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 8,104 codes. The source has the full list.
| Code | Code system | Status in this policy |
|---|---|---|
| 29065 | HCPCS | Covered |
| 29075 | HCPCS | Covered |
| 29085 | HCPCS | Covered |
| 29086 | HCPCS | Covered |
| 29105 | HCPCS | Covered |
| 29125 | HCPCS | Covered |
| 29126 | HCPCS | Covered |
| 29130 | HCPCS | Covered |
| 29131 | HCPCS | Covered |
| 29200 | HCPCS | Covered |
| 29240 | HCPCS | Covered |
| 29260 | HCPCS | Covered |
| 29280 | HCPCS | Covered |
| 29345 | HCPCS | Covered |
| 29365 | HCPCS | Covered |
| 29405 | HCPCS | Covered |
| 29505 | HCPCS | Covered |
| 29515 | HCPCS | Covered |
| 29520 | HCPCS | Covered |
| 29530 | HCPCS | Covered |
| 29540 | HCPCS | Covered |
| 29550 | HCPCS | Covered |
| 29799 | HCPCS | Covered |
| 90901 | HCPCS | Covered |
| 90912 | HCPCS | Covered |
| 90913 | HCPCS | Covered |
| 92526 | HCPCS | Covered |
| 92548 | HCPCS | Covered |
| 92610 | HCPCS | Covered |
| 92626 | HCPCS | Covered |
| 92627 | HCPCS | Covered |
| 95851 | HCPCS | Covered |
| 95852 | HCPCS | Covered |
| 96112 | HCPCS | Covered |
| 96113 | HCPCS | Covered |
| 96125 | HCPCS | Covered |
| 97010 | HCPCS | Covered |
| 97012 | HCPCS | Covered |
| 97016 | HCPCS | Covered |
| 97018 | HCPCS | Covered |
| 97022 | HCPCS | Covered |
| 97024 | HCPCS | Covered |
| 97026 | HCPCS | Covered |
| 97032 | HCPCS | Covered |
| 97033 | HCPCS | Covered |
| 97034 | HCPCS | Covered |
| 97035 | HCPCS | Covered |
| 97036 | HCPCS | Covered |
| 97110 | HCPCS | Covered |
| 97112 | HCPCS | Covered |
| 97113 | HCPCS | Covered |
| 97124 | HCPCS | Covered |
| 97129 | HCPCS | Covered |
| 97130 | HCPCS | Covered |
| 97140 | HCPCS | Covered |
| 97150 | HCPCS | Covered |
| 97165 | HCPCS | Covered |
| 97166 | HCPCS | Covered |
| 97167 | HCPCS | Covered |
| 97168 | HCPCS | Covered |
| 97530 | HCPCS | Covered |
| 97533 | HCPCS | Covered |
| 97535 | HCPCS | Covered |
| 97537 | HCPCS | Covered |
| 97542 | HCPCS | Covered |
| 97545 | HCPCS | Covered |
| 97546 | HCPCS | Covered |
| 97550 | HCPCS | Covered |
| 97551 | HCPCS | Covered |
| 97552 | HCPCS | Covered |
| 97597 | HCPCS | Covered |
| 97598 | HCPCS | Covered |
| 97602 | HCPCS | Covered |
| 97605 | HCPCS | Covered |
| 97606 | HCPCS | Covered |
| 97750 | HCPCS | Covered |
| 97755 | HCPCS | Covered |
| 97760 | HCPCS | Covered |
| 97761 | HCPCS | Covered |
| 97763 | HCPCS | Covered |
| 97799 | HCPCS | Covered |
| G0281 | HCPCS | Covered |
| G0283 | HCPCS | Covered |
| G0329 | HCPCS | Covered |
| A18.01 | ICD10CM | Covered |
| A18.02 | ICD10CM | Covered |
| A52.16 | ICD10CM | Covered |
| B91 | ICD10CM | Covered |
| E08.40 | ICD10CM | Covered |
| E08.41 | ICD10CM | Covered |
| E08.42 | ICD10CM | Covered |
| E08.44 | ICD10CM | Covered |
| E08.52 | ICD10CM | Covered |
| E08.610 | ICD10CM | Covered |
| E08.618 | ICD10CM | Covered |
| E09.40 | ICD10CM | Covered |
| E09.41 | ICD10CM | Covered |
| E09.42 | ICD10CM | Covered |
| E09.44 | ICD10CM | Covered |
| E09.52 | ICD10CM | Covered |
| E09.610 | ICD10CM | Covered |
| E09.618 | ICD10CM | Covered |
| E10.40 | ICD10CM | Covered |
| E10.41 | ICD10CM | Covered |
| E10.42 | ICD10CM | Covered |
| E10.44 | ICD10CM | Covered |
| E10.52 | ICD10CM | Covered |
| E10.610 | ICD10CM | Covered |
| E10.618 | ICD10CM | Covered |
| E11.40 | ICD10CM | Covered |
| E11.41 | ICD10CM | Covered |
| E11.42 | ICD10CM | Covered |
| E11.44 | ICD10CM | Covered |
| E11.52 | ICD10CM | Covered |
| E11.610 | ICD10CM | Covered |
| E11.618 | ICD10CM | Covered |
| E13.40 | ICD10CM | Covered |
| E13.41 | ICD10CM | Covered |
| E13.42 | ICD10CM | Covered |
| E13.44 | ICD10CM | Covered |
| E13.52 | ICD10CM | Covered |
| E13.610 | ICD10CM | Covered |
