Policy source
The recorded policy does not contain a public text excerpt. Read the official source for details.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
Showing the first 1,000 of 1,085 codes. The source has the full list.
| Code | Code system | Status in this policy |
|---|---|---|
| 92507 | HCPCS | Covered |
| 92508 | HCPCS | Covered |
| 92521 | HCPCS | Covered |
| 92522 | HCPCS | Covered |
| 92523 | HCPCS | Covered |
| 92524 | HCPCS | Covered |
| 92597 | HCPCS | Covered |
| 92607 | HCPCS | Covered |
| 92608 | HCPCS | Covered |
| 92609 | HCPCS | Covered |
| 96105 | HCPCS | Covered |
| 96110 | HCPCS | Covered |
| 96112 | HCPCS | Covered |
| 96113 | HCPCS | Covered |
| 96125 | HCPCS | Covered |
| 97110 | HCPCS | Covered |
| 97129 | HCPCS | Covered |
| 97130 | HCPCS | Covered |
| 97530 | HCPCS | Covered |
| 97533 | HCPCS | Covered |
| 97535 | HCPCS | Covered |
| A69.0 | 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 |
| 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 |
| C32.0 | ICD10CM | Covered |
| C32.1 | ICD10CM | Covered |
| C32.2 | ICD10CM | Covered |
| C32.3 | ICD10CM | Covered |
| C32.8 | ICD10CM | Covered |
| C32.9 | ICD10CM | Covered |
| D14.1 | ICD10CM | Covered |
| D38.0 | ICD10CM | Covered |
| F01.50 | ICD10CM | Covered |
| F01.511 | ICD10CM | Covered |
| F01.518 | ICD10CM | Covered |
| F01.52 | ICD10CM | Covered |
| F01.53 | ICD10CM | Covered |
| F01.54 | ICD10CM | Covered |
| F01.A0 | ICD10CM | Covered |
| F01.A11 | ICD10CM | Covered |
| F01.A18 | ICD10CM | Covered |
| F01.A2 | ICD10CM | Covered |
| F01.A3 | ICD10CM | Covered |
| F01.A4 | ICD10CM | Covered |
| F01.B0 | ICD10CM | Covered |
| F01.B11 | ICD10CM | Covered |
| F01.B18 | ICD10CM | Covered |
| F01.B2 | ICD10CM | Covered |
| F01.B3 | ICD10CM | Covered |
| F01.B4 | ICD10CM | Covered |
| F01.C0 | ICD10CM | Covered |
| F01.C11 | ICD10CM | Covered |
| F01.C18 | ICD10CM | Covered |
| F01.C2 | ICD10CM | Covered |
| F01.C3 | ICD10CM | Covered |
| F01.C4 | ICD10CM | Covered |
| F02.80 | ICD10CM | Covered |
| F02.811 | ICD10CM | Covered |
| F02.818 | ICD10CM | Covered |
| F02.82 | ICD10CM | Covered |
| F02.83 | ICD10CM | Covered |
| F02.84 | ICD10CM | Covered |
| F02.A0 | ICD10CM | Covered |
| F02.A11 | ICD10CM | Covered |
| F02.A18 | ICD10CM | Covered |
| F02.A2 | ICD10CM | Covered |
| F02.A3 | ICD10CM | Covered |
| F02.A4 | ICD10CM | Covered |
| F02.B0 | ICD10CM | Covered |
| F02.B11 | ICD10CM | Covered |
| F02.B18 | ICD10CM | Covered |
| F02.B2 | ICD10CM | Covered |
| F02.B3 | ICD10CM | Covered |
| F02.B4 | ICD10CM | Covered |
| F02.C0 | ICD10CM | Covered |
| F02.C11 | ICD10CM | Covered |
| F02.C18 | ICD10CM | Covered |
| F02.C2 | ICD10CM | Covered |
| F02.C3 | ICD10CM | Covered |
| F02.C4 | ICD10CM | Covered |
| F03.90 | ICD10CM | Covered |
| F03.911 | ICD10CM | Covered |
| F03.918 | ICD10CM | Covered |
| F03.92 | ICD10CM | Covered |
| F03.93 | ICD10CM | Covered |
| F03.94 | ICD10CM | Covered |
| F03.A0 | ICD10CM | Covered |
| F03.A11 | ICD10CM | Covered |
| F03.A18 | ICD10CM | Covered |
| F03.A2 | ICD10CM | Covered |
| F03.A3 | ICD10CM | Covered |
| F03.A4 | ICD10CM | Covered |
| F03.B0 | ICD10CM | Covered |
| F03.B11 | ICD10CM | Covered |
| F03.B18 | ICD10CM | Covered |
| F03.B2 | ICD10CM | Covered |
| F03.B3 | ICD10CM | Covered |
| F03.B4 | ICD10CM | Covered |
| F03.C0 | ICD10CM | Covered |
| F03.C11 | ICD10CM | Covered |
| F03.C18 | ICD10CM | Covered |
| F03.C2 | ICD10CM | Covered |
| F03.C3 | ICD10CM | Covered |
| F03.C4 | ICD10CM | Covered |
| F05 | ICD10CM | Covered |
| F06.0 | ICD10CM | Covered |
| F06.1 | ICD10CM | Covered |
| F06.8 | ICD10CM | Covered |
| F07.0 | ICD10CM | Covered |
| F07.89 | ICD10CM | Covered |
| F48.2 | ICD10CM | Covered |
