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 |
|---|---|---|
| 11055 | HCPCS | Covered |
| 11056 | HCPCS | Covered |
| 11057 | HCPCS | Covered |
| 11719 | HCPCS | Covered |
| 11720 | HCPCS | Covered |
| 11721 | HCPCS | Covered |
| G0127 | HCPCS | Covered |
| A30.0 | ICD10CM | Covered |
| A30.1 | ICD10CM | Covered |
| A30.2 | ICD10CM | Covered |
| A30.3 | ICD10CM | Covered |
| A30.4 | ICD10CM | Covered |
| A30.5 | ICD10CM | Covered |
| A50.1 | ICD10CM | Covered |
| A50.40 | ICD10CM | Covered |
| A50.41 | ICD10CM | Covered |
| A50.42 | ICD10CM | Covered |
| A50.43 | ICD10CM | Covered |
| A50.45 | ICD10CM | Covered |
| A52.11 | ICD10CM | Covered |
| A52.13 | ICD10CM | Covered |
| A52.14 | ICD10CM | Covered |
| A52.15 | ICD10CM | Covered |
| A52.16 | ICD10CM | Covered |
| A52.17 | ICD10CM | Covered |
| A52.19 | ICD10CM | Covered |
| A52.2 | ICD10CM | Covered |
| B20 | ICD10CM | Covered |
| B35.1 | ICD10CM | Covered |
| D51.0 | ICD10CM | Covered |
| D81.818 | ICD10CM | Covered |
| D81.819 | ICD10CM | Covered |
| E08.00 | ICD10CM | Covered |
| E08.01 | ICD10CM | Covered |
| E08.10 | ICD10CM | Covered |
| E08.11 | ICD10CM | Covered |
| E08.21 | ICD10CM | Covered |
| E08.22 | ICD10CM | Covered |
| E08.29 | ICD10CM | Covered |
| E08.311 | ICD10CM | Covered |
| E08.319 | ICD10CM | Covered |
| E08.3211 | ICD10CM | Covered |
| E08.3212 | ICD10CM | Covered |
| E08.3213 | ICD10CM | Covered |
| E08.3291 | ICD10CM | Covered |
| E08.3292 | ICD10CM | Covered |
| E08.3293 | ICD10CM | Covered |
| E08.3311 | ICD10CM | Covered |
| E08.3312 | ICD10CM | Covered |
| E08.3313 | ICD10CM | Covered |
| E08.3391 | ICD10CM | Covered |
| E08.3392 | ICD10CM | Covered |
| E08.3393 | ICD10CM | Covered |
| E08.3411 | ICD10CM | Covered |
| E08.3412 | ICD10CM | Covered |
| E08.3413 | ICD10CM | Covered |
| E08.3491 | ICD10CM | Covered |
| E08.3492 | ICD10CM | Covered |
| E08.3493 | ICD10CM | Covered |
| E08.3511 | ICD10CM | Covered |
| E08.3512 | ICD10CM | Covered |
| E08.3513 | ICD10CM | Covered |
| E08.3521 | ICD10CM | Covered |
| E08.3522 | ICD10CM | Covered |
| E08.3523 | ICD10CM | Covered |
| E08.3531 | ICD10CM | Covered |
| E08.3532 | ICD10CM | Covered |
| E08.3533 | ICD10CM | Covered |
| E08.3541 | ICD10CM | Covered |
| E08.3542 | ICD10CM | Covered |
| E08.3543 | ICD10CM | Covered |
| E08.3551 | ICD10CM | Covered |
| E08.3552 | ICD10CM | Covered |
| E08.3553 | ICD10CM | Covered |
| E08.3591 | ICD10CM | Covered |
| E08.3592 | ICD10CM | Covered |
| E08.3593 | ICD10CM | Covered |
| E08.36 | ICD10CM | Covered |
| E08.37X1 | ICD10CM | Covered |
| E08.37X2 | ICD10CM | Covered |
| E08.37X3 | ICD10CM | Covered |
| E08.39 | ICD10CM | Covered |
| E08.40 | ICD10CM | Covered |
| E08.41 | ICD10CM | Covered |
| E08.42 | ICD10CM | Covered |
| E08.43 | ICD10CM | Covered |
| E08.44 | ICD10CM | Covered |
| E08.49 | ICD10CM | Covered |
| E08.51 | ICD10CM | Covered |
| E08.52 | ICD10CM | Covered |
| E08.59 | ICD10CM | Covered |