| E13.618 | ICD10CM | Covered |
| F02.818 | ICD10CM | Covered |
| F02.A18 | ICD10CM | Covered |
| F02.B18 | ICD10CM | Covered |
| F02.C18 | ICD10CM | Covered |
| F07.0 | ICD10CM | Covered |
| F07.89 | ICD10CM | Covered |
| F48.2 | ICD10CM | Covered |
| F50.810 | ICD10CM | Covered |
| F50.811 | ICD10CM | Covered |
| F50.812 | ICD10CM | Covered |
| F50.813 | ICD10CM | Covered |
| F50.814 | ICD10CM | Covered |
| F50.819 | ICD10CM | Covered |
| F50.82 | ICD10CM | Covered |
| F50.83 | ICD10CM | Covered |
| F50.84 | ICD10CM | Covered |
| F50.9 | ICD10CM | Covered |
| F81.2 | ICD10CM | Covered |
| F98.29 | ICD10CM | Covered |
| G04.1 | ICD10CM | Covered |
| G04.82 | ICD10CM | Covered |
| G11.0 | ICD10CM | Covered |
| G11.10 | ICD10CM | Covered |
| G11.11 | ICD10CM | Covered |
| G11.19 | ICD10CM | Covered |
| G11.2 | ICD10CM | Covered |
| G11.3 | ICD10CM | Covered |
| G11.4 | ICD10CM | Covered |
| G11.8 | ICD10CM | Covered |
| G11.9 | ICD10CM | Covered |
| G12.0 | ICD10CM | Covered |
| G12.1 | ICD10CM | Covered |
| G12.20 | ICD10CM | Covered |
| G12.21 | ICD10CM | Covered |
| G12.22 | ICD10CM | Covered |
| G12.23 | ICD10CM | Covered |
| G12.24 | ICD10CM | Covered |
| G12.25 | ICD10CM | Covered |
| G12.29 | ICD10CM | Covered |
| G12.8 | ICD10CM | Covered |
| G12.9 | ICD10CM | Covered |
| G14 | ICD10CM | Covered |
| G20.A1 | ICD10CM | Covered |
| G20.A2 | ICD10CM | Covered |
| G20.B1 | ICD10CM | Covered |
| G20.B2 | ICD10CM | Covered |
| G20.C | ICD10CM | Covered |
| G24.01 | ICD10CM | Covered |
| G24.02 | ICD10CM | Covered |
| G24.09 | ICD10CM | Covered |
| G24.2 | ICD10CM | Covered |
| G24.3 | ICD10CM | Covered |
| G24.8 | ICD10CM | Covered |
| G25.82 | ICD10CM | Covered |
| G25.89 | ICD10CM | Covered |
| G31.80 | ICD10CM | Covered |
| G31.85 | ICD10CM | Covered |
| G31.86 | ICD10CM | Covered |
| G32.0 | ICD10CM | Covered |
| G32.81 | ICD10CM | Covered |
| G43.401 | ICD10CM | Covered |
| G43.409 | ICD10CM | Covered |
| G43.411 | ICD10CM | Covered |
| G43.419 | ICD10CM | Covered |
| G43.601 | ICD10CM | Covered |
| G43.609 | ICD10CM | Covered |
| G43.611 | ICD10CM | Covered |
| G43.619 | ICD10CM | Covered |
| G54.0 | ICD10CM | Covered |
| G54.1 | ICD10CM | Covered |
| G54.2 | ICD10CM | Covered |
| G54.3 | ICD10CM | Covered |
| G54.4 | ICD10CM | Covered |
| G54.5 | ICD10CM | Covered |
| G54.6 | ICD10CM | Covered |
| G54.7 | ICD10CM | Covered |
| G54.8 | ICD10CM | Covered |
| G54.9 | ICD10CM | Covered |
| G55 | ICD10CM | Covered |
| G56.01 | ICD10CM | Covered |
| G56.02 | ICD10CM | Covered |
| G56.03 | ICD10CM | Covered |
| G56.11 | ICD10CM | Covered |
| G56.12 | ICD10CM | Covered |
| G56.13 | ICD10CM | Covered |
| G56.21 | ICD10CM | Covered |
| G56.22 | ICD10CM | Covered |
| G56.23 | ICD10CM | Covered |
| G56.31 | ICD10CM | Covered |
| G56.32 | ICD10CM | Covered |
| G56.33 | ICD10CM | Covered |
| G56.41 | ICD10CM | Covered |
| G56.42 | ICD10CM | Covered |
| G56.43 | ICD10CM | Covered |
| G56.81 | ICD10CM | Covered |
| G56.82 | ICD10CM | Covered |
| G56.83 | ICD10CM | Covered |
| G56.91 | ICD10CM | Covered |
| G56.92 | ICD10CM | Covered |
| G56.93 | ICD10CM | Covered |
| G57.03 | ICD10CM | Covered |
| G57.11 | ICD10CM | Covered |
| G57.12 | ICD10CM | Covered |
| G57.13 | ICD10CM | Covered |
| G57.23 | ICD10CM | Covered |
| G57.33 | ICD10CM | Covered |
| G57.43 | ICD10CM | Covered |
| G57.53 | ICD10CM | Covered |
| G57.63 | ICD10CM | Covered |
| G57.71 | ICD10CM | Covered |
| G57.72 | ICD10CM | Covered |
| G57.73 | ICD10CM | Covered |
| G57.83 | ICD10CM | Covered |
| G57.93 | ICD10CM | Covered |
| G58.0 | ICD10CM | Covered |
| G58.7 | ICD10CM | Covered |
| G58.8 | ICD10CM | Covered |
| G58.9 | ICD10CM | Covered |
| G59 | 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 |