| F80.0 | ICD10CM | Covered |
| F80.1 | ICD10CM | Covered |
| F80.2 | ICD10CM | Covered |
| F80.4 | ICD10CM | Covered |
| F80.81 | ICD10CM | Covered |
| F80.89 | ICD10CM | Covered |
| F80.9 | ICD10CM | Covered |
| F81.0 | ICD10CM | Covered |
| F81.2 | ICD10CM | Covered |
| F81.81 | ICD10CM | Covered |
| F81.89 | ICD10CM | Covered |
| F82 | ICD10CM | Covered |
| F88 | ICD10CM | Covered |
| F95.2 | ICD10CM | Covered |
| F98.5 | ICD10CM | Covered |
| G10 | ICD10CM | Covered |
| G12.21 | ICD10CM | Covered |
| G12.25 | ICD10CM | Covered |
| G13.2 | ICD10CM | Covered |
| G13.8 | ICD10CM | Covered |
| G20.A1 | ICD10CM | Covered |
| G20.A2 | ICD10CM | Covered |
| G20.B1 | ICD10CM | Covered |
| G20.B2 | ICD10CM | Covered |
| G21.0 | ICD10CM | Covered |
| G21.11 | ICD10CM | Covered |
| G21.19 | ICD10CM | Covered |
| G21.2 | ICD10CM | Covered |
| G21.3 | ICD10CM | Covered |
| G21.4 | ICD10CM | Covered |
| G21.8 | ICD10CM | Covered |
| G21.9 | ICD10CM | Covered |
| G23.0 | ICD10CM | Covered |
| G23.1 | ICD10CM | Covered |
| G23.2 | ICD10CM | Covered |
| G23.8 | ICD10CM | Covered |
| G23.9 | ICD10CM | Covered |
| G24.01 | ICD10CM | Covered |
| G24.1 | ICD10CM | Covered |
| G24.3 | ICD10CM | Covered |
| G24.4 | ICD10CM | Covered |
| G24.5 | ICD10CM | Covered |
| G24.9 | ICD10CM | Covered |
| G25.3 | ICD10CM | Covered |
| G25.4 | ICD10CM | Covered |
| G25.5 | ICD10CM | Covered |
| G25.70 | ICD10CM | Covered |
| G25.71 | ICD10CM | Covered |
| G25.79 | ICD10CM | Covered |
| G25.81 | ICD10CM | Covered |
| G25.82 | ICD10CM | Covered |
| G25.83 | ICD10CM | Covered |
| G25.89 | ICD10CM | Covered |
| G25.9 | ICD10CM | Covered |
| G26 | ICD10CM | Covered |
| G30.0 | ICD10CM | Covered |
| G30.1 | ICD10CM | Covered |
| G30.8 | ICD10CM | Covered |
| G30.9 | ICD10CM | Covered |
| G31.01 | ICD10CM | Covered |
| G31.09 | ICD10CM | Covered |
| G31.1 | ICD10CM | Covered |
| G31.2 | ICD10CM | Covered |
| G31.83 | ICD10CM | Covered |
| G31.84 | ICD10CM | Covered |
| G31.85 | ICD10CM | Covered |
| G31.87 | ICD10CM | Covered |
| G31.89 | ICD10CM | Covered |
| G31.9 | ICD10CM | Covered |
| G36.0 | ICD10CM | Covered |
| G36.1 | ICD10CM | Covered |
| G36.8 | ICD10CM | Covered |
| G36.9 | ICD10CM | Covered |
| G37.0 | ICD10CM | Covered |
| G37.1 | ICD10CM | Covered |
| G37.2 | ICD10CM | Covered |
| G37.3 | ICD10CM | Covered |
| G37.4 | ICD10CM | Covered |
| G37.5 | ICD10CM | Covered |
| G37.89 | ICD10CM | Covered |
| G37.9 | ICD10CM | Covered |
| G45.0 | ICD10CM | Covered |
| G45.1 | ICD10CM | Covered |
| G45.2 | ICD10CM | Covered |
| G45.8 | ICD10CM | Covered |
| G45.9 | ICD10CM | Covered |
| G46.0 | ICD10CM | Covered |
| G46.1 | ICD10CM | Covered |
| G46.2 | ICD10CM | Covered |
| G52.1 | ICD10CM | Covered |
| G52.2 | ICD10CM | Covered |
| G52.3 | ICD10CM | Covered |
| G52.7 | ICD10CM | Covered |
| G52.8 | ICD10CM | Covered |
| G60.8 | ICD10CM | Covered |
| G81.00 | ICD10CM | Covered |
| G81.01 | ICD10CM | Covered |
| G81.02 | ICD10CM | Covered |
| G81.03 | ICD10CM | Covered |
| G81.04 | ICD10CM | Covered |
| G81.10 | ICD10CM | Covered |
| G81.11 | ICD10CM | Covered |
| G81.12 | ICD10CM | Covered |
| G81.13 | ICD10CM | Covered |
| G81.14 | ICD10CM | Covered |
| G81.90 | ICD10CM | Covered |
| G81.91 | ICD10CM | Covered |
| G81.92 | ICD10CM | Covered |
| G81.93 | ICD10CM | Covered |
| G81.94 | ICD10CM | Covered |
| G90.1 | ICD10CM | Covered |
| G90.3 | ICD10CM | Covered |
| G91.0 | ICD10CM | Covered |
| G91.1 | ICD10CM | Covered |
| G91.2 | ICD10CM | Covered |
| G91.3 | ICD10CM | Covered |
| G91.4 | ICD10CM | Covered |
| G91.8 | ICD10CM | Covered |
| G91.9 | ICD10CM | Covered |
| G93.7 | ICD10CM | Covered |
| G94 | ICD10CM | Covered |
| H90.0 | ICD10CM | Covered |
| H90.11 | ICD10CM | Covered |