| E08.610 | ICD10CM | Covered |
| E08.618 | ICD10CM | Covered |
| E08.620 | ICD10CM | Covered |
| E08.621 | ICD10CM | Covered |
| E08.622 | ICD10CM | Covered |
| E08.628 | ICD10CM | Covered |
| E08.630 | ICD10CM | Covered |
| E08.638 | ICD10CM | Covered |
| E08.641 | ICD10CM | Covered |
| E08.649 | ICD10CM | Covered |
| E08.65 | ICD10CM | Covered |
| E08.69 | ICD10CM | Covered |
| E08.8 | ICD10CM | Covered |
| E08.9 | ICD10CM | Covered |
| E09.00 | ICD10CM | Covered |
| E09.01 | ICD10CM | Covered |
| E09.10 | ICD10CM | Covered |
| E09.11 | ICD10CM | Covered |
| E09.21 | ICD10CM | Covered |
| E09.22 | ICD10CM | Covered |
| E09.29 | ICD10CM | Covered |
| E09.311 | ICD10CM | Covered |
| E09.319 | ICD10CM | Covered |
| E09.3211 | ICD10CM | Covered |
| E09.3212 | ICD10CM | Covered |
| E09.3213 | ICD10CM | Covered |
| E09.3291 | ICD10CM | Covered |
| E09.3292 | ICD10CM | Covered |
| E09.3293 | ICD10CM | Covered |
| E09.3311 | ICD10CM | Covered |
| E09.3312 | ICD10CM | Covered |
| E09.3313 | ICD10CM | Covered |
| E09.3391 | ICD10CM | Covered |
| E09.3392 | ICD10CM | Covered |
| E09.3393 | ICD10CM | Covered |
| E09.3411 | ICD10CM | Covered |
| E09.3412 | ICD10CM | Covered |
| E09.3413 | ICD10CM | Covered |
| E09.3491 | ICD10CM | Covered |
| E09.3492 | ICD10CM | Covered |
| E09.3493 | ICD10CM | Covered |
| E09.3511 | ICD10CM | Covered |
| E09.3512 | ICD10CM | Covered |
| E09.3513 | ICD10CM | Covered |
| E09.3521 | ICD10CM | Covered |
| E09.3522 | ICD10CM | Covered |
| E09.3523 | ICD10CM | Covered |
| E09.3531 | ICD10CM | Covered |
| E09.3532 | ICD10CM | Covered |
| E09.3533 | ICD10CM | Covered |
| E09.3541 | ICD10CM | Covered |
| E09.3542 | ICD10CM | Covered |
| E09.3543 | ICD10CM | Covered |
| E09.3551 | ICD10CM | Covered |
| E09.3552 | ICD10CM | Covered |
| E09.3553 | ICD10CM | Covered |
| E09.3591 | ICD10CM | Covered |
| E09.3592 | ICD10CM | Covered |
| E09.3593 | ICD10CM | Covered |
| E09.36 | ICD10CM | Covered |
| E09.37X1 | ICD10CM | Covered |
| E09.37X2 | ICD10CM | Covered |
| E09.37X3 | ICD10CM | Covered |
| E09.39 | ICD10CM | Covered |
| E09.40 | ICD10CM | Covered |
| E09.41 | ICD10CM | Covered |
| E09.42 | ICD10CM | Covered |
| E09.43 | ICD10CM | Covered |
| E09.44 | ICD10CM | Covered |
| E09.49 | ICD10CM | Covered |
| E09.51 | ICD10CM | Covered |
| E09.52 | ICD10CM | Covered |
| E09.59 | ICD10CM | Covered |
| E09.610 | ICD10CM | Covered |
| E09.618 | ICD10CM | Covered |
| E09.620 | ICD10CM | Covered |
| E09.621 | ICD10CM | Covered |
| E09.622 | ICD10CM | Covered |
| E09.628 | ICD10CM | Covered |
| E09.630 | ICD10CM | Covered |
| E09.638 | ICD10CM | Covered |
| E09.641 | ICD10CM | Covered |
| E09.649 | ICD10CM | Covered |
| E09.65 | ICD10CM | Covered |
| E09.69 | ICD10CM | Covered |
| E09.8 | ICD10CM | Covered |
| E09.9 | ICD10CM | Covered |
| E10.10 | ICD10CM | Covered |
| E10.11 | ICD10CM | Covered |
| E10.21 | ICD10CM | Covered |
| E10.22 | ICD10CM | Covered |