| G61.82 | ICD10CM | Covered |
| G62.0 | ICD10CM | Covered |
| G62.1 | ICD10CM | Covered |
| G62.2 | ICD10CM | Covered |
| G62.81 | ICD10CM | Covered |
| G70.80 | ICD10CM | Covered |
| G70.81 | ICD10CM | Covered |
| G71.00 | ICD10CM | Covered |
| G71.01 | ICD10CM | Covered |
| G71.02 | ICD10CM | Covered |
| G71.031 | ICD10CM | Covered |
| G71.032 | ICD10CM | Covered |
| G71.033 | ICD10CM | Covered |
| G71.0340 | ICD10CM | Covered |
| G71.0341 | ICD10CM | Covered |
| G71.0342 | ICD10CM | Covered |
| G71.0349 | ICD10CM | Covered |
| G71.035 | ICD10CM | Covered |
| G71.036 | ICD10CM | Covered |
| G71.038 | ICD10CM | Covered |
| G71.09 | ICD10CM | Covered |
| G71.11 | ICD10CM | Covered |
| G71.12 | ICD10CM | Covered |
| G71.13 | ICD10CM | Covered |
| G71.14 | ICD10CM | Covered |
| G71.19 | ICD10CM | Covered |
| G71.20 | ICD10CM | Covered |
| G71.21 | ICD10CM | Covered |
| G71.220 | ICD10CM | Covered |
| G71.228 | ICD10CM | Covered |
| G71.29 | ICD10CM | Covered |
| G72.0 | ICD10CM | Covered |
| G72.1 | ICD10CM | Covered |
| G72.2 | ICD10CM | Covered |
| G72.41 | ICD10CM | Covered |
| G72.49 | ICD10CM | Covered |
| G72.81 | ICD10CM | Covered |
| G73.1 | ICD10CM | Covered |
| G80.0 | ICD10CM | Covered |
| G80.1 | ICD10CM | Covered |
| G80.2 | ICD10CM | Covered |
| G80.3 | ICD10CM | Covered |
| G80.4 | ICD10CM | Covered |
| G80.8 | ICD10CM | Covered |
| G80.9 | ICD10CM | Covered |
| G81.01 | ICD10CM | Covered |
| G81.02 | ICD10CM | Covered |
| G81.03 | ICD10CM | Covered |
| G81.04 | ICD10CM | Covered |
| G81.11 | ICD10CM | Covered |
| G81.12 | ICD10CM | Covered |
| G81.13 | ICD10CM | Covered |
| G81.14 | ICD10CM | Covered |
| G81.91 | ICD10CM | Covered |
| G81.92 | ICD10CM | Covered |
| G81.93 | ICD10CM | Covered |
| G81.94 | ICD10CM | Covered |
| G82.21 | ICD10CM | Covered |
| G82.22 | ICD10CM | Covered |
| G82.51 | ICD10CM | Covered |
| G82.52 | ICD10CM | Covered |
| G82.53 | ICD10CM | Covered |
| G82.54 | ICD10CM | Covered |
| G83.0 | ICD10CM | Covered |
| G83.11 | ICD10CM | Covered |
| G83.12 | ICD10CM | Covered |
| G83.13 | ICD10CM | Covered |
| G83.14 | ICD10CM | Covered |
| G83.21 | ICD10CM | Covered |
| G83.22 | ICD10CM | Covered |
| G83.23 | ICD10CM | Covered |
| G83.24 | ICD10CM | Covered |
| G83.31 | ICD10CM | Covered |
| G83.32 | ICD10CM | Covered |
| G83.33 | ICD10CM | Covered |
| G83.34 | ICD10CM | Covered |
| G83.4 | ICD10CM | Covered |
| G83.5 | ICD10CM | Covered |
| G83.81 | ICD10CM | Covered |
| G83.82 | ICD10CM | Covered |
| G83.83 | ICD10CM | Covered |
| G83.84 | ICD10CM | Covered |
| G83.89 | ICD10CM | Covered |
| G83.9 | ICD10CM | Covered |
| G90.511 | ICD10CM | Covered |
| G90.512 | ICD10CM | Covered |
| G90.513 | ICD10CM | Covered |
| G90.521 | ICD10CM | Covered |
| G90.522 | ICD10CM | Covered |
| G90.523 | ICD10CM | Covered |
| G90.59 | ICD10CM | Covered |
| G95.0 | ICD10CM | Covered |
| G95.11 | ICD10CM | Covered |
| G95.19 | ICD10CM | Covered |
| G95.20 | ICD10CM | Covered |
| G95.29 | ICD10CM | Covered |
| G95.81 | ICD10CM | Covered |
| G95.89 | ICD10CM | Covered |
| G99.2 | ICD10CM | Covered |
| H53.411 | ICD10CM | Covered |
| H53.412 | ICD10CM | Covered |
| H53.413 | ICD10CM | Covered |
| H53.461 | ICD10CM | Covered |
| H53.462 | ICD10CM | Covered |
| H53.47 | ICD10CM | Covered |
| H53.481 | ICD10CM | Covered |
| H53.482 | ICD10CM | Covered |
| H53.483 | ICD10CM | Covered |
| H54.0X33 | ICD10CM | Covered |
| H54.0X34 | ICD10CM | Covered |
| H54.0X35 | ICD10CM | Covered |
| H54.0X43 | ICD10CM | Covered |
| H54.0X44 | ICD10CM | Covered |
| H54.0X45 | ICD10CM | Covered |
| H54.0X53 | ICD10CM | Covered |
| H54.0X54 | ICD10CM | Covered |
| H54.0X55 | ICD10CM | Covered |
| H54.10 | ICD10CM | Covered |