| H90.12 | ICD10CM | Covered |
| H90.2 | ICD10CM | Covered |
| H90.3 | ICD10CM | Covered |
| H90.41 | ICD10CM | Covered |
| H90.42 | ICD10CM | Covered |
| H90.5 | ICD10CM | Covered |
| H90.6 | ICD10CM | Covered |
| H90.71 | ICD10CM | Covered |
| H90.72 | ICD10CM | Covered |
| H90.8 | ICD10CM | Covered |
| H90.A11 | ICD10CM | Covered |
| H90.A12 | ICD10CM | Covered |
| H90.A21 | ICD10CM | Covered |
| H90.A22 | ICD10CM | Covered |
| H90.A31 | ICD10CM | Covered |
| H90.A32 | ICD10CM | Covered |
| H93.241 | ICD10CM | Covered |
| H93.242 | ICD10CM | Covered |
| H93.243 | ICD10CM | Covered |
| H93.249 | ICD10CM | Covered |
| H93.25 | ICD10CM | Covered |
| H93.291 | ICD10CM | Covered |
| H93.292 | ICD10CM | Covered |
| H93.293 | ICD10CM | Covered |
| H93.299 | ICD10CM | Covered |
| H93.90 | ICD10CM | Covered |
| H93.91 | ICD10CM | Covered |
| H93.92 | ICD10CM | Covered |
| H93.93 | ICD10CM | Covered |
| I67.841 | ICD10CM | Covered |
| I67.848 | ICD10CM | Covered |
| I67.89 | ICD10CM | Covered |
| I69.010 | ICD10CM | Covered |
| I69.011 | ICD10CM | Covered |
| I69.013 | ICD10CM | Covered |
| I69.014 | ICD10CM | Covered |
| I69.018 | ICD10CM | Covered |
| I69.020 | ICD10CM | Covered |
| I69.021 | ICD10CM | Covered |
| I69.022 | ICD10CM | Covered |
| I69.023 | ICD10CM | Covered |
| I69.028 | ICD10CM | Covered |
| I69.090 | ICD10CM | Covered |
| I69.092 | ICD10CM | Covered |
| I69.110 | ICD10CM | Covered |
| I69.111 | ICD10CM | Covered |
| I69.113 | ICD10CM | Covered |
| I69.114 | ICD10CM | Covered |
| I69.118 | ICD10CM | Covered |
| I69.120 | ICD10CM | Covered |
| I69.121 | ICD10CM | Covered |
| I69.122 | ICD10CM | Covered |
| I69.123 | ICD10CM | Covered |
| I69.128 | ICD10CM | Covered |
| I69.190 | ICD10CM | Covered |
| I69.192 | ICD10CM | Covered |
| I69.210 | ICD10CM | Covered |
| I69.211 | ICD10CM | Covered |
| I69.213 | ICD10CM | Covered |
| I69.214 | ICD10CM | Covered |
| I69.218 | ICD10CM | Covered |
| I69.220 | ICD10CM | Covered |
| I69.221 | ICD10CM | Covered |
| I69.222 | ICD10CM | Covered |
| I69.223 | ICD10CM | Covered |
| I69.228 | ICD10CM | Covered |
| I69.290 | ICD10CM | Covered |
| I69.292 | ICD10CM | Covered |
| I69.310 | ICD10CM | Covered |
| I69.311 | ICD10CM | Covered |
| I69.313 | ICD10CM | Covered |
| I69.314 | ICD10CM | Covered |
| I69.318 | ICD10CM | Covered |
| I69.320 | ICD10CM | Covered |
| I69.321 | ICD10CM | Covered |
| I69.322 | ICD10CM | Covered |
| I69.323 | ICD10CM | Covered |
| I69.328 | ICD10CM | Covered |
| I69.390 | ICD10CM | Covered |
| I69.392 | ICD10CM | Covered |
| I69.810 | ICD10CM | Covered |
| I69.811 | ICD10CM | Covered |
| I69.813 | ICD10CM | Covered |
| I69.814 | ICD10CM | Covered |
| I69.818 | ICD10CM | Covered |
| I69.820 | ICD10CM | Covered |
| I69.821 | ICD10CM | Covered |
| I69.822 | ICD10CM | Covered |
| I69.823 | ICD10CM | Covered |
| I69.828 | ICD10CM | Covered |
| I69.890 | ICD10CM | Covered |
| I69.892 | ICD10CM | Covered |
| I69.910 | ICD10CM | Covered |
| I69.911 | ICD10CM | Covered |
| I69.913 | ICD10CM | Covered |
| I69.914 | ICD10CM | Covered |
| I69.918 | ICD10CM | Covered |
| I69.920 | ICD10CM | Covered |
| I69.921 | ICD10CM | Covered |
| I69.922 | ICD10CM | Covered |
| I69.923 | ICD10CM | Covered |
| I69.928 | ICD10CM | Covered |
| I69.990 | ICD10CM | Covered |
| I69.992 | ICD10CM | Covered |
| J04.0 | ICD10CM | Covered |
| J04.10 | ICD10CM | Covered |
| J04.11 | ICD10CM | Covered |
| J04.2 | ICD10CM | Covered |
| J04.30 | ICD10CM | Covered |
| J04.31 | ICD10CM | Covered |
| J05.0 | ICD10CM | Covered |
| J05.10 | ICD10CM | Covered |
| J05.11 | ICD10CM | Covered |
| J06.0 | ICD10CM | Covered |
| J06.9 | ICD10CM | Covered |
| J20.8 | ICD10CM | Covered |
| J20.9 | ICD10CM | Covered |