| E10.29 | ICD10CM | Covered |
| E10.311 | ICD10CM | Covered |
| E10.319 | ICD10CM | Covered |
| E10.3211 | ICD10CM | Covered |
| E10.3212 | ICD10CM | Covered |
| E10.3213 | ICD10CM | Covered |
| E10.3291 | ICD10CM | Covered |
| E10.3292 | ICD10CM | Covered |
| E10.3293 | ICD10CM | Covered |
| E10.3311 | ICD10CM | Covered |
| E10.3312 | ICD10CM | Covered |
| E10.3313 | ICD10CM | Covered |
| E10.3391 | ICD10CM | Covered |
| E10.3392 | ICD10CM | Covered |
| E10.3393 | ICD10CM | Covered |
| E10.3411 | ICD10CM | Covered |
| E10.3412 | ICD10CM | Covered |
| E10.3413 | ICD10CM | Covered |
| E10.3491 | ICD10CM | Covered |
| E10.3492 | ICD10CM | Covered |
| E10.3493 | ICD10CM | Covered |
| E10.3511 | ICD10CM | Covered |
| E10.3512 | ICD10CM | Covered |
| E10.3513 | ICD10CM | Covered |
| E10.3521 | ICD10CM | Covered |
| E10.3522 | ICD10CM | Covered |
| E10.3523 | ICD10CM | Covered |
| E10.3531 | ICD10CM | Covered |
| E10.3532 | ICD10CM | Covered |
| E10.3533 | ICD10CM | Covered |
| E10.3541 | ICD10CM | Covered |
| E10.3542 | ICD10CM | Covered |
| E10.3543 | ICD10CM | Covered |
| E10.3551 | ICD10CM | Covered |
| E10.3552 | ICD10CM | Covered |
| E10.3553 | ICD10CM | Covered |
| E10.3591 | ICD10CM | Covered |
| E10.3592 | ICD10CM | Covered |
| E10.3593 | ICD10CM | Covered |
| E10.36 | ICD10CM | Covered |
| E10.39 | ICD10CM | Covered |
| E10.40 | ICD10CM | Covered |
| E10.41 | ICD10CM | Covered |
| E10.42 | ICD10CM | Covered |
| E10.43 | ICD10CM | Covered |
| E10.44 | ICD10CM | Covered |
| E10.49 | ICD10CM | Covered |
| E10.51 | ICD10CM | Covered |
| E10.52 | ICD10CM | Covered |
| E10.59 | ICD10CM | Covered |
| E10.610 | ICD10CM | Covered |
| E10.618 | ICD10CM | Covered |
| E10.620 | ICD10CM | Covered |
| E10.621 | ICD10CM | Covered |
| E10.622 | ICD10CM | Covered |
| E10.628 | ICD10CM | Covered |
| E10.630 | ICD10CM | Covered |
| E10.638 | ICD10CM | Covered |
| E10.641 | ICD10CM | Covered |
| E10.649 | ICD10CM | Covered |
| E10.65 | ICD10CM | Covered |
| E10.69 | ICD10CM | Covered |
| E10.8 | ICD10CM | Covered |
| E10.9 | ICD10CM | Covered |
| E11.00 | ICD10CM | Covered |
| E11.01 | ICD10CM | Covered |
| E11.10 | ICD10CM | Covered |
| E11.11 | ICD10CM | Covered |
| E11.21 | ICD10CM | Covered |
| E11.22 | ICD10CM | Covered |
| E11.29 | ICD10CM | Covered |
| E11.311 | ICD10CM | Covered |
| E11.319 | ICD10CM | Covered |
| E11.3211 | ICD10CM | Covered |
| E11.3212 | ICD10CM | Covered |
| E11.3213 | ICD10CM | Covered |
| E11.3291 | ICD10CM | Covered |
| E11.3292 | ICD10CM | Covered |
| E11.3293 | ICD10CM | Covered |
| E11.3311 | ICD10CM | Covered |
| E11.3312 | ICD10CM | Covered |
| E11.3313 | ICD10CM | Covered |
| E11.3391 | ICD10CM | Covered |
| E11.3392 | ICD10CM | Covered |
| E11.3393 | ICD10CM | Covered |
| E11.3411 | ICD10CM | Covered |
| E11.3412 | ICD10CM | Covered |
| E11.3413 | ICD10CM | Covered |
| E11.3491 | ICD10CM | Covered |
| E11.3492 | ICD10CM | Covered |
| E11.3493 | ICD10CM | Covered |