| H54.1131 | ICD10CM | Covered |
| H54.1132 | ICD10CM | Covered |
| H54.1141 | ICD10CM | Covered |
| H54.1142 | ICD10CM | Covered |
| H54.1151 | ICD10CM | Covered |
| H54.1152 | ICD10CM | Covered |
| H54.1213 | ICD10CM | Covered |
| H54.1214 | ICD10CM | Covered |
| H54.1215 | ICD10CM | Covered |
| H54.1223 | ICD10CM | Covered |
| H54.1224 | ICD10CM | Covered |
| H54.1225 | ICD10CM | Covered |
| H54.2X11 | ICD10CM | Covered |
| H54.2X12 | ICD10CM | Covered |
| H54.2X21 | ICD10CM | Covered |
| H54.2X22 | ICD10CM | Covered |
| H54.413A | ICD10CM | Covered |
| H54.414A | ICD10CM | Covered |
| H54.415A | ICD10CM | Covered |
| H54.42A3 | ICD10CM | Covered |
| H54.42A4 | ICD10CM | Covered |
| H54.42A5 | ICD10CM | Covered |
| H54.511A | ICD10CM | Covered |
| H54.512A | ICD10CM | Covered |
| H54.52A1 | ICD10CM | Covered |
| H54.52A2 | ICD10CM | Covered |
| H81.11 | ICD10CM | Covered |
| H81.12 | ICD10CM | Covered |
| H81.13 | ICD10CM | Covered |
| I63.81 | ICD10CM | Covered |
| I63.89 | ICD10CM | Covered |
| I67.850 | ICD10CM | Covered |
| I67.858 | ICD10CM | Covered |
| I69.00 | ICD10CM | Covered |
| I69.010 | ICD10CM | Covered |
| I69.011 | ICD10CM | Covered |
| I69.012 | ICD10CM | Covered |
| I69.013 | ICD10CM | Covered |
| I69.014 | ICD10CM | Covered |
| I69.015 | ICD10CM | Covered |
| I69.018 | ICD10CM | Covered |
| I69.019 | ICD10CM | Covered |
| I69.031 | ICD10CM | Covered |
| I69.032 | ICD10CM | Covered |
| I69.033 | ICD10CM | Covered |
| I69.034 | ICD10CM | Covered |
| I69.041 | ICD10CM | Covered |
| I69.042 | ICD10CM | Covered |
| I69.043 | ICD10CM | Covered |
| I69.044 | ICD10CM | Covered |
| I69.051 | ICD10CM | Covered |
| I69.052 | ICD10CM | Covered |
| I69.053 | ICD10CM | Covered |
| I69.054 | ICD10CM | Covered |
| I69.061 | ICD10CM | Covered |
| I69.062 | ICD10CM | Covered |
| I69.063 | ICD10CM | Covered |
| I69.064 | ICD10CM | Covered |
| I69.065 | ICD10CM | Covered |
| I69.090 | ICD10CM | Covered |
| I69.091 | ICD10CM | Covered |
| I69.092 | ICD10CM | Covered |
| I69.093 | ICD10CM | Covered |
| I69.098 | ICD10CM | Covered |
| I69.110 | ICD10CM | Covered |
| I69.111 | ICD10CM | Covered |
| I69.112 | ICD10CM | Covered |
| I69.113 | ICD10CM | Covered |
| I69.114 | ICD10CM | Covered |
| I69.115 | ICD10CM | Covered |
| I69.118 | ICD10CM | Covered |
| I69.119 | ICD10CM | Covered |
| I69.131 | ICD10CM | Covered |
| I69.132 | ICD10CM | Covered |
| I69.133 | ICD10CM | Covered |
| I69.134 | ICD10CM | Covered |
| I69.141 | ICD10CM | Covered |
| I69.142 | ICD10CM | Covered |
| I69.143 | ICD10CM | Covered |
| I69.144 | ICD10CM | Covered |
| I69.151 | ICD10CM | Covered |
| I69.152 | ICD10CM | Covered |
| I69.153 | ICD10CM | Covered |
| I69.154 | ICD10CM | Covered |
| I69.161 | ICD10CM | Covered |
| I69.162 | ICD10CM | Covered |
| I69.163 | ICD10CM | Covered |
| I69.164 | ICD10CM | Covered |
| I69.165 | ICD10CM | Covered |
| I69.190 | ICD10CM | Covered |
| I69.191 | ICD10CM | Covered |
| I69.192 | ICD10CM | Covered |
| I69.193 | ICD10CM | Covered |
| I69.198 | ICD10CM | Covered |
| I69.210 | ICD10CM | Covered |
| I69.211 | ICD10CM | Covered |
| I69.212 | ICD10CM | Covered |
| I69.213 | ICD10CM | Covered |
| I69.214 | ICD10CM | Covered |
| I69.215 | ICD10CM | Covered |
| I69.218 | ICD10CM | Covered |
| I69.219 | ICD10CM | Covered |
| I69.231 | ICD10CM | Covered |
| I69.232 | ICD10CM | Covered |
| I69.233 | ICD10CM | Covered |
| I69.234 | ICD10CM | Covered |
| I69.241 | ICD10CM | Covered |
| I69.242 | ICD10CM | Covered |
| I69.243 | ICD10CM | Covered |
| I69.244 | ICD10CM | Covered |
| I69.251 | ICD10CM | Covered |
| I69.252 | ICD10CM | Covered |
| I69.253 | ICD10CM | Covered |
| I69.254 | ICD10CM | Covered |
| I69.261 | ICD10CM | Covered |
