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 |
|---|---|---|
| 36140 | HCPCS | Covered |
| 36200 | HCPCS | Covered |
| 36215 | HCPCS | Covered |
| 36216 | HCPCS | Covered |
| 36217 | HCPCS | Covered |
| 36218 | HCPCS | Covered |
| 36245 | HCPCS | Covered |
| 36246 | HCPCS | Covered |
| 36247 | HCPCS | Covered |
| 36248 | HCPCS | Covered |
| 36251 | HCPCS | Covered |
| 36252 | HCPCS | Covered |
| 36253 | HCPCS | Covered |
| 36254 | HCPCS | Covered |
| 75625 | HCPCS | Covered |
| 75630 | HCPCS | Covered |
| 75705 | HCPCS | Covered |
| 75710 | HCPCS | Covered |
| 75716 | HCPCS | Covered |
| 92978 | HCPCS | Covered |
| 92979 | HCPCS | Covered |
| 93451 | HCPCS | Covered |
| 93452 | HCPCS | Covered |
| 93453 | HCPCS | Covered |
| 93454 | HCPCS | Covered |
| 93455 | HCPCS | Covered |
| 93456 | HCPCS | Covered |
| 93457 | HCPCS | Covered |
| 93458 | HCPCS | Covered |
| 93459 | HCPCS | Covered |
| 93460 | HCPCS | Covered |
| 93461 | HCPCS | Covered |
| 93462 | HCPCS | Covered |
| 93463 | HCPCS | Covered |
| 93464 | HCPCS | Covered |
| 93505 | HCPCS | Covered |
| 93563 | HCPCS | Covered |
| 93564 | HCPCS | Covered |
| 93565 | HCPCS | Covered |
| 93566 | HCPCS | Covered |
| 93567 | HCPCS | Covered |
| 93568 | HCPCS | Covered |
| 93571 | HCPCS | Covered |
| 93572 | HCPCS | Covered |
| 93593 | HCPCS | Covered |
| 93594 | HCPCS | Covered |
| 93595 | HCPCS | Covered |
| 93596 | HCPCS | Covered |
| 93597 | HCPCS | Covered |
| 93598 | HCPCS | Covered |
| G0269 | HCPCS | Covered |
| G0278 | HCPCS | Covered |
| A18.84 | ICD10CM | Covered |
| A39.50 | ICD10CM | Covered |
| A39.51 | ICD10CM | Covered |
| A39.52 | ICD10CM | Covered |
| A52.02 | ICD10CM | Covered |
| A52.03 | ICD10CM | Covered |
| A52.06 | ICD10CM | Covered |
| A54.83 | ICD10CM | Covered |
| A78 | ICD10CM | Covered |
| B33.20 | ICD10CM | Covered |
| B33.21 | ICD10CM | Covered |
| B33.22 | ICD10CM | Covered |
| B37.6 | ICD10CM | Covered |
| B57.0 | ICD10CM | Covered |
| B57.2 | ICD10CM | Covered |
| C38.0 | ICD10CM | Covered |
| C45.2 | ICD10CM | Covered |
| D15.1 | ICD10CM | Covered |
| D86.0 | ICD10CM | Covered |
| D86.1 | ICD10CM | Covered |
| D86.2 | ICD10CM | Covered |
| D86.3 | ICD10CM | Covered |
| D86.81 | ICD10CM | Covered |
| D86.82 | ICD10CM | Covered |
| D86.83 | ICD10CM | Covered |
| D86.84 | ICD10CM | Covered |
| D86.85 | ICD10CM | Covered |
| D86.86 | ICD10CM | Covered |
| D86.87 | ICD10CM | Covered |
| D86.89 | ICD10CM | Covered |
| D86.9 | ICD10CM | Covered |
| E51.11 | ICD10CM | Covered |
| E51.12 | ICD10CM | Covered |
| E61.9 | ICD10CM | Covered |
| E63.9 | ICD10CM | Covered |
| E64.9 | ICD10CM | Covered |
| E74.00 | ICD10CM | Covered |
| E74.01 | ICD10CM | Covered |
| E74.02 | ICD10CM | Covered |
| E74.03 | ICD10CM | Covered |
| E74.04 | ICD10CM | Covered |
| E74.05 | ICD10CM | Covered |
| E74.09 | ICD10CM | Covered |
| E74.4 | ICD10CM | Covered |
| E76.01 | ICD10CM | Covered |
