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 3,537 codes. The source has the full list.
| Code | Code system | Status in this policy |
|---|---|---|
| 90635 | HCPCS | Covered |
| 90637 | HCPCS | Covered |
| 90638 | HCPCS | Covered |
| 90653 | HCPCS | Covered |
| 90655 | HCPCS | Covered |
| 90656 | HCPCS | Covered |
| 90657 | HCPCS | Covered |
| 90660 | HCPCS | Covered |
| 90661 | HCPCS | Covered |
| 90662 | HCPCS | Covered |
| 90670 | HCPCS | Covered |
| 90671 | HCPCS | Covered |
| 90672 | HCPCS | Covered |
| 90673 | HCPCS | Covered |
| 90674 | HCPCS | Covered |
| 90675 | HCPCS | Covered |
| 90676 | HCPCS | Covered |
| 90677 | HCPCS | Covered |
| 90682 | HCPCS | Covered |
| 90685 | HCPCS | Covered |
| 90686 | HCPCS | Covered |
| 90687 | HCPCS | Covered |
| 90688 | HCPCS | Covered |
| 90689 | HCPCS | Covered |
| 90694 | HCPCS | Covered |
| 90695 | HCPCS | Covered |
| 90702 | HCPCS | Covered |
| 90714 | HCPCS | Covered |
| 90715 | HCPCS | Covered |
| 90732 | HCPCS | Covered |
| 90739 | HCPCS | Covered |
| 90740 | HCPCS | Covered |
| 90743 | HCPCS | Covered |
| 90744 | HCPCS | Covered |
| 90746 | HCPCS | Covered |
| 90747 | HCPCS | Covered |
| 90756 | HCPCS | Covered |
| 90759 | HCPCS | Covered |
| G0008 | HCPCS | Covered |
| G0009 | HCPCS | Covered |
| G0010 | HCPCS | Covered |
| Q2034 | HCPCS | Covered |
| Q2035 | HCPCS | Covered |
| Q2036 | HCPCS | Covered |
| Q2037 | HCPCS | Covered |
| Q2038 | HCPCS | Covered |
| Q2039 | HCPCS | Covered |
| S00.01XA | ICD10CM | Covered |
| S00.02XA | ICD10CM | Covered |
| S00.04XA | ICD10CM | Covered |
| S00.05XA | ICD10CM | Covered |
| S00.06XA | ICD10CM | Covered |
| S00.07XA | ICD10CM | Covered |
| S00.201A | ICD10CM | Covered |
| S00.202A | ICD10CM | Covered |
| S00.211A | ICD10CM | Covered |
| S00.212A | ICD10CM | Covered |
| S00.251A | ICD10CM | Covered |
| S00.252A | ICD10CM | Covered |
| S00.31XA | ICD10CM | Covered |
| S00.35XA | ICD10CM | Covered |
| S00.411A | ICD10CM | Covered |
| S00.412A | ICD10CM | Covered |
| S00.451A | ICD10CM | Covered |
| S00.452A | ICD10CM | Covered |
| S00.511A | ICD10CM | Covered |
| S00.512A | ICD10CM | Covered |
| S00.551A | ICD10CM | Covered |
| S00.552A | ICD10CM | Covered |
| S00.81XA | ICD10CM | Covered |
| S00.85XA | ICD10CM | Covered |
| S01.00XA | ICD10CM | Covered |
| S01.00XD | ICD10CM | Covered |
| S01.00XS | ICD10CM | Covered |
| S01.01XA | ICD10CM | Covered |
| S01.01XD | ICD10CM | Covered |
| S01.01XS | ICD10CM | Covered |
| S01.02XA | ICD10CM | Covered |
| S01.02XD | ICD10CM | Covered |
| S01.02XS | ICD10CM | Covered |
| S01.03XA | ICD10CM | Covered |
| S01.04XA | ICD10CM | Covered |
| S01.04XD | ICD10CM | Covered |
| S01.04XS | ICD10CM | Covered |
| S01.05XA | ICD10CM | Covered |
| S01.05XD | ICD10CM | Covered |
| S01.05XS | ICD10CM | Covered |
| S01.101A | ICD10CM | Covered |
| S01.101D | ICD10CM | Covered |
| S01.101S | ICD10CM | Covered |
| S01.102A | ICD10CM | Covered |