| J21.0 | ICD10CM | Covered |
| J21.1 | ICD10CM | Covered |
| J21.8 | ICD10CM | Covered |
| J21.9 | ICD10CM | Covered |
| J31.0 | ICD10CM | Covered |
| J31.1 | ICD10CM | Covered |
| J31.2 | ICD10CM | Covered |
| J32.0 | ICD10CM | Covered |
| J32.1 | ICD10CM | Covered |
| J32.2 | ICD10CM | Covered |
| J32.3 | ICD10CM | Covered |
| J32.4 | ICD10CM | Covered |
| J32.8 | ICD10CM | Covered |
| J32.9 | ICD10CM | Covered |
| J33.0 | ICD10CM | Covered |
| J33.1 | ICD10CM | Covered |
| J33.8 | ICD10CM | Covered |
| J33.9 | ICD10CM | Covered |
| J34.2 | ICD10CM | Covered |
| J37.0 | ICD10CM | Covered |
| J37.1 | ICD10CM | Covered |
| J38.00 | ICD10CM | Covered |
| J38.01 | ICD10CM | Covered |
| J38.02 | ICD10CM | Covered |
| J38.1 | ICD10CM | Covered |
| J38.2 | ICD10CM | Covered |
| J38.3 | ICD10CM | Covered |
| J38.4 | ICD10CM | Covered |
| J38.5 | ICD10CM | Covered |
| J38.6 | ICD10CM | Covered |
| J38.7 | ICD10CM | Covered |
| J39.8 | ICD10CM | Covered |
| J39.9 | ICD10CM | Covered |
| K09.8 | ICD10CM | Covered |
| K09.9 | ICD10CM | Covered |
| K12.0 | ICD10CM | Covered |
| K12.1 | ICD10CM | Covered |
| K12.2 | ICD10CM | Covered |
| K12.30 | ICD10CM | Covered |
| K12.31 | ICD10CM | Covered |
| K12.32 | ICD10CM | Covered |
| K12.33 | ICD10CM | Covered |
| K12.39 | ICD10CM | Covered |
| K13.0 | ICD10CM | Covered |
| K13.1 | ICD10CM | Covered |
| K13.21 | ICD10CM | Covered |
| K13.22 | ICD10CM | Covered |
| K13.23 | ICD10CM | Covered |
| K13.24 | ICD10CM | Covered |
| K13.29 | ICD10CM | Covered |
| K13.3 | ICD10CM | Covered |
| K13.4 | ICD10CM | Covered |
| K13.5 | ICD10CM | Covered |
| K13.6 | ICD10CM | Covered |
| K13.70 | ICD10CM | Covered |
| K13.79 | ICD10CM | Covered |
| M26.50 | ICD10CM | Covered |
| M26.51 | ICD10CM | Covered |
| M26.52 | ICD10CM | Covered |
| M26.53 | ICD10CM | Covered |
| M26.54 | ICD10CM | Covered |
| M26.55 | ICD10CM | Covered |
| M26.56 | ICD10CM | Covered |
| M26.57 | ICD10CM | Covered |
| M26.59 | ICD10CM | Covered |
| P29.38 | ICD10CM | Covered |
| Q00.0 | ICD10CM | Covered |
| Q00.1 | ICD10CM | Covered |
| Q00.2 | ICD10CM | Covered |
| Q01.0 | ICD10CM | Covered |
| Q01.1 | ICD10CM | Covered |
| Q01.2 | ICD10CM | Covered |
| Q01.8 | ICD10CM | Covered |
| Q01.9 | ICD10CM | Covered |
| Q02 | ICD10CM | Covered |
| Q03.0 | ICD10CM | Covered |
| Q03.1 | ICD10CM | Covered |
| Q03.8 | ICD10CM | Covered |
| Q03.9 | ICD10CM | Covered |
| Q04.0 | ICD10CM | Covered |
| Q04.1 | ICD10CM | Covered |
| Q04.2 | ICD10CM | Covered |
| Q04.3 | ICD10CM | Covered |
| Q04.4 | ICD10CM | Covered |
| Q04.5 | ICD10CM | Covered |
| Q04.6 | ICD10CM | Covered |
| Q04.8 | ICD10CM | Covered |
| Q04.9 | ICD10CM | Covered |
| Q05.0 | ICD10CM | Covered |
| Q05.1 | ICD10CM | Covered |
| Q05.2 | ICD10CM | Covered |
| Q05.3 | ICD10CM | Covered |
| Q05.4 | ICD10CM | Covered |
| Q05.5 | ICD10CM | Covered |
| Q05.6 | ICD10CM | Covered |
| Q05.7 | ICD10CM | Covered |
| Q05.8 | ICD10CM | Covered |
| Q05.9 | ICD10CM | Covered |
| Q06.0 | ICD10CM | Covered |
| Q06.1 | ICD10CM | Covered |
| Q06.2 | ICD10CM | Covered |
| Q06.3 | ICD10CM | Covered |
| Q06.4 | ICD10CM | Covered |
| Q06.8 | ICD10CM | Covered |
| Q06.9 | ICD10CM | Covered |
| Q07.00 | ICD10CM | Covered |
| Q07.01 | ICD10CM | Covered |
| Q07.02 | ICD10CM | Covered |
| Q07.03 | ICD10CM | Covered |
| Q07.8 | ICD10CM | Covered |
| Q07.9 | ICD10CM | Covered |
| Q10.0 | ICD10CM | Covered |
| Q10.1 | ICD10CM | Covered |
| Q10.2 | ICD10CM | Covered |
| Q10.3 | ICD10CM | Covered |
| Q10.4 | ICD10CM | Covered |
| Q10.5 | ICD10CM | Covered |
| Q10.6 | ICD10CM | Covered |
| Q10.7 | ICD10CM | Covered |
| Q11.0 | ICD10CM | Covered |
| Q11.1 | ICD10CM | Covered |
| Q11.2 | ICD10CM | Covered |
| Q11.3 | ICD10CM | Covered |