| E76.02 | ICD10CM | Covered |
| E76.03 | ICD10CM | Covered |
| E76.1 | ICD10CM | Covered |
| E76.210 | ICD10CM | Covered |
| E76.211 | ICD10CM | Covered |
| E76.219 | ICD10CM | Covered |
| E76.22 | ICD10CM | Covered |
| E76.29 | ICD10CM | Covered |
| E76.3 | ICD10CM | Covered |
| E76.8 | ICD10CM | Covered |
| E76.9 | ICD10CM | Covered |
| E84.0 | ICD10CM | Covered |
| E85.1 | ICD10CM | Covered |
| E85.2 | ICD10CM | Covered |
| E85.3 | ICD10CM | Covered |
| E85.4 | ICD10CM | Covered |
| E85.81 | ICD10CM | Covered |
| E85.82 | ICD10CM | Covered |
| E85.89 | ICD10CM | Covered |
| E85.9 | ICD10CM | Covered |
| E88.810 | ICD10CM | Covered |
| E88.811 | ICD10CM | Covered |
| E88.818 | ICD10CM | Covered |
| E88.819 | ICD10CM | Covered |
| E88.9 | ICD10CM | Covered |
| G11.11 | ICD10CM | Covered |
| G45.8 | ICD10CM | Covered |
| G45.9 | ICD10CM | Covered |
| G71.01 | ICD10CM | Covered |
| G71.02 | ICD10CM | Covered |
| G71.09 | ICD10CM | Covered |
| G71.11 | ICD10CM | Covered |
| I01.0 | ICD10CM | Covered |
| I01.1 | ICD10CM | Covered |
| I01.2 | ICD10CM | Covered |
| I01.8 | ICD10CM | Covered |
| I01.9 | ICD10CM | Covered |
| I05.0 | ICD10CM | Covered |
| I05.1 | ICD10CM | Covered |
| I05.2 | ICD10CM | Covered |
| I05.8 | ICD10CM | Covered |
| I05.9 | ICD10CM | Covered |
| I06.0 | ICD10CM | Covered |
| I06.1 | ICD10CM | Covered |
| I06.2 | ICD10CM | Covered |
| I06.8 | ICD10CM | Covered |
| I06.9 | ICD10CM | Covered |
| I07.0 | ICD10CM | Covered |
| I07.1 | ICD10CM | Covered |
| I07.2 | ICD10CM | Covered |
| I07.8 | ICD10CM | Covered |
| I07.9 | ICD10CM | Covered |
| I08.0 | ICD10CM | Covered |
| I08.1 | ICD10CM | Covered |
| I08.2 | ICD10CM | Covered |
| I08.3 | ICD10CM | Covered |
| I08.8 | ICD10CM | Covered |
| I08.9 | ICD10CM | Covered |
| I09.0 | ICD10CM | Covered |
| I09.1 | ICD10CM | Covered |
| I09.2 | ICD10CM | Covered |
| I09.81 | ICD10CM | Covered |
| I09.89 | ICD10CM | Covered |
| I09.9 | ICD10CM | Covered |
| I10 | ICD10CM | Covered |
| I11.0 | ICD10CM | Covered |
| I11.9 | ICD10CM | Covered |
| I12.0 | ICD10CM | Covered |
| I12.9 | ICD10CM | Covered |
| I13.0 | ICD10CM | Covered |
| I13.10 | ICD10CM | Covered |
| I13.11 | ICD10CM | Covered |
| I13.2 | ICD10CM | Covered |
| I15.0 | ICD10CM | Covered |
| I15.1 | ICD10CM | Covered |
| I16.0 | ICD10CM | Covered |
| I16.1 | ICD10CM | Covered |
| I16.9 | ICD10CM | Covered |
| I20.0 | ICD10CM | Covered |
| I20.1 | ICD10CM | Covered |
| I20.81 | ICD10CM | Covered |
| I20.89 | ICD10CM | Covered |
| I20.9 | ICD10CM | Covered |
| I21.01 | ICD10CM | Covered |
| I21.02 | ICD10CM | Covered |
| I21.09 | ICD10CM | Covered |
| I21.11 | ICD10CM | Covered |
| I21.19 | ICD10CM | Covered |
| I21.21 | ICD10CM | Covered |
| I21.29 | ICD10CM | Covered |
| I21.3 | ICD10CM | Covered |
| I21.4 | ICD10CM | Covered |
| I21.9 | ICD10CM | Covered |
| I21.A1 | ICD10CM | Covered |
| I21.A9 | ICD10CM | Covered |
