICD10CM | Covered |
| C82.58 | ICD10CM | Covered |
| C82.59 | ICD10CM | Covered |
| C83.00 | ICD10CM | Covered |
| C83.01 | ICD10CM | Covered |
| C83.02 | ICD10CM | Covered |
| C83.03 | ICD10CM | Covered |
| C83.04 | ICD10CM | Covered |
| C83.05 | ICD10CM | Covered |
| C83.06 | ICD10CM | Covered |
| C83.07 | ICD10CM | Covered |
| C83.08 | ICD10CM | Covered |
| C83.09 | ICD10CM | Covered |
| C83.80 | ICD10CM | Covered |
| C83.81 | ICD10CM | Covered |
| C83.82 | ICD10CM | Covered |
| C83.83 | ICD10CM | Covered |
| C83.84 | ICD10CM | Covered |
| C83.85 | ICD10CM | Covered |
| C83.86 | ICD10CM | Covered |
| C83.87 | ICD10CM | Covered |
| C83.88 | ICD10CM | Covered |
| C83.89 | ICD10CM | Covered |
| C83.90 | ICD10CM | Covered |
| C83.91 | ICD10CM | Covered |
| C83.92 | ICD10CM | Covered |
| C83.94 | ICD10CM | Covered |
| C83.95 | ICD10CM | Covered |
| C83.96 | ICD10CM | Covered |
| C83.97 | ICD10CM | Covered |
| C83.98 | ICD10CM | Covered |
| C83.99 | ICD10CM | Covered |
| C84.40 | ICD10CM | Covered |
| C84.41 | ICD10CM | Covered |
| C84.42 | ICD10CM | Covered |
| C84.43 | ICD10CM | Covered |
| C84.44 | ICD10CM | Covered |
| C84.45 | ICD10CM | Covered |
| C84.46 | ICD10CM | Covered |
| C84.47 | ICD10CM | Covered |
| C84.48 | ICD10CM | Covered |
| C84.49 | ICD10CM | Covered |
| C84.90 | ICD10CM | Covered |
| C84.91 | ICD10CM | Covered |
| C84.92 | ICD10CM | Covered |
| C84.93 | ICD10CM | Covered |
| C84.94 | ICD10CM | Covered |
| C84.95 | ICD10CM | Covered |
| C84.96 | ICD10CM | Covered |
| C84.97 | ICD10CM | Covered |
| C84.99 | ICD10CM | Covered |
| C84.A0 | ICD10CM | Covered |
| C84.A1 | ICD10CM | Covered |
| C84.A2 | ICD10CM | Covered |
| C84.A3 | ICD10CM | Covered |
| C84.A4 | ICD10CM | Covered |
| C84.A5 | ICD10CM | Covered |
| C84.A6 | ICD10CM | Covered |
| C84.A7 | ICD10CM | Covered |
| C84.A8 | ICD10CM | Covered |
| C84.A9 | ICD10CM | Covered |
| C84.Z0 | ICD10CM | Covered |
| C84.Z1 | ICD10CM | Covered |
| C84.Z2 | ICD10CM | Covered |
| C84.Z3 | ICD10CM | Covered |
| C84.Z4 | ICD10CM | Covered |
| C84.Z5 | ICD10CM | Covered |
| C84.Z6 | ICD10CM | Covered |
| C84.Z7 | ICD10CM | Covered |
| C84.Z8 | ICD10CM | Covered |
| C84.Z9 | ICD10CM | Covered |
| C85.10 | ICD10CM | Covered |
| C85.11 | ICD10CM | Covered |
| C85.12 | ICD10CM | Covered |
| C85.13 | ICD10CM | Covered |
| C85.14 | ICD10CM | Covered |
| C85.15 | ICD10CM | Covered |
| C85.16 | ICD10CM | Covered |
| C85.17 | ICD10CM | Covered |
| C85.18 | ICD10CM | Covered |
| C85.19 | ICD10CM | Covered |