| Q12.0 | ICD10CM | Covered |
| Q12.1 | ICD10CM | Covered |
| Q12.2 | ICD10CM | Covered |
| Q12.3 | ICD10CM | Covered |
| Q12.4 | ICD10CM | Covered |
| Q12.8 | ICD10CM | Covered |
| Q12.9 | ICD10CM | Covered |
| Q13.0 | ICD10CM | Covered |
| Q13.1 | ICD10CM | Covered |
| Q13.2 | ICD10CM | Covered |
| Q13.3 | ICD10CM | Covered |
| Q13.4 | ICD10CM | Covered |
| Q13.5 | ICD10CM | Covered |
| Q13.81 | ICD10CM | Covered |
| Q13.89 | ICD10CM | Covered |
| Q13.9 | ICD10CM | Covered |
| Q14.0 | ICD10CM | Covered |
| Q14.1 | ICD10CM | Covered |
| Q14.2 | ICD10CM | Covered |
| Q14.3 | ICD10CM | Covered |
| Q14.8 | ICD10CM | Covered |
| Q14.9 | ICD10CM | Covered |
| Q15.0 | ICD10CM | Covered |
| Q15.8 | ICD10CM | Covered |
| Q15.9 | ICD10CM | Covered |
| Q16.0 | ICD10CM | Covered |
| Q16.1 | ICD10CM | Covered |
| Q16.2 | ICD10CM | Covered |
| Q16.3 | ICD10CM | Covered |
| Q16.4 | ICD10CM | Covered |
| Q16.5 | ICD10CM | Covered |
| Q16.9 | ICD10CM | Covered |
| Q17.0 | ICD10CM | Covered |
| Q17.1 | ICD10CM | Covered |
| Q17.2 | ICD10CM | Covered |
| Q17.3 | ICD10CM | Covered |
| Q17.4 | ICD10CM | Covered |
| Q17.5 | ICD10CM | Covered |
| Q17.8 | ICD10CM | Covered |
| Q17.9 | ICD10CM | Covered |
| Q18.0 | ICD10CM | Covered |
| Q18.1 | ICD10CM | Covered |
| Q18.2 | ICD10CM | Covered |
| Q18.3 | ICD10CM | Covered |
| Q18.4 | ICD10CM | Covered |
| Q18.5 | ICD10CM | Covered |
| Q18.6 | ICD10CM | Covered |
| Q18.7 | ICD10CM | Covered |
| Q18.8 | ICD10CM | Covered |
| Q18.9 | 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 |
| Q21.11 | 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 |
| Q24.0 | ICD10CM | Covered |
| Q24.1 | ICD10CM | Covered |
| Q24.2 | ICD10CM | Covered |
| Q24.3 | ICD10CM | Covered |
| Q24.4 | ICD10CM | Covered |
| Q24.5 | ICD10CM | Covered |
| Q24.6 | ICD10CM | Covered |
| Q24.8 | ICD10CM | Covered |
| Q24.9 | ICD10CM | Covered |
| Q25.0 | ICD10CM | Covered |
| Q25.1 | ICD10CM | Covered |
| Q25.3 | 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 |
| Q26.0 | ICD10CM | Covered |
| Q26.1 | ICD10CM | Covered |
| Q26.2 | ICD10CM | Covered |
| Q26.3 | ICD10CM | Covered |
| Q26.4 | ICD10CM | Covered |
| Q26.5 | ICD10CM | Covered |
| Q26.6 | ICD10CM | Covered |
| Q26.8 | ICD10CM | Covered |
| Q26.9 | ICD10CM | Covered |
| Q27.0 | ICD10CM | Covered |
| Q27.1 | ICD10CM | Covered |
| Q27.2 | ICD10CM | Covered |
| Q27.30 | ICD10CM | Covered |
| Q27.31 | ICD10CM | Covered |
| Q27.32 | ICD10CM | Covered |
| Q27.33 | ICD10CM | Covered |
| Q27.34 | ICD10CM | Covered |
| Q27.39 | ICD10CM | Covered |
| Q27.4 | ICD10CM | Covered |
| Q27.8 | ICD10CM | Covered |
| Q27.9 | ICD10CM | Covered |
| Q28.0 | ICD10CM | Covered |
| Q28.1 | ICD10CM | Covered |
| Q28.2 | ICD10CM | Covered |
| Q28.3 | ICD10CM | Covered |
| Q28.8 | ICD10CM | Covered |
| Q28.9 | ICD10CM | Covered |
| Q30.0 | ICD10CM | Covered |
| Q30.1 | ICD10CM | Covered |
| Q30.2 | ICD10CM | Covered |
| Q30.3 | ICD10CM | Covered |
| Q30.8 | ICD10CM | Covered |
| Q30.9 | ICD10CM | Covered |
| Q31.0 | ICD10CM | Covered |
| Q31.1 | ICD10CM | Covered |
| Q31.2 | ICD10CM | Covered |
| Q31.3 | ICD10CM | Covered |
| Q31.5 | ICD10CM | Covered |
| Q31.8 | ICD10CM | Covered |
| Q31.9 | ICD10CM | Covered |
| Q32.0 | ICD10CM | Covered |
| Q32.1 | ICD10CM | Covered |
| Q32.2 | ICD10CM | Covered |
| Q32.3 | ICD10CM | Covered |
| Q32.4 | ICD10CM | Covered |
| Q35.1 | ICD10CM | Covered |
| Q35.3 | ICD10CM | Covered |
| Q35.5 | ICD10CM | Covered |
| Q35.7 | ICD10CM | Covered |
| Q35.9 | ICD10CM | Covered |
| Q36.9 | ICD10CM | Covered |
| Q37.9 | ICD10CM | Covered |
| Q38.1 | ICD10CM | Covered |
| Q38.2 | ICD10CM | Covered |
| Q38.3 | ICD10CM | Covered |
| Q90.0 | ICD10CM | Covered |
| Q90.1 | ICD10CM | Covered |