| I22.0 | ICD10CM | Covered |
| I22.1 | ICD10CM | Covered |
| I22.2 | ICD10CM | Covered |
| I22.8 | ICD10CM | Covered |
| I22.9 | ICD10CM | Covered |
| I23.0 | ICD10CM | Covered |
| I23.1 | ICD10CM | Covered |
| I23.2 | ICD10CM | Covered |
| I23.3 | ICD10CM | Covered |
| I23.4 | ICD10CM | Covered |
| I23.5 | ICD10CM | Covered |
| I23.6 | ICD10CM | Covered |
| I23.7 | ICD10CM | Covered |
| I23.8 | ICD10CM | Covered |
| I24.0 | ICD10CM | Covered |
| I24.1 | ICD10CM | Covered |
| I24.81 | ICD10CM | Covered |
| I24.89 | ICD10CM | Covered |
| I24.9 | ICD10CM | Covered |
| I25.10 | ICD10CM | Covered |
| I25.110 | ICD10CM | Covered |
| I25.111 | ICD10CM | Covered |
| I25.118 | ICD10CM | Covered |
| I25.119 | ICD10CM | Covered |
| I25.2 | ICD10CM | Covered |
| I25.3 | ICD10CM | Covered |
| I25.41 | ICD10CM | Covered |
| I25.42 | ICD10CM | Covered |
| I25.5 | ICD10CM | Covered |
| I25.6 | ICD10CM | Covered |
| I25.700 | ICD10CM | Covered |
| I25.701 | ICD10CM | Covered |
| I25.708 | ICD10CM | Covered |
| I25.709 | ICD10CM | Covered |
| I25.710 | ICD10CM | Covered |
| I25.711 | ICD10CM | Covered |
| I25.718 | ICD10CM | Covered |
| I25.719 | ICD10CM | Covered |
| I25.720 | ICD10CM | Covered |
| I25.721 | ICD10CM | Covered |
| I25.728 | ICD10CM | Covered |
| I25.729 | ICD10CM | Covered |
| I25.730 | ICD10CM | Covered |
| I25.731 | ICD10CM | Covered |
| I25.738 | ICD10CM | Covered |
| I25.739 | ICD10CM | Covered |
| I25.750 | ICD10CM | Covered |
| I25.751 | ICD10CM | Covered |
| I25.758 | ICD10CM | Covered |
| I25.759 | ICD10CM | Covered |
| I25.760 | ICD10CM | Covered |
| I25.761 | ICD10CM | Covered |
| I25.768 | ICD10CM | Covered |
| I25.769 | ICD10CM | Covered |
| I25.790 | ICD10CM | Covered |
| I25.791 | ICD10CM | Covered |
| I25.798 | ICD10CM | Covered |
| I25.799 | ICD10CM | Covered |
| I25.810 | ICD10CM | Covered |
| I25.811 | ICD10CM | Covered |
| I25.812 | ICD10CM | Covered |
| I25.82 | ICD10CM | Covered |
| I25.84 | ICD10CM | Covered |
| I25.85 | ICD10CM | Covered |
| I25.89 | ICD10CM | Covered |
| I25.9 | ICD10CM | Covered |
| I26.01 | ICD10CM | Covered |
| I26.02 | ICD10CM | Covered |
| I26.09 | ICD10CM | Covered |
| I26.92 | ICD10CM | Covered |
| I26.99 | ICD10CM | Covered |
| I27.0 | ICD10CM | Covered |
| I27.1 | ICD10CM | Covered |
| I27.20 | ICD10CM | Covered |
| I27.21 | ICD10CM | Covered |
| I27.22 | ICD10CM | Covered |
| I27.23 | ICD10CM | Covered |
| I27.24 | ICD10CM | Covered |
| I27.29 | ICD10CM | Covered |
| I27.81 | ICD10CM | Covered |
| I27.82 | ICD10CM | Covered |
| I27.83 | ICD10CM | Covered |
| I27.89 | ICD10CM | Covered |
| I27.9 | ICD10CM | Covered |
| I28.0 | ICD10CM | Covered |
| I28.1 | ICD10CM | Covered |
| I28.8 | ICD10CM | Covered |
| I28.9 | ICD10CM | Covered |
| I30.0 | ICD10CM | Covered |
| I30.1 | ICD10CM | Covered |
| I30.8 | ICD10CM | Covered |
| I30.9 | ICD10CM | Covered |
| I31.0 | ICD10CM | Covered |
| I31.1 | ICD10CM | Covered |