| S01.102D | ICD10CM | Covered |
| S01.102S | ICD10CM | Covered |
| S01.111A | ICD10CM | Covered |
| S01.111D | ICD10CM | Covered |
| S01.111S | ICD10CM | Covered |
| S01.112A | ICD10CM | Covered |
| S01.112D | ICD10CM | Covered |
| S01.112S | ICD10CM | Covered |
| S01.121A | ICD10CM | Covered |
| S01.121D | ICD10CM | Covered |
| S01.121S | ICD10CM | Covered |
| S01.122A | ICD10CM | Covered |
| S01.122D | ICD10CM | Covered |
| S01.122S | ICD10CM | Covered |
| S01.131A | ICD10CM | Covered |
| S01.131D | ICD10CM | Covered |
| S01.131S | ICD10CM | Covered |
| S01.132A | ICD10CM | Covered |
| S01.132D | ICD10CM | Covered |
| S01.132S | ICD10CM | Covered |
| S01.141A | ICD10CM | Covered |
| S01.141D | ICD10CM | Covered |
| S01.141S | ICD10CM | Covered |
| S01.142A | ICD10CM | Covered |
| S01.142D | ICD10CM | Covered |
| S01.142S | ICD10CM | Covered |
| S01.151A | ICD10CM | Covered |
| S01.151D | ICD10CM | Covered |
| S01.151S | ICD10CM | Covered |
| S01.152A | ICD10CM | Covered |
| S01.152D | ICD10CM | Covered |
| S01.152S | ICD10CM | Covered |
| S01.20XA | ICD10CM | Covered |
| S01.20XD | ICD10CM | Covered |
| S01.20XS | ICD10CM | Covered |
| S01.21XA | ICD10CM | Covered |
| S01.21XD | ICD10CM | Covered |
| S01.21XS | ICD10CM | Covered |
| S01.22XA | ICD10CM | Covered |
| S01.22XD | ICD10CM | Covered |
| S01.22XS | ICD10CM | Covered |
| S01.23XA | ICD10CM | Covered |
| S01.23XD | ICD10CM | Covered |
| S01.23XS | ICD10CM | Covered |
| S01.24XA | ICD10CM | Covered |
| S01.24XD | ICD10CM | Covered |
| S01.24XS | ICD10CM | Covered |
| S01.25XA | ICD10CM | Covered |
| S01.25XD | ICD10CM | Covered |
| S01.25XS | ICD10CM | Covered |
| S01.301A | ICD10CM | Covered |
| S01.301D | ICD10CM | Covered |
| S01.301S | ICD10CM | Covered |
| S01.302A | ICD10CM | Covered |
| S01.302D | ICD10CM | Covered |
| S01.302S | ICD10CM | Covered |
| S01.311A | ICD10CM | Covered |
| S01.311D | ICD10CM | Covered |
| S01.311S | ICD10CM | Covered |
| S01.312A | ICD10CM | Covered |
| S01.312D | ICD10CM | Covered |
| S01.312S | ICD10CM | Covered |
| S01.321A | ICD10CM | Covered |
| S01.321D | ICD10CM | Covered |
| S01.321S | ICD10CM | Covered |
| S01.322A | ICD10CM | Covered |
| S01.322D | ICD10CM | Covered |
| S01.322S | ICD10CM | Covered |
| S01.341A | ICD10CM | Covered |
| S01.341D | ICD10CM | Covered |
| S01.341S | ICD10CM | Covered |
| S01.342A | ICD10CM | Covered |
| S01.342D | ICD10CM | Covered |
| S01.342S | ICD10CM | Covered |
| S01.351A | ICD10CM | Covered |
| S01.351D | ICD10CM | Covered |
| S01.351S | ICD10CM | Covered |
| S01.352A | ICD10CM | Covered |
| S01.352D | ICD10CM | Covered |
| S01.352S | ICD10CM | Covered |
| S01.401A | ICD10CM | Covered |
| S01.401D | ICD10CM | Covered |
| S01.401S | ICD10CM | Covered |
| S01.402A | ICD10CM | Covered |
| S01.402D | ICD10CM | Covered |
| S01.402S | ICD10CM | Covered |
| S01.411A | ICD10CM | Covered |
| S01.411D | ICD10CM | Covered |
| S01.411S | ICD10CM | Covered |