| I69.262 | ICD10CM | Covered |
| I69.263 | ICD10CM | Covered |
| I69.264 | ICD10CM | Covered |
| I69.265 | ICD10CM | Covered |
| I69.290 | ICD10CM | Covered |
| I69.291 | ICD10CM | Covered |
| I69.292 | ICD10CM | Covered |
| I69.293 | ICD10CM | Covered |
| I69.298 | ICD10CM | Covered |
| I69.310 | ICD10CM | Covered |
| I69.311 | ICD10CM | Covered |
| I69.312 | ICD10CM | Covered |
| I69.313 | ICD10CM | Covered |
| I69.314 | ICD10CM | Covered |
| I69.315 | ICD10CM | Covered |
| I69.318 | ICD10CM | Covered |
| I69.319 | ICD10CM | Covered |
| I69.331 | ICD10CM | Covered |
| I69.332 | ICD10CM | Covered |
| I69.333 | ICD10CM | Covered |
| I69.334 | ICD10CM | Covered |
| I69.341 | ICD10CM | Covered |
| I69.342 | ICD10CM | Covered |
| I69.343 | ICD10CM | Covered |
| I69.344 | ICD10CM | Covered |
| I69.351 | ICD10CM | Covered |
| I69.352 | ICD10CM | Covered |
| I69.353 | ICD10CM | Covered |
| I69.354 | ICD10CM | Covered |
| I69.361 | ICD10CM | Covered |
| I69.362 | ICD10CM | Covered |
| I69.363 | ICD10CM | Covered |
| I69.364 | ICD10CM | Covered |
| I69.365 | ICD10CM | Covered |
| I69.390 | ICD10CM | Covered |
| I69.391 | ICD10CM | Covered |
| I69.392 | ICD10CM | Covered |
| I69.393 | ICD10CM | Covered |
| I69.398 | ICD10CM | Covered |
| I69.810 | ICD10CM | Covered |
| I69.811 | ICD10CM | Covered |
| I69.812 | ICD10CM | Covered |
| I69.813 | ICD10CM | Covered |
| I69.814 | ICD10CM | Covered |
| I69.815 | ICD10CM | Covered |
| I69.818 | ICD10CM | Covered |
| I69.831 | ICD10CM | Covered |
| I69.832 | ICD10CM | Covered |
| I69.833 | ICD10CM | Covered |
| I69.834 | ICD10CM | Covered |
| I69.841 | ICD10CM | Covered |
| I69.842 | ICD10CM | Covered |
| I69.843 | ICD10CM | Covered |
| I69.844 | ICD10CM | Covered |
| I69.851 | ICD10CM | Covered |
| I69.852 | ICD10CM | Covered |
| I69.853 | ICD10CM | Covered |
| I69.854 | ICD10CM | Covered |
| I69.861 | ICD10CM | Covered |
| I69.862 | ICD10CM | Covered |
| I69.863 | ICD10CM | Covered |
| I69.864 | ICD10CM | Covered |
| I69.865 | ICD10CM | Covered |
| I69.890 | ICD10CM | Covered |
| I69.891 | ICD10CM | Covered |
| I69.892 | ICD10CM | Covered |
| I69.893 | ICD10CM | Covered |
| I69.898 | ICD10CM | Covered |
| I69.910 | ICD10CM | Covered |
| I69.911 | ICD10CM | Covered |
| I69.912 | ICD10CM | Covered |
| I69.913 | ICD10CM | Covered |
| I69.914 | ICD10CM | Covered |
| I69.915 | ICD10CM | Covered |
| I69.918 | ICD10CM | Covered |
| I69.931 | ICD10CM | Covered |
| I69.932 | ICD10CM | Covered |
| I69.933 | ICD10CM | Covered |
| I69.934 | ICD10CM | Covered |
| I69.941 | ICD10CM | Covered |
| I69.942 | ICD10CM | Covered |
| I69.943 | ICD10CM | Covered |
| I69.944 | ICD10CM | Covered |
| I69.951 | ICD10CM | Covered |
| I69.952 | ICD10CM | Covered |
| I69.953 | ICD10CM | Covered |
| I69.954 | ICD10CM | Covered |
| I69.961 | ICD10CM | Covered |
| I69.962 | ICD10CM | Covered |
| I69.963 | ICD10CM | Covered |
| I69.964 | ICD10CM | Covered |
| I69.965 | ICD10CM | Covered |
| I69.990 | ICD10CM | Covered |
| I69.991 | ICD10CM | Covered |
| I69.992 | ICD10CM | Covered |
| I69.993 | ICD10CM | Covered |
| I69.998 | 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 |
| I70.331 | ICD10CM | Covered |
| I70.332 | ICD10CM | Covered |
| I70.333 | ICD10CM | Covered |
| I70.334 | ICD10CM | Covered |
| I70.335 | ICD10CM | Covered |
| I70.338 | ICD10CM | Covered |
| I70.339 | ICD10CM | Covered |
| I70.341 | ICD10CM | Covered |
| I70.342 | ICD10CM | Covered |
| I70.343 | ICD10CM | Covered |
| I70.344 | ICD10CM | Covered |
| I70.345 | ICD10CM | Covered |
| I70.348 | ICD10CM | Covered |
| I70.349 | ICD10CM | Covered |
| I70.35 | ICD10CM | Covered |
| I70.361 | ICD10CM | Covered |
| I70.362 | ICD10CM | Covered |
| I70.363 | ICD10CM | Covered |