| I31.2 | ICD10CM | Covered |
| I31.31 | ICD10CM | Covered |
| I31.39 | ICD10CM | Covered |
| I31.4 | ICD10CM | Covered |
| I31.8 | ICD10CM | Covered |
| I31.9 | ICD10CM | Covered |
| I32 | ICD10CM | Covered |
| I33.0 | ICD10CM | Covered |
| I33.9 | ICD10CM | Covered |
| I34.0 | ICD10CM | Covered |
| I34.1 | ICD10CM | Covered |
| I34.2 | ICD10CM | Covered |
| I34.81 | ICD10CM | Covered |
| I34.89 | ICD10CM | Covered |
| I34.9 | ICD10CM | Covered |
| I35.0 | ICD10CM | Covered |
| I35.1 | ICD10CM | Covered |
| I35.2 | ICD10CM | Covered |
| I35.8 | ICD10CM | Covered |
| I35.9 | ICD10CM | Covered |
| I36.0 | ICD10CM | Covered |
| I36.1 | ICD10CM | Covered |
| I36.2 | ICD10CM | Covered |
| I36.8 | ICD10CM | Covered |
| I36.9 | ICD10CM | Covered |
| I37.0 | ICD10CM | Covered |
| I37.1 | ICD10CM | Covered |
| I37.2 | ICD10CM | Covered |
| I37.8 | ICD10CM | Covered |
| I37.9 | ICD10CM | Covered |
| I38 | ICD10CM | Covered |
| I39 | ICD10CM | Covered |
| I40.0 | ICD10CM | Covered |
| I40.1 | ICD10CM | Covered |
| I40.8 | ICD10CM | Covered |
| I40.9 | ICD10CM | Covered |
| I41 | ICD10CM | Covered |
| I42.0 | ICD10CM | Covered |
| I42.1 | ICD10CM | Covered |
| I42.2 | ICD10CM | Covered |
| I42.3 | ICD10CM | Covered |
| I42.4 | ICD10CM | Covered |
| I42.5 | ICD10CM | Covered |
| I42.6 | ICD10CM | Covered |
| I42.7 | ICD10CM | Covered |
| I42.8 | ICD10CM | Covered |
| I42.9 | ICD10CM | Covered |
| I43 | ICD10CM | Covered |
| I46.2 | ICD10CM | Covered |
| I46.8 | ICD10CM | Covered |
| I46.9 | ICD10CM | Covered |
| I47.0 | ICD10CM | Covered |
| I47.20 | ICD10CM | Covered |
| I47.21 | ICD10CM | Covered |
| I47.29 | ICD10CM | Covered |
| I47.9 | ICD10CM | Covered |
| I49.01 | ICD10CM | Covered |
| I49.02 | ICD10CM | Covered |
| I50.1 | ICD10CM | Covered |
| I50.20 | ICD10CM | Covered |
| I50.21 | ICD10CM | Covered |
| I50.22 | ICD10CM | Covered |
| I50.23 | ICD10CM | Covered |
| I50.30 | ICD10CM | Covered |
| I50.31 | ICD10CM | Covered |
| I50.32 | ICD10CM | Covered |
| I50.33 | ICD10CM | Covered |
| I50.40 | ICD10CM | Covered |
| I50.41 | ICD10CM | Covered |
| I50.42 | ICD10CM | Covered |
| I50.43 | ICD10CM | Covered |
| I50.810 | ICD10CM | Covered |
| I50.811 | ICD10CM | Covered |
| I50.812 | ICD10CM | Covered |
| I50.813 | ICD10CM | Covered |
| I50.814 | ICD10CM | Covered |
| I50.82 | ICD10CM | Covered |
| I50.83 | ICD10CM | Covered |
| I50.84 | ICD10CM | Covered |
| I50.89 | ICD10CM | Covered |
| I50.9 | ICD10CM | Covered |
| I51.0 | ICD10CM | Covered |
| I51.1 | ICD10CM | Covered |
| I51.2 | ICD10CM | Covered |
| I51.3 | ICD10CM | Covered |
| I51.4 | ICD10CM | Covered |
| I51.5 | ICD10CM | Covered |
| I51.7 | ICD10CM | Covered |
| I51.81 | ICD10CM | Covered |
| I51.89 | ICD10CM | Covered |
| I63.031 | ICD10CM | Covered |
| I63.032 | ICD10CM | Covered |
| I63.039 | ICD10CM | Covered |
| I63.131 | ICD10CM | Covered |
| I63.132 | ICD10CM | Covered |