| E11.3511 | ICD10CM | Covered |
| E11.3512 | ICD10CM | Covered |
| E11.3513 | ICD10CM | Covered |
| E11.3521 | ICD10CM | Covered |
| E11.3522 | ICD10CM | Covered |
| E11.3523 | ICD10CM | Covered |
| E11.3531 | ICD10CM | Covered |
| E11.3532 | ICD10CM | Covered |
| E11.3533 | ICD10CM | Covered |
| E11.3541 | ICD10CM | Covered |
| E11.3542 | ICD10CM | Covered |
| E11.3543 | ICD10CM | Covered |
| E11.3551 | ICD10CM | Covered |
| E11.3552 | ICD10CM | Covered |
| E11.3553 | ICD10CM | Covered |
| E11.3591 | ICD10CM | Covered |
| E11.3592 | ICD10CM | Covered |
| E11.3593 | ICD10CM | Covered |
| E11.36 | ICD10CM | Covered |
| E11.37X1 | ICD10CM | Covered |
| E11.37X2 | ICD10CM | Covered |
| E11.37X3 | ICD10CM | Covered |
| E11.39 | ICD10CM | Covered |
| E11.40 | ICD10CM | Covered |
| E11.41 | ICD10CM | Covered |
| E11.42 | ICD10CM | Covered |
| E11.43 | ICD10CM | Covered |
| E11.44 | ICD10CM | Covered |
| E11.49 | ICD10CM | Covered |
| E11.51 | ICD10CM | Covered |
| E11.52 | ICD10CM | Covered |
| E11.59 | ICD10CM | Covered |
| E11.610 | ICD10CM | Covered |
| E11.618 | ICD10CM | Covered |
| E11.620 | ICD10CM | Covered |
| E11.621 | ICD10CM | Covered |
| E11.622 | ICD10CM | Covered |
| E11.628 | ICD10CM | Covered |
| E11.630 | ICD10CM | Covered |
| E11.638 | ICD10CM | Covered |
| E11.641 | ICD10CM | Covered |
| E11.649 | ICD10CM | Covered |
| E11.65 | ICD10CM | Covered |
| E11.69 | ICD10CM | Covered |
| E11.8 | ICD10CM | Covered |
| E11.9 | ICD10CM | Covered |
| E13.00 | ICD10CM | Covered |
| E13.01 | ICD10CM | Covered |
| E13.10 | ICD10CM | Covered |
| E13.11 | ICD10CM | Covered |
| E13.21 | ICD10CM | Covered |
| E13.22 | ICD10CM | Covered |
| E13.29 | ICD10CM | Covered |
| E13.311 | ICD10CM | Covered |
| E13.319 | ICD10CM | Covered |
| E13.3211 | ICD10CM | Covered |
| E13.3212 | ICD10CM | Covered |
| E13.3213 | ICD10CM | Covered |
| E13.3291 | ICD10CM | Covered |
| E13.3292 | ICD10CM | Covered |
| E13.3293 | ICD10CM | Covered |
| E13.3311 | ICD10CM | Covered |
| E13.3312 | ICD10CM | Covered |
| E13.3313 | ICD10CM | Covered |
| E13.3391 | ICD10CM | Covered |
| E13.3392 | ICD10CM | Covered |
| E13.3393 | ICD10CM | Covered |
| E13.3411 | ICD10CM | Covered |
| E13.3412 | ICD10CM | Covered |
| E13.3413 | ICD10CM | Covered |
| E13.3491 | ICD10CM | Covered |
| E13.3492 | ICD10CM | Covered |
| E13.3493 | ICD10CM | Covered |
| E13.3511 | ICD10CM | Covered |
| E13.3512 | ICD10CM | Covered |
| E13.3513 | ICD10CM | Covered |
| E13.3521 | ICD10CM | Covered |
| E13.3522 | ICD10CM | Covered |
| E13.3523 | ICD10CM | Covered |
| E13.3531 | ICD10CM | Covered |
| E13.3532 | ICD10CM | Covered |
| E13.3533 | ICD10CM | Covered |
| E13.3541 | ICD10CM | Covered |
| E13.3542 | ICD10CM | Covered |
| E13.3543 | ICD10CM | Covered |
| E13.3551 | ICD10CM | Covered |
| E13.3552 | ICD10CM | Covered |
| E13.3553 | ICD10CM | Covered |
| E13.3591 | ICD10CM | Covered |
| E13.3592 | ICD10CM | Covered |