| S01.412A | ICD10CM | Covered |
| S01.412D | ICD10CM | Covered |
| S01.412S | ICD10CM | Covered |
| S01.421A | ICD10CM | Covered |
| S01.421D | ICD10CM | Covered |
| S01.421S | ICD10CM | Covered |
| S01.422A | ICD10CM | Covered |
| S01.422D | ICD10CM | Covered |
| S01.422S | ICD10CM | Covered |
| S01.431A | ICD10CM | Covered |
| S01.431D | ICD10CM | Covered |
| S01.431S | ICD10CM | Covered |
| S01.432A | ICD10CM | Covered |
| S01.432D | ICD10CM | Covered |
| S01.432S | ICD10CM | Covered |
| S01.441A | ICD10CM | Covered |
| S01.441D | ICD10CM | Covered |
| S01.441S | ICD10CM | Covered |
| S01.442A | ICD10CM | Covered |
| S01.442D | ICD10CM | Covered |
| S01.442S | ICD10CM | Covered |
| S01.451A | ICD10CM | Covered |
| S01.451D | ICD10CM | Covered |
| S01.451S | ICD10CM | Covered |
| S01.452A | ICD10CM | Covered |
| S01.452D | ICD10CM | Covered |
| S01.452S | ICD10CM | Covered |
| S01.501A | ICD10CM | Covered |
| S01.501D | ICD10CM | Covered |
| S01.501S | ICD10CM | Covered |
| S01.502A | ICD10CM | Covered |
| S01.502D | ICD10CM | Covered |
| S01.502S | ICD10CM | Covered |
| S01.511A | ICD10CM | Covered |
| S01.511D | ICD10CM | Covered |
| S01.511S | ICD10CM | Covered |
| S01.512A | ICD10CM | Covered |
| S01.512D | ICD10CM | Covered |
| S01.512S | ICD10CM | Covered |
| S01.521A | ICD10CM | Covered |
| S01.521D | ICD10CM | Covered |
| S01.521S | ICD10CM | Covered |
| S01.522A | ICD10CM | Covered |
| S01.522D | ICD10CM | Covered |
| S01.522S | ICD10CM | Covered |
| S01.531A | ICD10CM | Covered |
| S01.531D | ICD10CM | Covered |
| S01.531S | ICD10CM | Covered |
| S01.532A | ICD10CM | Covered |
| S01.532D | ICD10CM | Covered |
| S01.532S | ICD10CM | Covered |
| S01.541A | ICD10CM | Covered |
| S01.541D | ICD10CM | Covered |
| S01.541S | ICD10CM | Covered |
| S01.542A | ICD10CM | Covered |
| S01.542D | ICD10CM | Covered |
| S01.542S | ICD10CM | Covered |
| S01.551A | ICD10CM | Covered |
| S01.551D | ICD10CM | Covered |
| S01.551S | ICD10CM | Covered |
| S01.552A | ICD10CM | Covered |
| S01.552D | ICD10CM | Covered |
| S01.552S | ICD10CM | Covered |
| S01.80XA | ICD10CM | Covered |
| S01.80XD | ICD10CM | Covered |
| S01.80XS | ICD10CM | Covered |
| S01.81XA | ICD10CM | Covered |
| S01.81XD | ICD10CM | Covered |
| S01.81XS | ICD10CM | Covered |
| S01.82XA | ICD10CM | Covered |
| S01.82XD | ICD10CM | Covered |
| S01.82XS | ICD10CM | Covered |
| S01.83XA | ICD10CM | Covered |
| S01.83XD | ICD10CM | Covered |
| S01.83XS | ICD10CM | Covered |
| S01.84XA | ICD10CM | Covered |
| S01.84XD | ICD10CM | Covered |
| S01.84XS | ICD10CM | Covered |
| S01.85XA | ICD10CM | Covered |
| S01.85XD | ICD10CM | Covered |
| S01.85XS | ICD10CM | Covered |
| S01.90XA | ICD10CM | Covered |
| S01.90XD | ICD10CM | Covered |
| S01.90XS | ICD10CM | Covered |
| S01.91XA | ICD10CM | Covered |
| S01.91XD | ICD10CM | Covered |
| S01.91XS | ICD10CM | Covered |
| S01.92XA | ICD10CM | Covered |
| S01.92XD | ICD10CM | Covered |