| I63.139 | ICD10CM | Covered |
| I63.231 | ICD10CM | Covered |
| I63.232 | ICD10CM | Covered |
| I63.59 | ICD10CM | Covered |
| I65.21 | ICD10CM | Covered |
| I65.22 | ICD10CM | Covered |
| I65.23 | ICD10CM | Covered |
| I65.8 | ICD10CM | Covered |
| I67.0 | ICD10CM | Covered |
| I67.841 | ICD10CM | Covered |
| I67.848 | ICD10CM | Covered |
| I67.850 | ICD10CM | Covered |
| I67.858 | ICD10CM | Covered |
| I70.0 | ICD10CM | Covered |
| I70.1 | ICD10CM | Covered |
| I70.211 | ICD10CM | Covered |
| I70.212 | ICD10CM | Covered |
| I70.213 | ICD10CM | Covered |
| I70.218 | ICD10CM | Covered |
| I70.221 | ICD10CM | Covered |
| I70.222 | ICD10CM | Covered |
| I70.223 | ICD10CM | Covered |
| I70.228 | ICD10CM | Covered |
| I70.231 | ICD10CM | Covered |
| I70.232 | ICD10CM | Covered |
| I70.233 | ICD10CM | Covered |
| I70.234 | ICD10CM | Covered |
| I70.235 | ICD10CM | Covered |
| I70.238 | ICD10CM | Covered |
| I70.239 | ICD10CM | Covered |
| I70.241 | ICD10CM | Covered |
| I70.242 | ICD10CM | Covered |
| I70.243 | ICD10CM | Covered |
| I70.244 | ICD10CM | Covered |
| I70.245 | ICD10CM | Covered |
| I70.248 | ICD10CM | Covered |
| I70.249 | ICD10CM | Covered |
| I70.25 | ICD10CM | Covered |
| I70.261 | ICD10CM | Covered |
| I70.262 | ICD10CM | Covered |
| I70.263 | ICD10CM | Covered |
| I70.268 | ICD10CM | Covered |
| I70.401 | ICD10CM | Covered |
| I70.402 | ICD10CM | Covered |
| I70.403 | ICD10CM | Covered |
| I70.408 | ICD10CM | Covered |
| I70.411 | ICD10CM | Covered |
| I70.412 | ICD10CM | Covered |
| I70.413 | ICD10CM | Covered |
| I70.418 | ICD10CM | Covered |
| I70.421 | ICD10CM | Covered |
| I70.422 | ICD10CM | Covered |
| I70.423 | ICD10CM | Covered |
| I70.428 | ICD10CM | Covered |
| I70.431 | ICD10CM | Covered |
| I70.432 | ICD10CM | Covered |
| I70.433 | ICD10CM | Covered |
| I70.434 | ICD10CM | Covered |
| I70.435 | ICD10CM | Covered |
| I70.438 | ICD10CM | Covered |
| I70.439 | ICD10CM | Covered |
| I70.441 | ICD10CM | Covered |
| I70.442 | ICD10CM | Covered |
| I70.443 | ICD10CM | Covered |
| I70.444 | ICD10CM | Covered |
| I70.445 | ICD10CM | Covered |
| I70.448 | ICD10CM | Covered |
| I70.449 | ICD10CM | Covered |
| I70.45 | ICD10CM | Covered |
| I70.461 | ICD10CM | Covered |
| I70.462 | ICD10CM | Covered |
| I70.463 | ICD10CM | Covered |
| I70.491 | ICD10CM | Covered |
| I70.492 | ICD10CM | Covered |
| I70.493 | ICD10CM | Covered |
| I70.498 | ICD10CM | Covered |
| I70.501 | ICD10CM | Covered |
| I70.502 | ICD10CM | Covered |
| I70.503 | ICD10CM | Covered |
| I70.508 | ICD10CM | Covered |
| I70.511 | ICD10CM | Covered |
| I70.512 | ICD10CM | Covered |
| I70.513 | ICD10CM | Covered |
| I70.518 | ICD10CM | Covered |
| I70.521 | ICD10CM | Covered |
| I70.522 | ICD10CM | Covered |
| I70.523 | ICD10CM | Covered |
| I70.528 | ICD10CM | Covered |
| I70.531 | ICD10CM | Covered |
| I70.532 | ICD10CM | Covered |
| I70.533 | ICD10CM | Covered |
| I70.534 | ICD10CM | Covered |