| I70.368 | 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 |
| I70.468 | 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 |
| I70.568 | ICD10CM | Covered |
| I70.631 | ICD10CM | Covered |
| I70.632 | ICD10CM | Covered |
| I70.633 | ICD10CM | Covered |
| I70.634 | ICD10CM | Covered |
| I70.635 | ICD10CM | Covered |
| I70.638 | ICD10CM | Covered |
| I70.639 | ICD10CM | Covered |
| I70.641 | ICD10CM | Covered |
| I70.642 | ICD10CM | Covered |
| I70.643 | ICD10CM | Covered |
| I70.644 | ICD10CM | Covered |
| I70.645 | ICD10CM | Covered |
| I70.648 | ICD10CM | Covered |
| I70.649 | ICD10CM | Covered |
| I70.65 | ICD10CM | Covered |
| I70.661 | ICD10CM | Covered |
| I70.662 | ICD10CM | Covered |
| I70.663 | ICD10CM | Covered |
| I70.668 | ICD10CM | Covered |
| I70.731 | ICD10CM | Covered |
| I70.732 | ICD10CM | Covered |
| I70.733 | ICD10CM | Covered |
| I70.734 | ICD10CM | Covered |
| I70.735 | ICD10CM | Covered |
| I70.738 | ICD10CM | Covered |
| I70.739 | ICD10CM | Covered |
| I70.741 | ICD10CM | Covered |
| I70.742 | ICD10CM | Covered |
| I70.743 | ICD10CM | Covered |
| I70.744 | ICD10CM | Covered |
| I70.745 | ICD10CM | Covered |
| I70.748 | ICD10CM | Covered |
| I70.749 | ICD10CM | Covered |
| I70.75 | ICD10CM | Covered |
| I70.761 | ICD10CM | Covered |
| I70.762 | ICD10CM | Covered |
| I70.763 | ICD10CM | Covered |
| I70.768 | ICD10CM | Covered |
| I73.00 | ICD10CM | Covered |
| I73.01 | ICD10CM | Covered |
| I87.011 | ICD10CM | Covered |
| I87.012 | ICD10CM | Covered |
| I87.013 | ICD10CM | Covered |
| I87.019 | ICD10CM | Covered |
| I87.031 | ICD10CM | Covered |
| I87.032 | ICD10CM | Covered |
| I87.033 | ICD10CM | Covered |
| I87.311 | ICD10CM | Covered |
| I87.312 | ICD10CM | Covered |
| I87.313 | ICD10CM | Covered |
| I87.331 | ICD10CM | Covered |
| I87.332 | ICD10CM | Covered |
| I87.333 | ICD10CM | Covered |
| I89.0 | ICD10CM | Covered |
| I96 | ICD10CM | Covered |
| I97.2 | ICD10CM | Covered |
| J41.0 | ICD10CM | Covered |
| J41.1 | ICD10CM | Covered |
| J41.8 | ICD10CM | Covered |
| J42 | ICD10CM | Covered |
| J43.0 | ICD10CM | Covered |
| J43.1 | ICD10CM | Covered |
| J43.2 | ICD10CM | Covered |
| J43.8 | ICD10CM | Covered |
| J43.9 | ICD10CM | Covered |
| J44.0 | ICD10CM | Covered |
| J44.1 | ICD10CM | Covered |
| J44.9 | ICD10CM | Covered |
| J45.20 | ICD10CM | Covered |
| J45.21 | ICD10CM | Covered |
| J45.22 | ICD10CM | Covered |
| J45.30 | ICD10CM | Covered |
| J45.31 | ICD10CM | Covered |
| J45.32 | ICD10CM | Covered |
| J45.40 | ICD10CM | Covered |
| J45.41 | ICD10CM | Covered |
| J45.42 | ICD10CM | Covered |
| J45.50 | ICD10CM | Covered |
| J45.51 | ICD10CM | Covered |
| J45.52 | ICD10CM | Covered |
| J45.901 | ICD10CM | Covered |
| J45.902 | ICD10CM | Covered |
| J45.909 | ICD10CM | Covered |
| J45.990 | ICD10CM | Covered |
| J45.991 | ICD10CM | Covered |
| J45.998 | ICD10CM | Covered |
| J47.0 | ICD10CM | Covered |
| J47.1 | ICD10CM | Covered |
| J47.9 | ICD10CM | Covered |
| K61.31 | ICD10CM | Covered |
| K61.39 | ICD10CM | Covered |
| K61.5 | ICD10CM | Covered |
| K82.A1 | ICD10CM | Covered |
| K82.A2 | ICD10CM | Covered |
| L02.411 | ICD10CM | Covered |
| L02.412 | ICD10CM | Covered |
| L02.413 | ICD10CM | Covered |
| L02.414 | ICD10CM | Covered |
| L02.511 | ICD10CM | Covered |
| L02.512 | ICD10CM | Covered |
| L03.011 | ICD10CM | Covered |
| L03.012 | ICD10CM | Covered |
| L03.021 | ICD10CM | Covered |
| L03.022 | ICD10CM | Covered |
| L03.111 | ICD10CM | Covered |
| L03.112 | ICD10CM | Covered |
| L03.113 | ICD10CM | Covered |
| L03.114 | ICD10CM | Covered |
| L03.121 | ICD10CM | Covered |
| L03.122 | ICD10CM | Covered |
| L03.123 | ICD10CM | Covered |
| L03.124 | ICD10CM | Covered |