| Q90.2 | ICD10CM | Covered |
| Q90.9 | ICD10CM | Covered |
| R41.4 | ICD10CM | Covered |
| R41.841 | ICD10CM | Covered |
| R47.01 | ICD10CM | Covered |
| R47.02 | ICD10CM | Covered |
| R47.1 | ICD10CM | Covered |
| R47.81 | ICD10CM | Covered |
| R47.82 | ICD10CM | Covered |
| R47.89 | ICD10CM | Covered |
| R47.9 | ICD10CM | Covered |
| R48.0 | ICD10CM | Covered |
| R48.1 | ICD10CM | Covered |
| R48.2 | ICD10CM | Covered |
| R48.8 | ICD10CM | Covered |
| R48.9 | ICD10CM | Covered |
| R49.0 | ICD10CM | Covered |
| R49.1 | ICD10CM | Covered |
| R49.21 | ICD10CM | Covered |
| R49.22 | ICD10CM | Covered |
| R49.8 | ICD10CM | Covered |
| R49.9 | ICD10CM | Covered |
| R62.0 | ICD10CM | Covered |
| S01.522A | ICD10CM | Covered |
| S01.542A | ICD10CM | Covered |
| S01.90XA | ICD10CM | Covered |
| S02.0XXS | ICD10CM | Covered |
| S02.101S | ICD10CM | Covered |
| S02.102S | ICD10CM | Covered |
| S02.110S | ICD10CM | Covered |
| S02.111S | ICD10CM | Covered |
| S02.112S | ICD10CM | Covered |
| S02.113S | ICD10CM | Covered |
| S02.118S | ICD10CM | Covered |
| S02.119S | ICD10CM | Covered |
| S02.19XS | ICD10CM | Covered |
| S02.2XXS | ICD10CM | Covered |
| S02.400S | ICD10CM | Covered |
| S02.401S | ICD10CM | Covered |
| S02.402S | ICD10CM | Covered |
| S02.40AS | ICD10CM | Covered |
| S02.40BS | ICD10CM | Covered |
| S02.40CS | ICD10CM | Covered |
| S02.40DS | ICD10CM | Covered |
| S02.411S | ICD10CM | Covered |
| S02.412S | ICD10CM | Covered |
| S02.413S | ICD10CM | Covered |
| S02.42XS | ICD10CM | Covered |
| S02.5XXA | ICD10CM | Covered |
| S02.5XXB | ICD10CM | Covered |
| S02.5XXS | ICD10CM | Covered |
| S02.600S | ICD10CM | Covered |
| S02.609S | ICD10CM | Covered |
| S02.611S | ICD10CM | Covered |
| S02.612S | ICD10CM | Covered |
| S02.621S | ICD10CM | Covered |
| S02.622S | ICD10CM | Covered |
| S02.641S | ICD10CM | Covered |
| S02.642S | ICD10CM | Covered |
| S02.651S | ICD10CM | Covered |
| S02.652S | ICD10CM | Covered |
| S02.66XS | ICD10CM | Covered |
| S02.671S | ICD10CM | Covered |
| S02.672S | ICD10CM | Covered |
| S02.69XS | ICD10CM | Covered |
| S02.91XS | ICD10CM | Covered |
| S02.92XS | ICD10CM | Covered |
| S04.011S | ICD10CM | Covered |
| S04.012S | ICD10CM | Covered |
| S04.019S | ICD10CM | Covered |
| S04.02XS | ICD10CM | Covered |
| S04.031S | ICD10CM | Covered |
| S04.032S | ICD10CM | Covered |
| S04.039S | ICD10CM | Covered |
| S04.041S | ICD10CM | Covered |
| S04.042S | ICD10CM | Covered |
| S04.049S | ICD10CM | Covered |
| S04.10XS | ICD10CM | Covered |
| S04.11XS | ICD10CM | Covered |
| S04.12XS | ICD10CM | Covered |
| S04.20XS | ICD10CM | Covered |
| S04.21XS | ICD10CM | Covered |
| S04.22XS | ICD10CM | Covered |
| S04.30XS | ICD10CM | Covered |
| S04.31XS | ICD10CM | Covered |
| S04.32XS | ICD10CM | Covered |
| S04.40XS | ICD10CM | Covered |
| S04.41XS | ICD10CM | Covered |
| S04.42XS | ICD10CM | Covered |
| S04.50XS | ICD10CM | Covered |
| S04.51XS | ICD10CM | Covered |
| S04.52XS | ICD10CM | Covered |
| S04.60XS | ICD10CM | Covered |
| S04.61XS | ICD10CM | Covered |
| S04.62XS | ICD10CM | Covered |
| S04.70XS | ICD10CM | Covered |
| S04.71XS | ICD10CM | Covered |
| S04.72XS | ICD10CM | Covered |
| S04.811S | ICD10CM | Covered |
| S04.812S | ICD10CM | Covered |
| S04.819S | ICD10CM | Covered |
| S04.891S | ICD10CM | Covered |
| S04.892S | ICD10CM | Covered |
| S04.899S | ICD10CM | Covered |
| S04.9XXS | ICD10CM | Covered |
| S06.0X0A | ICD10CM | Covered |
| S06.0X0S | ICD10CM | Covered |
| S06.0X1A | ICD10CM | Covered |
| S06.0X1S | ICD10CM | Covered |
| S06.0X9A | ICD10CM | Covered |
| S06.0X9S | ICD10CM | Covered |
| S06.1X0A | ICD10CM | Covered |
| S06.1X0S | ICD10CM | Covered |
| S06.1X1A | ICD10CM | Covered |