| I70.535 | ICD10CM | Covered |
| I70.538 | ICD10CM | Covered |
| I70.539 | ICD10CM | Covered |
| I70.541 | ICD10CM | Covered |
| I70.542 | ICD10CM | Covered |
| I70.543 | ICD10CM | Covered |
| I70.544 | ICD10CM | Covered |
| I70.545 | ICD10CM | Covered |
| I70.548 | ICD10CM | Covered |
| I70.549 | ICD10CM | Covered |
| I70.55 | ICD10CM | Covered |
| I70.561 | ICD10CM | Covered |
| I70.562 | ICD10CM | Covered |
| I70.563 | ICD10CM | Covered |
| I70.591 | ICD10CM | Covered |
| I70.592 | ICD10CM | Covered |
| I70.593 | ICD10CM | Covered |
| I70.598 | ICD10CM | Covered |
| I71.00 | ICD10CM | Covered |
| I71.010 | ICD10CM | Covered |
| I71.011 | ICD10CM | Covered |
| I71.012 | ICD10CM | Covered |
| I71.019 | ICD10CM | Covered |
| I71.02 | ICD10CM | Covered |
| I71.03 | ICD10CM | Covered |
| I71.11 | ICD10CM | Covered |
| I71.12 | ICD10CM | Covered |
| I71.13 | ICD10CM | Covered |
| I71.21 | ICD10CM | Covered |
| I71.22 | ICD10CM | Covered |
| I71.23 | ICD10CM | Covered |
| I71.31 | ICD10CM | Covered |
| I71.32 | ICD10CM | Covered |
| I71.33 | ICD10CM | Covered |
| I71.41 | ICD10CM | Covered |
| I71.42 | ICD10CM | Covered |
| I71.43 | ICD10CM | Covered |
| I71.51 | ICD10CM | Covered |
| I71.52 | ICD10CM | Covered |
| I71.61 | ICD10CM | Covered |
| I71.62 | ICD10CM | Covered |
| I71.8 | ICD10CM | Covered |
| I71.9 | ICD10CM | Covered |
| I72.0 | ICD10CM | Covered |
| I72.1 | ICD10CM | Covered |
| I72.2 | ICD10CM | Covered |
| I72.3 | ICD10CM | Covered |
| I72.4 | ICD10CM | Covered |
| I72.5 | ICD10CM | Covered |
| I72.6 | ICD10CM | Covered |
| I72.8 | ICD10CM | Covered |
| I73.1 | ICD10CM | Covered |
| I74.01 | ICD10CM | Covered |
| I74.09 | ICD10CM | Covered |
| I74.10 | ICD10CM | Covered |
| I74.11 | ICD10CM | Covered |
| I74.19 | ICD10CM | Covered |
| I74.2 | ICD10CM | Covered |
| I74.3 | ICD10CM | Covered |
| I74.5 | ICD10CM | Covered |
| I74.8 | ICD10CM | Covered |
| I75.011 | ICD10CM | Covered |
| I75.012 | ICD10CM | Covered |
| I75.013 | ICD10CM | Covered |
| I75.021 | ICD10CM | Covered |
| I75.022 | ICD10CM | Covered |
| I75.023 | ICD10CM | Covered |
| I75.81 | ICD10CM | Covered |
| I75.89 | ICD10CM | Covered |
| I77.3 | ICD10CM | Covered |
| I77.70 | ICD10CM | Covered |
| I77.71 | ICD10CM | Covered |
| I77.72 | ICD10CM | Covered |
| I77.73 | ICD10CM | Covered |
| I77.74 | ICD10CM | Covered |
| I77.75 | ICD10CM | Covered |
| I77.76 | ICD10CM | Covered |
| I77.77 | ICD10CM | Covered |
| I77.79 | ICD10CM | Covered |
| I79.0 | ICD10CM | Covered |
| I97.0 | ICD10CM | Covered |
| I97.110 | ICD10CM | Covered |
| I97.111 | ICD10CM | Covered |
| I97.120 | ICD10CM | Covered |
| I97.121 | ICD10CM | Covered |
| I97.130 | ICD10CM | Covered |
| I97.131 | ICD10CM | Covered |
| I97.190 | ICD10CM | Covered |
| I97.191 | ICD10CM | Covered |
| M05.20 | ICD10CM | Covered |
| M05.211 | ICD10CM | Covered |
| M05.212 | ICD10CM | Covered |
| M05.221 | ICD10CM | Covered |