| L04.0 | ICD10CM | Covered |
| L04.1 | ICD10CM | Covered |
| L04.2 | ICD10CM | Covered |
| L04.3 | ICD10CM | Covered |
| L04.8 | ICD10CM | Covered |
| L59.9 | ICD10CM | Covered |
| L89.001 | ICD10CM | Covered |
| L89.002 | ICD10CM | Covered |
| L89.003 | ICD10CM | Covered |
| L89.004 | ICD10CM | Covered |
| L89.006 | ICD10CM | Covered |
| L89.010 | ICD10CM | Covered |
| L89.011 | ICD10CM | Covered |
| L89.012 | ICD10CM | Covered |
| L89.013 | ICD10CM | Covered |
| L89.014 | ICD10CM | Covered |
| L89.016 | ICD10CM | Covered |
| L89.020 | ICD10CM | Covered |
| L89.021 | ICD10CM | Covered |
| L89.022 | ICD10CM | Covered |
| L89.023 | ICD10CM | Covered |
| L89.024 | ICD10CM | Covered |
| L89.026 | ICD10CM | Covered |
| L89.100 | ICD10CM | Covered |
| L89.101 | ICD10CM | Covered |
| L89.102 | ICD10CM | Covered |
| L89.103 | ICD10CM | Covered |
| L89.104 | ICD10CM | Covered |
| L89.106 | ICD10CM | Covered |
| L89.110 | ICD10CM | Covered |
| L89.111 | ICD10CM | Covered |
| L89.112 | ICD10CM | Covered |
| L89.113 | ICD10CM | Covered |
| L89.114 | ICD10CM | Covered |
| L89.116 | ICD10CM | Covered |
| L89.120 | ICD10CM | Covered |
| L89.121 | ICD10CM | Covered |
| L89.122 | ICD10CM | Covered |
| L89.123 | ICD10CM | Covered |
| L89.124 | ICD10CM | Covered |
| L89.126 | ICD10CM | Covered |
| L89.130 | ICD10CM | Covered |
| L89.131 | ICD10CM | Covered |
| L89.132 | ICD10CM | Covered |
| L89.133 | ICD10CM | Covered |
| L89.134 | ICD10CM | Covered |
| L89.136 | ICD10CM | Covered |
| L89.140 | ICD10CM | Covered |
| L89.141 | ICD10CM | Covered |
| L89.142 | ICD10CM | Covered |
| L89.143 | ICD10CM | Covered |
| L89.144 | ICD10CM | Covered |
| L89.146 | ICD10CM | Covered |
| L89.150 | ICD10CM | Covered |
| L89.151 | ICD10CM | Covered |
| L89.152 | ICD10CM | Covered |
| L89.153 | ICD10CM | Covered |
| L89.154 | ICD10CM | Covered |
| L89.156 | ICD10CM | Covered |
| L89.200 | ICD10CM | Covered |
| L89.201 | ICD10CM | Covered |
| L89.202 | ICD10CM | Covered |
| L89.203 | ICD10CM | Covered |
| L89.204 | ICD10CM | Covered |
| L89.206 | ICD10CM | Covered |
| L89.210 | ICD10CM | Covered |
| L89.211 | ICD10CM | Covered |
| L89.212 | ICD10CM | Covered |
| L89.213 | ICD10CM | Covered |
| L89.214 | ICD10CM | Covered |
| L89.216 | ICD10CM | Covered |
| L89.220 | ICD10CM | Covered |
| L89.221 | ICD10CM | Covered |
| L89.222 | ICD10CM | Covered |
| L89.223 | ICD10CM | Covered |
| L89.224 | ICD10CM | Covered |
| L89.226 | ICD10CM | Covered |
| L89.306 | ICD10CM | Covered |
| L89.310 | ICD10CM | Covered |
| L89.311 | ICD10CM | Covered |
| L89.312 | ICD10CM | Covered |
| L89.313 | ICD10CM | Covered |
| L89.314 | ICD10CM | Covered |
| L89.316 | ICD10CM | Covered |
| L89.320 | ICD10CM | Covered |
| L89.321 | ICD10CM | Covered |
| L89.322 | ICD10CM | Covered |
| L89.323 | ICD10CM | Covered |
| L89.324 | ICD10CM | Covered |
| L89.326 | ICD10CM | Covered |
| L89.41 | ICD10CM | Covered |
| L89.42 | ICD10CM | Covered |
| L89.43 | ICD10CM | Covered |
| L89.44 | ICD10CM | Covered |
| L89.45 | ICD10CM | Covered |
| L89.46 | ICD10CM | Covered |
| L89.506 | ICD10CM | Covered |
| L89.510 | ICD10CM | Covered |
| L89.511 | ICD10CM | Covered |
| L89.512 | ICD10CM | Covered |
| L89.513 | ICD10CM | Covered |
| L89.514 | ICD10CM | Covered |
| L89.516 | ICD10CM | Covered |
| L89.520 | ICD10CM | Covered |
| L89.521 | ICD10CM | Covered |
| L89.522 | ICD10CM | Covered |
| L89.523 | ICD10CM | Covered |
| L89.524 | ICD10CM | Covered |
| L89.526 | ICD10CM | Covered |
| L89.600 | ICD10CM | Covered |
| L89.601 | ICD10CM | Covered |
| L89.602 | ICD10CM | Covered |
| L89.603 | ICD10CM | Covered |
| L89.604 | ICD10CM | Covered |
| L89.606 | ICD10CM | Covered |
| L89.610 | ICD10CM | Covered |
| L89.611 | ICD10CM | Covered |