| S06.1X1S | ICD10CM | Covered |
| S06.1X2A | ICD10CM | Covered |
| S06.1X2S | ICD10CM | Covered |
| S06.1X3A | ICD10CM | Covered |
| S06.1X3S | ICD10CM | Covered |
| S06.1X4A | ICD10CM | Covered |
| S06.1X4S | ICD10CM | Covered |
| S06.1X5A | ICD10CM | Covered |
| S06.1X5S | ICD10CM | Covered |
| S06.1X6A | ICD10CM | Covered |
| S06.1X6S | ICD10CM | Covered |
| S06.1X9A | ICD10CM | Covered |
| S06.1X9S | ICD10CM | Covered |
| S06.2X0A | ICD10CM | Covered |
| S06.2X0S | ICD10CM | Covered |
| S06.2X1A | ICD10CM | Covered |
| S06.2X1S | ICD10CM | Covered |
| S06.2X2A | ICD10CM | Covered |
| S06.2X2S | ICD10CM | Covered |
| S06.2X3A | ICD10CM | Covered |
| S06.2X3S | ICD10CM | Covered |
| S06.2X4A | ICD10CM | Covered |
| S06.2X4S | ICD10CM | Covered |
| S06.2X5A | ICD10CM | Covered |
| S06.2X5S | ICD10CM | Covered |
| S06.2X6A | ICD10CM | Covered |
| S06.2X6S | ICD10CM | Covered |
| S06.2X9A | ICD10CM | Covered |
| S06.2X9S | ICD10CM | Covered |
| S06.300A | ICD10CM | Covered |
| S06.300S | ICD10CM | Covered |
| S06.301A | ICD10CM | Covered |
| S06.301S | ICD10CM | Covered |
| S06.302A | ICD10CM | Covered |
| S06.302S | ICD10CM | Covered |
| S06.303A | ICD10CM | Covered |
| S06.303S | ICD10CM | Covered |
| S06.304A | ICD10CM | Covered |
| S06.304S | ICD10CM | Covered |
| S06.305A | ICD10CM | Covered |
| S06.305S | ICD10CM | Covered |
| S06.306A | ICD10CM | Covered |
| S06.306S | ICD10CM | Covered |
| S06.309A | ICD10CM | Covered |
| S06.309S | ICD10CM | Covered |
| S06.310A | ICD10CM | Covered |
| S06.310S | ICD10CM | Covered |
| S06.311A | ICD10CM | Covered |
| S06.311S | ICD10CM | Covered |
| S06.312A | ICD10CM | Covered |
| S06.312S | ICD10CM | Covered |
| S06.313A | ICD10CM | Covered |
| S06.313S | ICD10CM | Covered |
| S06.314A | ICD10CM | Covered |
| S06.314S | ICD10CM | Covered |
| S06.315A | ICD10CM | Covered |
| S06.315S | ICD10CM | Covered |
| S06.316A | ICD10CM | Covered |
| S06.316S | ICD10CM | Covered |
| S06.319A | ICD10CM | Covered |
| S06.319S | ICD10CM | Covered |
| S06.320A | ICD10CM | Covered |
| S06.320S | ICD10CM | Covered |
| S06.321A | ICD10CM | Covered |
| S06.321S | ICD10CM | Covered |
| S06.322A | ICD10CM | Covered |
| S06.322S | ICD10CM | Covered |
| S06.323A | ICD10CM | Covered |
| S06.323S | ICD10CM | Covered |
| S06.324A | ICD10CM | Covered |
| S06.324S | ICD10CM | Covered |
| S06.325A | ICD10CM | Covered |
| S06.325S | ICD10CM | Covered |
| S06.326A | ICD10CM | Covered |
| S06.326S | ICD10CM | Covered |
| S06.329A | ICD10CM | Covered |
| S06.329S | ICD10CM | Covered |
| S06.330A | ICD10CM | Covered |
| S06.330S | ICD10CM | Covered |
| S06.331A | ICD10CM | Covered |
| S06.331S | ICD10CM | Covered |
| S06.332A | ICD10CM | Covered |
| S06.332S | ICD10CM | Covered |
| S06.333A | ICD10CM | Covered |
| S06.333S | ICD10CM | Covered |
| S06.334A | ICD10CM | Covered |
| S06.334S | ICD10CM | Covered |
| S06.335A | ICD10CM | Covered |
| S06.335S | ICD10CM | Covered |
| S06.336A | ICD10CM | Covered |
| S06.336S | ICD10CM | Covered |
| S06.339A | ICD10CM | Covered |
| S06.339S | ICD10CM | Covered |
| S06.340S | ICD10CM | Covered |
| S06.341S | ICD10CM | Covered |
| S06.342S | ICD10CM | Covered |
| S06.343S | ICD10CM | Covered |
| S06.344S | ICD10CM | Covered |
| S06.345S | ICD10CM | Covered |
| S06.346S | ICD10CM | Covered |
| S06.349S | ICD10CM | Covered |
| S06.350S | ICD10CM | Covered |
| S06.351S | ICD10CM | Covered |
| S06.352S | ICD10CM | Covered |
| S06.353S | ICD10CM | Covered |
| S06.354S | ICD10CM | Covered |
| S06.355S | ICD10CM | Covered |
| S06.356S | ICD10CM | Covered |
| S06.359S | ICD10CM | Covered |
| S06.360S | ICD10CM | Covered |
| S06.361S | ICD10CM | Covered |
| S06.362S | ICD10CM | Covered |