| M05.222 | ICD10CM | Covered |
| M05.231 | ICD10CM | Covered |
| M05.232 | ICD10CM | Covered |
| M05.241 | ICD10CM | Covered |
| M05.242 | ICD10CM | Covered |
| M05.251 | ICD10CM | Covered |
| M05.252 | ICD10CM | Covered |
| M05.261 | ICD10CM | Covered |
| M05.262 | ICD10CM | Covered |
| M05.271 | ICD10CM | Covered |
| M05.272 | ICD10CM | Covered |
| M05.29 | ICD10CM | Covered |
| M05.311 | ICD10CM | Covered |
| M05.312 | ICD10CM | Covered |
| M05.321 | ICD10CM | Covered |
| M05.322 | ICD10CM | Covered |
| M05.331 | ICD10CM | Covered |
| M05.332 | ICD10CM | Covered |
| M05.341 | ICD10CM | Covered |
| M05.342 | ICD10CM | Covered |
| M05.351 | ICD10CM | Covered |
| M05.352 | ICD10CM | Covered |
| M05.361 | ICD10CM | Covered |
| M05.362 | ICD10CM | Covered |
| M05.371 | ICD10CM | Covered |
| M05.372 | ICD10CM | Covered |
| M05.39 | ICD10CM | Covered |
| M05.611 | ICD10CM | Covered |
| M05.612 | ICD10CM | Covered |
| M05.621 | ICD10CM | Covered |
| M05.622 | ICD10CM | Covered |
| M05.631 | ICD10CM | Covered |
| M05.632 | ICD10CM | Covered |
| M05.641 | ICD10CM | Covered |
| M05.642 | ICD10CM | Covered |
| M05.651 | ICD10CM | Covered |
| M05.652 | ICD10CM | Covered |
| M05.661 | ICD10CM | Covered |
| M05.662 | ICD10CM | Covered |
| M05.671 | ICD10CM | Covered |
| M05.672 | ICD10CM | Covered |
| M05.69 | ICD10CM | Covered |
| M06.1 | ICD10CM | Covered |
| M31.4 | ICD10CM | Covered |
| M32.0 | ICD10CM | Covered |
| M32.10 | ICD10CM | Covered |
| M32.11 | ICD10CM | Covered |
| M32.12 | ICD10CM | Covered |
| M32.13 | ICD10CM | Covered |
| M32.14 | ICD10CM | Covered |
| M32.15 | ICD10CM | Covered |
| M32.19 | ICD10CM | Covered |
| M32.8 | ICD10CM | Covered |
| M32.9 | ICD10CM | Covered |
| N26.2 | ICD10CM | Covered |
| O90.3 | ICD10CM | Covered |
| Q20.0 | ICD10CM | Covered |
| Q20.1 | ICD10CM | Covered |
| Q20.2 | ICD10CM | Covered |
| Q20.3 | ICD10CM | Covered |
| Q20.4 | ICD10CM | Covered |
| Q20.5 | ICD10CM | Covered |
| Q20.6 | ICD10CM | Covered |
| Q20.8 | ICD10CM | Covered |
| Q20.9 | ICD10CM | Covered |
| Q21.0 | ICD10CM | Covered |
| Q21.10 | ICD10CM | Covered |
| Q21.11 | ICD10CM | Covered |
| Q21.12 | ICD10CM | Covered |
| Q21.13 | ICD10CM | Covered |
| Q21.14 | ICD10CM | Covered |
| Q21.15 | ICD10CM | Covered |
| Q21.16 | ICD10CM | Covered |
| Q21.19 | ICD10CM | Covered |
| Q21.20 | ICD10CM | Covered |
| Q21.21 | ICD10CM | Covered |
| Q21.22 | ICD10CM | Covered |
| Q21.23 | ICD10CM | Covered |
| Q21.3 | ICD10CM | Covered |
| Q21.4 | ICD10CM | Covered |
| Q21.8 | ICD10CM | Covered |
| Q21.9 | ICD10CM | Covered |
| Q22.0 | ICD10CM | Covered |
| Q22.1 | ICD10CM | Covered |
| Q22.2 | ICD10CM | Covered |
| Q22.3 | ICD10CM | Covered |
| Q22.4 | ICD10CM | Covered |
| Q22.5 | ICD10CM | Covered |
| Q22.6 | ICD10CM | Covered |
| Q22.8 | ICD10CM | Covered |
| Q22.9 | ICD10CM | Covered |
| Q23.0 | ICD10CM | Covered |
| Q23.1 | ICD10CM | Covered |