| E13.3593 | ICD10CM | Covered |
| E13.36 | ICD10CM | Covered |
| E13.37X1 | ICD10CM | Covered |
| E13.37X2 | ICD10CM | Covered |
| E13.37X3 | ICD10CM | Covered |
| E13.39 | ICD10CM | Covered |
| E13.40 | ICD10CM | Covered |
| E13.41 | ICD10CM | Covered |
| E13.42 | ICD10CM | Covered |
| E13.43 | ICD10CM | Covered |
| E13.44 | ICD10CM | Covered |
| E13.49 | ICD10CM | Covered |
| E13.51 | ICD10CM | Covered |
| E13.52 | ICD10CM | Covered |
| E13.59 | ICD10CM | Covered |
| E13.610 | ICD10CM | Covered |
| E13.618 | ICD10CM | Covered |
| E13.620 | ICD10CM | Covered |
| E13.621 | ICD10CM | Covered |
| E13.622 | ICD10CM | Covered |
| E13.628 | ICD10CM | Covered |
| E13.630 | ICD10CM | Covered |
| E13.638 | ICD10CM | Covered |
| E13.641 | ICD10CM | Covered |
| E13.649 | ICD10CM | Covered |
| E13.65 | ICD10CM | Covered |
| E13.69 | ICD10CM | Covered |
| E13.8 | ICD10CM | Covered |
| E13.9 | ICD10CM | Covered |
| E52 | ICD10CM | Covered |
| E53.0 | ICD10CM | Covered |
| E53.1 | ICD10CM | Covered |
| E53.8 | ICD10CM | Covered |
| E53.9 | ICD10CM | Covered |
| E75.21 | ICD10CM | Covered |
| E75.22 | ICD10CM | Covered |
| E75.240 | ICD10CM | Covered |
| E75.241 | ICD10CM | Covered |
| E75.242 | ICD10CM | Covered |
| E75.243 | ICD10CM | Covered |
| E75.244 | ICD10CM | Covered |
| E75.248 | ICD10CM | Covered |
| E75.249 | ICD10CM | Covered |
| E75.3 | ICD10CM | Covered |
| E77.0 | ICD10CM | Covered |
| E77.1 | ICD10CM | Covered |
| E77.8 | ICD10CM | Covered |
| E77.9 | 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 |
| G12.21 | ICD10CM | Covered |
| G12.25 | ICD10CM | Covered |
| G13.0 | ICD10CM | Covered |
| G13.1 | ICD10CM | Covered |
| G35.A | ICD10CM | Covered |
| G35.B1 | ICD10CM | Covered |
| G35.B2 | ICD10CM | Covered |
| G35.C1 | ICD10CM | Covered |
| G35.C2 | ICD10CM | Covered |
| G60.0 | ICD10CM | Covered |
| G60.1 | ICD10CM | Covered |
| G60.2 | ICD10CM | Covered |
| G60.3 | ICD10CM | Covered |
| G60.8 | ICD10CM | Covered |
| G60.9 | ICD10CM | Covered |
| G61.0 | ICD10CM | Covered |
| G61.1 | ICD10CM | Covered |
| G61.81 | ICD10CM | Covered |
| G61.89 | ICD10CM | Covered |
| G61.9 | ICD10CM | Covered |
| G62.0 | ICD10CM | Covered |
| G62.1 | ICD10CM | Covered |
| G62.2 | ICD10CM | Covered |
| G62.81 | ICD10CM | Covered |
| G62.82 | ICD10CM | Covered |
| G62.89 | ICD10CM | Covered |
| G62.9 | ICD10CM | Covered |
| G63 | ICD10CM | Covered |
| G64 | ICD10CM | Covered |
| G65.0 | ICD10CM | Covered |
| G65.1 | ICD10CM | Covered |
| G65.2 | ICD10CM | Covered |
| G90.09 | ICD10CM | Covered |
| G99.0 | ICD10CM | Covered |
| I70.201 | ICD10CM | Covered |
| I70.202 | ICD10CM | Covered |
| I70.203 | ICD10CM | Covered |
| I70.208 | ICD10CM | Covered |
| I70.209 | ICD10CM | Covered |
| I70.211 | ICD10CM | Covered |
| I70.212 | ICD10CM | Covered |
| I70.213 | ICD10CM | Covered |
| I70.218 | ICD10CM | Covered |
| I70.219 | ICD10CM | Covered |
| I70.221 | ICD10CM | Covered |
| I70.222 | ICD10CM | Covered |