| L89.612 | ICD10CM | Covered |
| L89.613 | ICD10CM | Covered |
| L89.614 | ICD10CM | Covered |
| L89.616 | ICD10CM | Covered |
| L89.620 | ICD10CM | Covered |
| L89.621 | ICD10CM | Covered |
| L89.622 | ICD10CM | Covered |
| L89.623 | ICD10CM | Covered |
| L89.624 | ICD10CM | Covered |
| L89.626 | ICD10CM | Covered |
| L90.0 | ICD10CM | Covered |
| L90.5 | ICD10CM | Covered |
| L91.0 | ICD10CM | Covered |
| L94.0 | ICD10CM | Covered |
| L94.1 | ICD10CM | Covered |
| L94.3 | ICD10CM | Covered |
| L97.112 | ICD10CM | Covered |
| L97.113 | ICD10CM | Covered |
| L97.114 | ICD10CM | Covered |
| L97.115 | ICD10CM | Covered |
| L97.116 | ICD10CM | Covered |
| L97.118 | ICD10CM | Covered |
| L97.122 | ICD10CM | Covered |
| L97.123 | ICD10CM | Covered |
| L97.124 | ICD10CM | Covered |
| L97.125 | ICD10CM | Covered |
| L97.126 | ICD10CM | Covered |
| L97.128 | ICD10CM | Covered |
| L97.212 | ICD10CM | Covered |
| L97.213 | ICD10CM | Covered |
| L97.214 | ICD10CM | Covered |
| L97.215 | ICD10CM | Covered |
| L97.216 | ICD10CM | Covered |
| L97.218 | ICD10CM | Covered |
| L97.222 | ICD10CM | Covered |
| L97.223 | ICD10CM | Covered |
| L97.224 | ICD10CM | Covered |
| L97.225 | ICD10CM | Covered |
| L97.226 | ICD10CM | Covered |
| L97.228 | ICD10CM | Covered |
| L97.312 | ICD10CM | Covered |
| L97.313 | ICD10CM | Covered |
| L97.314 | ICD10CM | Covered |
| L97.315 | ICD10CM | Covered |
| L97.316 | ICD10CM | Covered |
| L97.318 | ICD10CM | Covered |
| L97.322 | ICD10CM | Covered |
| L97.323 | ICD10CM | Covered |
| L97.324 | ICD10CM | Covered |
| L97.325 | ICD10CM | Covered |
| L97.326 | ICD10CM | Covered |
| L97.328 | ICD10CM | Covered |
| L97.412 | ICD10CM | Covered |
| L97.413 | ICD10CM | Covered |
| L97.414 | ICD10CM | Covered |
| L97.415 | ICD10CM | Covered |
| L97.416 | ICD10CM | Covered |
| L97.418 | ICD10CM | Covered |
| L97.422 | ICD10CM | Covered |
| L97.423 | ICD10CM | Covered |
| L97.424 | ICD10CM | Covered |
| L97.425 | ICD10CM | Covered |
| L97.426 | ICD10CM | Covered |
| L97.428 | ICD10CM | Covered |
| L97.512 | ICD10CM | Covered |
| L97.513 | ICD10CM | Covered |
| L97.514 | ICD10CM | Covered |
| L97.515 | ICD10CM | Covered |
| L97.516 | ICD10CM | Covered |
| L97.518 | ICD10CM | Covered |
| L97.522 | ICD10CM | Covered |
| L97.523 | ICD10CM | Covered |
| L97.524 | ICD10CM | Covered |
| L97.525 | ICD10CM | Covered |
| L97.526 | ICD10CM | Covered |
| L97.528 | ICD10CM | Covered |
| L97.812 | ICD10CM | Covered |
| L97.813 | ICD10CM | Covered |
| L97.814 | ICD10CM | Covered |
| L97.815 | ICD10CM | Covered |
| L97.816 | ICD10CM | Covered |
| L97.818 | ICD10CM | Covered |
| L97.822 | ICD10CM | Covered |
| L97.823 | ICD10CM | Covered |
| L97.824 | ICD10CM | Covered |
| L97.825 | ICD10CM | Covered |
| L97.826 | ICD10CM | Covered |
| L97.828 | ICD10CM | Covered |
| L97.912 | ICD10CM | Covered |
| L97.913 | ICD10CM | Covered |
| L97.914 | ICD10CM | Covered |
| L97.915 | ICD10CM | Covered |
| L97.916 | ICD10CM | Covered |
| L97.918 | ICD10CM | Covered |
| L97.922 | ICD10CM | Covered |
| L97.923 | ICD10CM | Covered |
| L97.924 | ICD10CM | Covered |
| L97.925 | ICD10CM | Covered |
| L97.926 | ICD10CM | Covered |
| L97.928 | ICD10CM | Covered |
| L98.412 | ICD10CM | Covered |
| L98.413 | ICD10CM | Covered |
| L98.414 | ICD10CM | Covered |
| L98.415 | ICD10CM | Covered |
| L98.416 | ICD10CM | Covered |
| L98.418 | ICD10CM | Covered |
| L98.422 | ICD10CM | Covered |
| L98.423 | ICD10CM | Covered |
| L98.424 | ICD10CM | Covered |
| L98.425 | ICD10CM | Covered |
| L98.426 | ICD10CM | Covered |
| L98.428 | ICD10CM | Covered |
| L98.431 | ICD10CM | Covered |
| L98.432 | ICD10CM | Covered |
| L98.433 | ICD10CM | Covered |
| L98.434 | ICD10CM | Covered |