| Q23.2 | ICD10CM | Covered |
| Q23.3 | ICD10CM | Covered |
| Q23.4 | ICD10CM | Covered |
| Q23.81 | ICD10CM | Covered |
| Q23.82 | ICD10CM | Covered |
| Q23.88 | ICD10CM | Covered |
| Q23.9 | ICD10CM | Covered |
| Q24.2 | ICD10CM | Covered |
| Q24.3 | ICD10CM | Covered |
| Q24.4 | ICD10CM | Covered |
| Q24.5 | ICD10CM | Covered |
| Q24.8 | ICD10CM | Covered |
| Q24.9 | ICD10CM | Covered |
| Q25.0 | ICD10CM | Covered |
| Q25.1 | ICD10CM | Covered |
| Q25.21 | ICD10CM | Covered |
| Q25.29 | ICD10CM | Covered |
| Q25.3 | ICD10CM | Covered |
| Q25.40 | ICD10CM | Covered |
| Q25.41 | ICD10CM | Covered |
| Q25.42 | ICD10CM | Covered |
| Q25.43 | ICD10CM | Covered |
| Q25.44 | ICD10CM | Covered |
| Q25.45 | ICD10CM | Covered |
| Q25.46 | ICD10CM | Covered |
| Q25.47 | ICD10CM | Covered |
| Q25.48 | ICD10CM | Covered |
| Q25.49 | ICD10CM | Covered |
| Q25.5 | ICD10CM | Covered |
| Q25.6 | ICD10CM | Covered |
| Q25.71 | ICD10CM | Covered |
| Q25.72 | ICD10CM | Covered |
| Q25.79 | ICD10CM | Covered |
| Q25.8 | ICD10CM | Covered |
| Q25.9 | ICD10CM | Covered |
| Q26.2 | ICD10CM | Covered |
| Q26.3 | ICD10CM | Covered |
| Q26.4 | ICD10CM | Covered |
| Q26.9 | ICD10CM | Covered |
| R07.2 | ICD10CM | Covered |
| R07.82 | ICD10CM | Covered |
| R07.89 | ICD10CM | Covered |
| R07.9 | ICD10CM | Covered |
| R93.1 | ICD10CM | Covered |
| R93.89 | ICD10CM | Covered |
| R94.39 | ICD10CM | Covered |
| T82.01XA | ICD10CM | Covered |
| T82.01XD | ICD10CM | Covered |
| T82.01XS | ICD10CM | Covered |
| T82.02XA | ICD10CM | Covered |
| T82.02XD | ICD10CM | Covered |
| T82.02XS | ICD10CM | Covered |
| T82.03XA | ICD10CM | Covered |
| T82.03XD | ICD10CM | Covered |
| T82.03XS | ICD10CM | Covered |
| T82.09XA | ICD10CM | Covered |
| T82.09XD | ICD10CM | Covered |
| T82.09XS | ICD10CM | Covered |
| T82.211A | ICD10CM | Covered |
| T82.211D | ICD10CM | Covered |
| T82.211S | ICD10CM | Covered |
| T82.212A | ICD10CM | Covered |
| T82.212D | ICD10CM | Covered |
| T82.212S | ICD10CM | Covered |
| T82.213A | ICD10CM | Covered |
| T82.213D | ICD10CM | Covered |
| T82.213S | ICD10CM | Covered |
| T82.218A | ICD10CM | Covered |
| T82.218D | ICD10CM | Covered |
| T82.218S | ICD10CM | Covered |
| T86.20 | ICD10CM | Covered |
| T86.21 | ICD10CM | Covered |
| T86.22 | ICD10CM | Covered |
| T86.23 | ICD10CM | Covered |
| T86.290 | ICD10CM | Covered |
| T86.298 | ICD10CM | Covered |
| T86.30 | ICD10CM | Covered |
| T86.31 | ICD10CM | Covered |
| T86.32 | ICD10CM | Covered |
| T86.33 | ICD10CM | Covered |
| T86.39 | ICD10CM | Covered |
| Z09 | ICD10CM | Covered |
| Z48.21 | ICD10CM | Covered |
| Z48.280 | ICD10CM | Covered |
| Z86.711 | ICD10CM | Covered |
| Z86.718 | ICD10CM | Covered |
| Z94.1 | ICD10CM | Covered |
| Z94.3 | ICD10CM | Covered |
| Z95.1 | ICD10CM | Covered |
| Z95.3 | ICD10CM | Covered |
| Z95.4 | ICD10CM | Covered |
| Z95.5 | ICD10CM | Covered |
| Z98.61 | ICD10CM | Covered |