| S01.92XS | ICD10CM | Covered |
| S01.93XA | ICD10CM | Covered |
| S01.93XD | ICD10CM | Covered |
| S01.93XS | ICD10CM | Covered |
| S01.94XA | ICD10CM | Covered |
| S01.94XD | ICD10CM | Covered |
| S01.94XS | ICD10CM | Covered |
| S01.95XA | ICD10CM | Covered |
| S01.95XD | ICD10CM | Covered |
| S01.95XS | ICD10CM | Covered |
| S02.0XXB | ICD10CM | Covered |
| S02.101B | ICD10CM | Covered |
| S02.102B | ICD10CM | Covered |
| S02.110B | ICD10CM | Covered |
| S02.111B | ICD10CM | Covered |
| S02.112B | ICD10CM | Covered |
| S02.118B | ICD10CM | Covered |
| S02.119B | ICD10CM | Covered |
| S02.11AB | ICD10CM | Covered |
| S02.11BB | ICD10CM | Covered |
| S02.11CB | ICD10CM | Covered |
| S02.11DB | ICD10CM | Covered |
| S02.11EB | ICD10CM | Covered |
| S02.11FB | ICD10CM | Covered |
| S02.11GB | ICD10CM | Covered |
| S02.11HB | ICD10CM | Covered |
| S02.121B | ICD10CM | Covered |
| S02.122B | ICD10CM | Covered |
| S02.129B | ICD10CM | Covered |
| S02.19XB | ICD10CM | Covered |
| S02.2XXB | ICD10CM | Covered |
| S02.31XB | ICD10CM | Covered |
| S02.32XB | ICD10CM | Covered |
| S02.401B | ICD10CM | Covered |
| S02.402B | ICD10CM | Covered |
| S02.40AB | ICD10CM | Covered |
| S02.40BB | ICD10CM | Covered |
| S02.40CB | ICD10CM | Covered |
| S02.40DB | ICD10CM | Covered |
| S02.40EB | ICD10CM | Covered |
| S02.40FB | ICD10CM | Covered |
| S02.411B | ICD10CM | Covered |
| S02.412B | ICD10CM | Covered |
| S02.42XB | ICD10CM | Covered |
| S02.600B | ICD10CM | Covered |
| S02.601B | ICD10CM | Covered |
| S02.602B | ICD10CM | Covered |
| S02.609B | ICD10CM | Covered |
| S02.611B | ICD10CM | Covered |
| S02.612B | ICD10CM | Covered |
| S02.621B | ICD10CM | Covered |
| S02.622B | ICD10CM | Covered |
| S02.631B | ICD10CM | Covered |
| S02.632B | ICD10CM | Covered |
| S02.641B | ICD10CM | Covered |
| S02.642B | ICD10CM | Covered |
| S02.651B | ICD10CM | Covered |
| S02.652B | ICD10CM | Covered |
| S02.66XB | ICD10CM | Covered |
| S02.671B | ICD10CM | Covered |
| S02.672B | ICD10CM | Covered |
| S02.69XB | ICD10CM | Covered |
| S02.81XB | ICD10CM | Covered |
| S02.82XB | ICD10CM | Covered |
| S02.831B | ICD10CM | Covered |
| S02.832B | ICD10CM | Covered |
| S02.839B | ICD10CM | Covered |
| S02.841B | ICD10CM | Covered |
| S02.842B | ICD10CM | Covered |
| S02.849B | ICD10CM | Covered |
| S02.85XB | ICD10CM | Covered |
| S02.91XB | ICD10CM | Covered |
| S02.92XB | ICD10CM | Covered |
| S05.21XA | ICD10CM | Covered |
| S05.21XD | ICD10CM | Covered |
| S05.21XS | ICD10CM | Covered |
| S05.22XA | ICD10CM | Covered |
| S05.22XD | ICD10CM | Covered |
| S05.22XS | ICD10CM | Covered |
| S05.31XA | ICD10CM | Covered |
| S05.31XD | ICD10CM | Covered |
| S05.31XS | ICD10CM | Covered |
| S05.32XA | ICD10CM | Covered |
| S05.32XD | ICD10CM | Covered |
| S05.32XS | ICD10CM | Covered |
| S05.41XA | ICD10CM | Covered |
| S05.41XD | ICD10CM | Covered |
| S05.41XS | ICD10CM | Covered |
| S05.42XA | ICD10CM | Covered |