| I70.223 | ICD10CM | Covered |
| I70.228 | ICD10CM | Covered |
| I70.229 | 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 |
| I70.269 | ICD10CM | Covered |
| I70.291 | ICD10CM | Covered |
| I70.292 | ICD10CM | Covered |
| I70.293 | ICD10CM | Covered |
| I70.298 | ICD10CM | Covered |
| I70.299 | ICD10CM | Covered |
| I70.90 | ICD10CM | Covered |
| I70.91 | ICD10CM | Covered |
| I73.00 | ICD10CM | Covered |
| I73.01 | ICD10CM | Covered |
| I73.1 | ICD10CM | Covered |
| I73.81 | ICD10CM | Covered |
| I73.89 | ICD10CM | Covered |
| I73.9 | ICD10CM | Covered |
| I77.1 | ICD10CM | Covered |
| I77.6 | ICD10CM | Covered |
| I79.1 | ICD10CM | Covered |
| I79.8 | ICD10CM | Covered |
| I80.00 | ICD10CM | Covered |
| I80.01 | ICD10CM | Covered |
| I80.02 | ICD10CM | Covered |
| I80.03 | ICD10CM | Covered |
| I80.10 | ICD10CM | Covered |
| I80.11 | ICD10CM | Covered |
| I80.12 | ICD10CM | Covered |
| I80.13 | ICD10CM | Covered |
| I80.201 | ICD10CM | Covered |
| I80.202 | ICD10CM | Covered |
| I80.203 | ICD10CM | Covered |
| I80.209 | ICD10CM | Covered |
| I80.221 | ICD10CM | Covered |
| I80.222 | ICD10CM | Covered |
| I80.223 | ICD10CM | Covered |
| I80.229 | ICD10CM | Covered |
| I80.231 | ICD10CM | Covered |
| I80.232 | ICD10CM | Covered |
| I80.233 | ICD10CM | Covered |
| I80.239 | ICD10CM | Covered |
| I80.241 | ICD10CM | Covered |
| I80.242 | ICD10CM | Covered |
| I80.243 | ICD10CM | Covered |
| I80.251 | ICD10CM | Covered |
| I80.252 | ICD10CM | Covered |
| I80.253 | ICD10CM | Covered |
| I80.291 | ICD10CM | Covered |
| I80.292 | ICD10CM | Covered |
| I80.293 | ICD10CM | Covered |
| I80.299 | ICD10CM | Covered |
| I80.3 | ICD10CM | Covered |
| I87.001 | ICD10CM | Covered |
| I87.002 | ICD10CM | Covered |
| I87.003 | ICD10CM | Covered |
| I87.009 | ICD10CM | Covered |
| I87.011 | ICD10CM | Covered |
| I87.012 | ICD10CM | Covered |
| I87.013 | ICD10CM | Covered |
| I87.019 | ICD10CM | Covered |
| I87.021 | ICD10CM | Covered |
| I87.022 | ICD10CM | Covered |
| I87.023 | ICD10CM | Covered |
| I87.029 | ICD10CM | Covered |
| I87.031 | ICD10CM | Covered |
| I87.032 | ICD10CM | Covered |
| I87.033 | ICD10CM | Covered |
| I87.039 | ICD10CM | Covered |
| I87.091 | ICD10CM | Covered |
| I87.092 | ICD10CM | Covered |
| I87.093 | ICD10CM | Covered |
| I87.099 | ICD10CM | Covered |
| I87.1 | ICD10CM | Covered |
| I87.2 | ICD10CM | Covered |
| I87.301 | ICD10CM | Covered |
| I87.302 | ICD10CM | Covered |
| I87.303 | ICD10CM | Covered |
| I87.309 | ICD10CM | Covered |
| I87.311 | ICD10CM | Covered |
| I87.312 | ICD10CM | Covered |
| I87.313 | ICD10CM | Covered |
| I87.319 | ICD10CM | Covered |
| I87.321 | ICD10CM | Covered |
| I87.322 | ICD10CM | Covered |
| I87.323 | ICD10CM | Covered |
| I87.329 | ICD10CM | Covered |
| I87.331 | ICD10CM | Covered |
| I87.332 | ICD10CM | Covered |
| I87.333 | ICD10CM | Covered |
| I87.339 | ICD10CM | Covered |
| I87.391 | ICD10CM | Covered |