| C85.1A | ICD10CM | Covered |
| C85.20 | ICD10CM | Covered |
| C85.21 | ICD10CM | Covered |
| C85.22 | ICD10CM | Covered |
| C85.23 | ICD10CM | Covered |
| C85.24 | ICD10CM | Covered |
| C85.25 | ICD10CM | Covered |
| C85.26 | ICD10CM | Covered |
| C85.27 | ICD10CM | Covered |
| C85.28 | ICD10CM | Covered |
| C85.29 | ICD10CM | Covered |
| C85.2A | ICD10CM | Covered |
| C85.80 | ICD10CM | Covered |
| C85.81 | ICD10CM | Covered |
| C85.82 | ICD10CM | Covered |
| C85.83 | ICD10CM | Covered |
| C85.84 | ICD10CM | Covered |
| C85.85 | ICD10CM | Covered |
| C85.86 | ICD10CM | Covered |
| C85.87 | ICD10CM | Covered |
| C85.88 | ICD10CM | Covered |
| C85.89 | ICD10CM | Covered |
| C85.8A | ICD10CM | Covered |
| C85.90 | ICD10CM | Covered |
| C85.91 | ICD10CM | Covered |
| C85.92 | ICD10CM | Covered |
| C85.93 | ICD10CM | Covered |
| C85.94 | ICD10CM | Covered |
| C85.95 | ICD10CM | Covered |
| C85.96 | ICD10CM | Covered |
| C85.97 | ICD10CM | Covered |
| C85.98 | ICD10CM | Covered |
| C85.99 | ICD10CM | Covered |
| C86.00 | ICD10CM | Covered |
| C86.01 | ICD10CM | Covered |
| C86.10 | ICD10CM | Covered |
| C86.11 | ICD10CM | Covered |
| C86.20 | ICD10CM | Covered |
| C86.21 | ICD10CM | Covered |
| C86.30 | ICD10CM | Covered |
| C86.31 | ICD10CM | Covered |
| C86.40 | ICD10CM | Covered |
| C86.41 | ICD10CM | Covered |
| C86.50 | ICD10CM | Covered |
| C86.51 | ICD10CM | Covered |
| C86.60 | ICD10CM | Covered |
| C86.61 | ICD10CM | Covered |
| C90.00 | ICD10CM | Covered |
| C90.01 | ICD10CM | Covered |
| C90.02 | ICD10CM | Covered |
| C96.4 | ICD10CM | Covered |
| C96.9 | ICD10CM | Covered |
| C96.Z | ICD10CM | Covered |
| D03.0 | ICD10CM | Covered |
| D03.10 | ICD10CM | Covered |
| D03.111 | ICD10CM | Covered |
| D03.112 | ICD10CM | Covered |
| D03.121 | ICD10CM | Covered |
| D03.122 | ICD10CM | Covered |
| D03.20 | ICD10CM | Covered |
| D03.21 | ICD10CM | Covered |
| D03.22 | ICD10CM | Covered |
| D03.30 | ICD10CM | Covered |
| D03.39 | ICD10CM | Covered |
| D03.4 | ICD10CM | Covered |
| D03.51 | ICD10CM | Covered |
| D03.52 | ICD10CM | Covered |
| D03.59 | ICD10CM | Covered |
| D03.60 | ICD10CM | Covered |
| D03.61 | ICD10CM | Covered |
| D03.62 | ICD10CM | Covered |
| D03.70 | ICD10CM | Covered |
| D03.71 | ICD10CM | Covered |
| D03.72 | ICD10CM | Covered |
| D03.8 | ICD10CM | Covered |
| D03.9 | ICD10CM | Covered |
| D09.0 | ICD10CM | Covered |
| D15.0 | ICD10CM | Covered |
| D37.01 | ICD10CM | Covered |
| D37.02 | ICD10CM | Covered |