| S06.363S | ICD10CM | Covered |
| S06.364S | ICD10CM | Covered |
| S06.365S | ICD10CM | Covered |
| S06.366S | ICD10CM | Covered |
| S06.369S | ICD10CM | Covered |
| S06.370A | ICD10CM | Covered |
| S06.370S | ICD10CM | Covered |
| S06.371A | ICD10CM | Covered |
| S06.371S | ICD10CM | Covered |
| S06.372A | ICD10CM | Covered |
| S06.372S | ICD10CM | Covered |
| S06.373A | ICD10CM | Covered |
| S06.373S | ICD10CM | Covered |
| S06.374A | ICD10CM | Covered |
| S06.374S | ICD10CM | Covered |
| S06.375A | ICD10CM | Covered |
| S06.375S | ICD10CM | Covered |
| S06.376A | ICD10CM | Covered |
| S06.376S | ICD10CM | Covered |
| S06.379A | ICD10CM | Covered |
| S06.379S | ICD10CM | Covered |
| S06.380A | ICD10CM | Covered |
| S06.380S | ICD10CM | Covered |
| S06.381A | ICD10CM | Covered |
| S06.381S | ICD10CM | Covered |
| S06.382A | ICD10CM | Covered |
| S06.382S | ICD10CM | Covered |
| S06.383A | ICD10CM | Covered |
| S06.383S | ICD10CM | Covered |
| S06.384A | ICD10CM | Covered |
| S06.384S | ICD10CM | Covered |
| S06.385A | ICD10CM | Covered |
| S06.385S | ICD10CM | Covered |
| S06.386A | ICD10CM | Covered |
| S06.386S | ICD10CM | Covered |
| S06.389A | ICD10CM | Covered |
| S06.389S | ICD10CM | Covered |
| S06.4X0S | ICD10CM | Covered |
| S06.4X1S | ICD10CM | Covered |
| S06.4X2S | ICD10CM | Covered |
| S06.4X3S | ICD10CM | Covered |
| S06.4X4S | ICD10CM | Covered |
| S06.4X5S | ICD10CM | Covered |
| S06.4X6S | ICD10CM | Covered |
| S06.4X9S | ICD10CM | Covered |
| S06.5X0S | ICD10CM | Covered |
| S06.5X1S | ICD10CM | Covered |
| S06.5X2S | ICD10CM | Covered |
| S06.5X3S | ICD10CM | Covered |
| S06.5X4S | ICD10CM | Covered |
| S06.5X5S | ICD10CM | Covered |
| S06.5X6S | ICD10CM | Covered |
| S06.5X9S | ICD10CM | Covered |
| S06.6X0S | ICD10CM | Covered |
| S06.6X1S | ICD10CM | Covered |
| S06.6X2S | ICD10CM | Covered |
| S06.6X3S | ICD10CM | Covered |
| S06.6X4S | ICD10CM | Covered |
| S06.6X5S | ICD10CM | Covered |
| S06.6X6S | ICD10CM | Covered |
| S06.6X9S | ICD10CM | Covered |
| S06.810A | ICD10CM | Covered |
| S06.810S | ICD10CM | Covered |
| S06.811A | ICD10CM | Covered |
| S06.811S | ICD10CM | Covered |
| S06.812A | ICD10CM | Covered |
| S06.812S | ICD10CM | Covered |
| S06.813A | ICD10CM | Covered |
| S06.813S | ICD10CM | Covered |
| S06.814A | ICD10CM | Covered |
| S06.814S | ICD10CM | Covered |
| S06.815A | ICD10CM | Covered |
| S06.815S | ICD10CM | Covered |
| S06.816A | ICD10CM | Covered |
| S06.816S | ICD10CM | Covered |
| S06.819A | ICD10CM | Covered |
| S06.819S | ICD10CM | Covered |
| S06.820A | ICD10CM | Covered |
| S06.820S | ICD10CM | Covered |
| S06.821A | ICD10CM | Covered |
| S06.821S | ICD10CM | Covered |
| S06.822A | ICD10CM | Covered |
| S06.822S | ICD10CM | Covered |
| S06.823A | ICD10CM | Covered |
| S06.823S | ICD10CM | Covered |
| S06.824A | ICD10CM | Covered |
| S06.824S | ICD10CM | Covered |
| S06.825A | ICD10CM | Covered |
| S06.825S | ICD10CM | Covered |
| S06.826A | ICD10CM | Covered |
| S06.826S | ICD10CM | Covered |
| S06.829A | ICD10CM | Covered |
| S06.829S | ICD10CM | Covered |
| S06.890A | ICD10CM | Covered |
| S06.890S | ICD10CM | Covered |
| S06.891A | ICD10CM | Covered |
| S06.891S | ICD10CM | Covered |
| S06.892A | ICD10CM | Covered |
| S06.892S | ICD10CM | Covered |
| S06.893A | ICD10CM | Covered |
| S06.893S | ICD10CM | Covered |
| S06.894A | ICD10CM | Covered |
| S06.894S | ICD10CM | Covered |
| S06.895A | ICD10CM | Covered |
| S06.895S | ICD10CM | Covered |
| S06.896A | ICD10CM | Covered |
| S06.896S | ICD10CM | Covered |
| S06.899A | ICD10CM | Covered |
| S06.899S | ICD10CM | Covered |
| S06.9X0A | ICD10CM | Covered |
| S06.9X0S | ICD10CM | Covered |
| S06.9X1A | ICD10CM | Covered |
| S06.9X1S | ICD10CM | Covered |