| I87.392 | ICD10CM | Covered |
| I87.393 | ICD10CM | Covered |
| I87.399 | ICD10CM | Covered |
| I87.9 | ICD10CM | Covered |
| I89.0 | ICD10CM | Covered |
| I99.9 | ICD10CM | Covered |
| K90.0 | ICD10CM | Covered |
| K90.1 | ICD10CM | Covered |
| K90.9 | ICD10CM | Covered |
| L02.415 | ICD10CM | Covered |
| L02.416 | ICD10CM | Covered |
| L02.419 | ICD10CM | Covered |
| L02.611 | ICD10CM | Covered |
| L02.612 | ICD10CM | Covered |
| L02.619 | ICD10CM | Covered |
| L02.91 | ICD10CM | Covered |
| L03.031 | ICD10CM | Covered |
| L03.032 | ICD10CM | Covered |
| L03.039 | ICD10CM | Covered |
| L03.041 | ICD10CM | Covered |
| L03.042 | ICD10CM | Covered |
| L03.049 | ICD10CM | Covered |
| L03.115 | ICD10CM | Covered |
| L03.116 | ICD10CM | Covered |
| L03.119 | ICD10CM | Covered |
| L03.125 | ICD10CM | Covered |
| L03.126 | ICD10CM | Covered |
| L03.129 | ICD10CM | Covered |
| L03.90 | ICD10CM | Covered |
| L03.91 | ICD10CM | Covered |
| L98.3 | ICD10CM | Covered |
| M05.50 | ICD10CM | Covered |
| M05.511 | ICD10CM | Covered |
| M05.512 | ICD10CM | Covered |
| M05.519 | ICD10CM | Covered |
| M05.521 | ICD10CM | Covered |
| M05.522 | ICD10CM | Covered |
| M05.529 | ICD10CM | Covered |
| M05.531 | ICD10CM | Covered |
| M05.532 | ICD10CM | Covered |
| M05.539 | ICD10CM | Covered |
| M05.541 | ICD10CM | Covered |
| M05.542 | ICD10CM | Covered |
| M05.549 | ICD10CM | Covered |
| M05.551 | ICD10CM | Covered |
| M05.552 | ICD10CM | Covered |
| M05.559 | ICD10CM | Covered |
| M05.561 | ICD10CM | Covered |
| M05.562 | ICD10CM | Covered |
| M05.569 | ICD10CM | Covered |
| M05.571 | ICD10CM | Covered |
| M05.572 | ICD10CM | Covered |
| M05.579 | ICD10CM | Covered |
| M05.59 | ICD10CM | Covered |
| M34.83 | ICD10CM | Covered |
| N18.1 | ICD10CM | Covered |
| N18.2 | ICD10CM | Covered |
| N18.31 | ICD10CM | Covered |
| N18.32 | ICD10CM | Covered |
| N18.4 | ICD10CM | Covered |
| N18.5 | ICD10CM | Covered |
| N18.6 | ICD10CM | Covered |
| N18.9 | ICD10CM | Covered |
| O24.011 | ICD10CM | Covered |
| O24.012 | ICD10CM | Covered |
| O24.013 | ICD10CM | Covered |
| O24.019 | ICD10CM | Covered |
| O24.02 | ICD10CM | Covered |
| O24.03 | ICD10CM | Covered |
| O24.111 | ICD10CM | Covered |
| O24.112 | ICD10CM | Covered |
| O24.113 | ICD10CM | Covered |
| O24.119 | ICD10CM | Covered |
| O24.12 | ICD10CM | Covered |
| O24.13 | ICD10CM | Covered |
| O24.311 | ICD10CM | Covered |
| O24.312 | ICD10CM | Covered |
| O24.313 | ICD10CM | Covered |
| O24.319 | ICD10CM | Covered |
| O24.32 | ICD10CM | Covered |
| O24.33 | ICD10CM | Covered |
| O24.811 | ICD10CM | Covered |
| O24.812 | ICD10CM | Covered |
| O24.813 | ICD10CM | Covered |
| O24.819 | ICD10CM | Covered |
| O24.82 | ICD10CM | Covered |
| O24.83 | ICD10CM | Covered |
| O24.911 | ICD10CM | Covered |
| O24.912 | ICD10CM | Covered |
| O24.913 | ICD10CM | Covered |
| O24.919 | ICD10CM | Covered |
| O24.92 | ICD10CM | Covered |
| O24.93 | ICD10CM | Covered |