| D37.031 | ICD10CM | Covered |
| D37.032 | ICD10CM | Covered |
| D37.039 | ICD10CM | Covered |
| D37.04 | ICD10CM | Covered |
| D37.05 | ICD10CM | Covered |
| D37.09 | ICD10CM | Covered |
| D37.1 | ICD10CM | Covered |
| D37.2 | ICD10CM | Covered |
| D37.3 | ICD10CM | Covered |
| D37.4 | ICD10CM | Covered |
| D37.5 | ICD10CM | Covered |
| D37.8 | ICD10CM | Covered |
| D37.9 | ICD10CM | Covered |
| D38.0 | ICD10CM | Covered |
| D38.4 | ICD10CM | Covered |
| D38.5 | ICD10CM | Covered |
| D38.6 | ICD10CM | Covered |
| D39.2 | ICD10CM | Covered |
| D49.0 | ICD10CM | Covered |
| D49.1 | ICD10CM | Covered |
| D49.2 | ICD10CM | Covered |
| D49.6 | ICD10CM | Covered |
| D49.89 | ICD10CM | Covered |
| D49.9 | ICD10CM | Covered |
| D89.89 | ICD10CM | Covered |
| D89.9 | ICD10CM | Covered |
| O01.9 | ICD10CM | Covered |
| O09.891 | ICD10CM | Covered |
| O09.892 | ICD10CM | Covered |
| O09.893 | ICD10CM | Covered |
| O09.899 | ICD10CM | Covered |
| O09.90 | ICD10CM | Covered |
| O09.91 | ICD10CM | Covered |
| O09.92 | ICD10CM | Covered |
| O09.93 | ICD10CM | Covered |
| O9A.111 | ICD10CM | Covered |
| O9A.112 | ICD10CM | Covered |
| O9A.113 | ICD10CM | Covered |
| O9A.119 | ICD10CM | Covered |
| O9A.12 | ICD10CM | Covered |
| O9A.13 | ICD10CM | Covered |
| T45.0X5A | ICD10CM | Covered |
| T45.0X5D | ICD10CM | Covered |
| T45.0X5S | ICD10CM | Covered |
| T45.1X5A | ICD10CM | Covered |
| T45.1X5D | ICD10CM | Covered |
| T45.1X5S | ICD10CM | Covered |
| T47.7X5A | ICD10CM | Covered |
| T47.7X5D | ICD10CM | Covered |
| T47.7X5S | ICD10CM | Covered |
| T50.995A | ICD10CM | Covered |
| T50.995D | ICD10CM | Covered |
| T50.995S | ICD10CM | Covered |
| Z80.49 | ICD10CM | Covered |
| Z85.00 | ICD10CM | Covered |
| Z85.01 | ICD10CM | Covered |
| Z85.028 | ICD10CM | Covered |
| Z85.068 | ICD10CM | Covered |
| Z85.07 | ICD10CM | Covered |
| Z85.09 | ICD10CM | Covered |
| Z85.118 | ICD10CM | Covered |
| Z85.12 | ICD10CM | Covered |
| Z85.21 | ICD10CM | Covered |
| Z85.22 | ICD10CM | Covered |
| Z85.238 | ICD10CM | Covered |
| Z85.29 | ICD10CM | Covered |
| Z85.3 | ICD10CM | Covered |
| Z85.42 | ICD10CM | Covered |
| Z85.43 | ICD10CM | Covered |
| Z85.47 | ICD10CM | Covered |
| Z85.49 | ICD10CM | Covered |
| Z85.51 | ICD10CM | Covered |
| Z85.59 | ICD10CM | Covered |
| Z85.810 | ICD10CM | Covered |
| Z85.818 | ICD10CM | Covered |
| Z85.819 | ICD10CM | Covered |
| Z85.820 | ICD10CM | Covered |
| Z85.831 | ICD10CM | Covered |
| Z94.81 | ICD10CM | Covered |
| Z94.89 | ICD10CM | Covered |