| Q82.0 | ICD10CM | Covered |
| R60.0 | ICD10CM | Covered |
| R60.1 | ICD10CM | Covered |
| R60.9 | ICD10CM | Covered |
| S86.001A | ICD10CM | Covered |
| S86.002A | ICD10CM | Covered |
| S86.009A | ICD10CM | Covered |
| S86.091A | ICD10CM | Covered |
| S86.092A | ICD10CM | Covered |
| S86.099A | ICD10CM | Covered |
| S86.101A | ICD10CM | Covered |
| S86.102A | ICD10CM | Covered |
| S86.109A | ICD10CM | Covered |
| S86.191A | ICD10CM | Covered |
| S86.192A | ICD10CM | Covered |
| S86.199A | ICD10CM | Covered |
| S86.201A | ICD10CM | Covered |
| S86.202A | ICD10CM | Covered |
| S86.209A | ICD10CM | Covered |
| S86.291A | ICD10CM | Covered |
| S86.292A | ICD10CM | Covered |
| S86.299A | ICD10CM | Covered |
| S86.301A | ICD10CM | Covered |
| S86.302A | ICD10CM | Covered |
| S86.309A | ICD10CM | Covered |
| S86.391A | ICD10CM | Covered |
| S86.392A | ICD10CM | Covered |
| S86.399A | ICD10CM | Covered |
| S86.801A | ICD10CM | Covered |
| S86.802A | ICD10CM | Covered |
| S86.809A | ICD10CM | Covered |
| S86.891A | ICD10CM | Covered |
| S86.892A | ICD10CM | Covered |
| S86.899A | ICD10CM | Covered |
| S86.901A | ICD10CM | Covered |
| S86.902A | ICD10CM | Covered |
| S86.909A | ICD10CM | Covered |
| S86.991A | ICD10CM | Covered |
| S86.992A | ICD10CM | Covered |
| S86.999A | ICD10CM | Covered |
| S89.80XA | ICD10CM | Covered |
| S89.81XA | ICD10CM | Covered |
| S89.82XA | ICD10CM | Covered |
| S89.90XA | ICD10CM | Covered |
| S89.91XA | ICD10CM | Covered |
| S89.92XA | ICD10CM | Covered |
| S96.001A | ICD10CM | Covered |
| S96.002A | ICD10CM | Covered |
| S96.009A | ICD10CM | Covered |
| S96.091A | ICD10CM | Covered |
| S96.092A | ICD10CM | Covered |
| S96.099A | ICD10CM | Covered |
| S96.101A | ICD10CM | Covered |
| S96.102A | ICD10CM | Covered |
| S96.109A | ICD10CM | Covered |
| S96.191A | ICD10CM | Covered |
| S96.192A | ICD10CM | Covered |
| S96.199A | ICD10CM | Covered |
| S96.201A | ICD10CM | Covered |
| S96.202A | ICD10CM | Covered |
| S96.209A | ICD10CM | Covered |
| S96.291A | ICD10CM | Covered |
| S96.292A | ICD10CM | Covered |
| S96.299A | ICD10CM | Covered |
| S96.801A | ICD10CM | Covered |
| S96.802A | ICD10CM | Covered |
| S96.809A | ICD10CM | Covered |
| S96.891A | ICD10CM | Covered |
| S96.892A | ICD10CM | Covered |
| S96.899A | ICD10CM | Covered |
| S96.901A | ICD10CM | Covered |
| S96.902A | ICD10CM | Covered |
| S96.909A | ICD10CM | Covered |
| S96.991A | ICD10CM | Covered |
| S96.992A | ICD10CM | Covered |
| S96.999A | ICD10CM | Covered |
| S99.811A | ICD10CM | Covered |
| S99.812A | ICD10CM | Covered |
| S99.819A | ICD10CM | Covered |
| S99.821A | ICD10CM | Covered |
| S99.822A | ICD10CM | Covered |
| S99.829A | ICD10CM | Covered |
| S99.911A | ICD10CM | Covered |
| S99.912A | ICD10CM | Covered |
| S99.919A | ICD10CM | Covered |
| S99.921A | ICD10CM | Covered |
| S99.922A | ICD10CM | Covered |
| S99.929A | ICD10CM | Covered |
| Z79.01 | ICD10CM | Covered |