| S05.42XD | ICD10CM | Covered |
| S05.42XS | ICD10CM | Covered |
| S05.51XA | ICD10CM | Covered |
| S05.51XD | ICD10CM | Covered |
| S05.51XS | ICD10CM | Covered |
| S05.52XA | ICD10CM | Covered |
| S05.52XD | ICD10CM | Covered |
| S05.52XS | ICD10CM | Covered |
| S05.61XA | ICD10CM | Covered |
| S05.61XD | ICD10CM | Covered |
| S05.61XS | ICD10CM | Covered |
| S05.62XA | ICD10CM | Covered |
| S05.62XD | ICD10CM | Covered |
| S05.62XS | ICD10CM | Covered |
| S05.71XA | ICD10CM | Covered |
| S05.71XD | ICD10CM | Covered |
| S05.71XS | ICD10CM | Covered |
| S05.72XA | ICD10CM | Covered |
| S05.72XD | ICD10CM | Covered |
| S05.72XS | ICD10CM | Covered |
| S07.0XXA | ICD10CM | Covered |
| S07.0XXD | ICD10CM | Covered |
| S07.0XXS | ICD10CM | Covered |
| S07.1XXA | ICD10CM | Covered |
| S07.1XXD | ICD10CM | Covered |
| S07.1XXS | ICD10CM | Covered |
| S07.8XXA | ICD10CM | Covered |
| S07.8XXD | ICD10CM | Covered |
| S07.8XXS | ICD10CM | Covered |
| S07.9XXA | ICD10CM | Covered |
| S07.9XXD | ICD10CM | Covered |
| S07.9XXS | ICD10CM | Covered |
| S08.0XXA | ICD10CM | Covered |
| S08.0XXD | ICD10CM | Covered |
| S08.0XXS | ICD10CM | Covered |
| S08.111A | ICD10CM | Covered |
| S08.111D | ICD10CM | Covered |
| S08.111S | ICD10CM | Covered |
| S08.112A | ICD10CM | Covered |
| S08.112D | ICD10CM | Covered |
| S08.112S | ICD10CM | Covered |
| S08.121A | ICD10CM | Covered |
| S08.121D | ICD10CM | Covered |
| S08.121S | ICD10CM | Covered |
| S08.122A | ICD10CM | Covered |
| S08.122D | ICD10CM | Covered |
| S08.122S | ICD10CM | Covered |
| S08.811A | ICD10CM | Covered |
| S08.811D | ICD10CM | Covered |
| S08.811S | ICD10CM | Covered |
| S08.812A | ICD10CM | Covered |
| S08.812D | ICD10CM | Covered |
| S08.812S | ICD10CM | Covered |
| S10.11XA | ICD10CM | Covered |
| S10.17XA | ICD10CM | Covered |
| S10.81XA | ICD10CM | Covered |
| S10.85XA | ICD10CM | Covered |
| S11.011A | ICD10CM | Covered |
| S11.011D | ICD10CM | Covered |
| S11.011S | ICD10CM | Covered |
| S11.012A | ICD10CM | Covered |
| S11.012D | ICD10CM | Covered |
| S11.012S | ICD10CM | Covered |
| S11.013A | ICD10CM | Covered |
| S11.013D | ICD10CM | Covered |
| S11.013S | ICD10CM | Covered |
| S11.014A | ICD10CM | Covered |
| S11.014D | ICD10CM | Covered |
| S11.014S | ICD10CM | Covered |
| S11.015A | ICD10CM | Covered |
| S11.015D | ICD10CM | Covered |
| S11.015S | ICD10CM | Covered |
| S11.019A | ICD10CM | Covered |
| S11.019D | ICD10CM | Covered |
| S11.019S | ICD10CM | Covered |
| S11.021A | ICD10CM | Covered |
| S11.021D | ICD10CM | Covered |
| S11.021S | ICD10CM | Covered |
| S11.022A | ICD10CM | Covered |
| S11.022D | ICD10CM | Covered |
| S11.022S | ICD10CM | Covered |
| S11.023A | ICD10CM | Covered |
| S11.023D | ICD10CM | Covered |
| S11.023S | ICD10CM | Covered |
| S11.024A | ICD10CM | Covered |
| S11.024D | ICD10CM | Covered |
| S11.024S | ICD10CM | Covered |
| S11.025A | ICD10CM | Covered |
| S11.025D | ICD10CM | Covered |
| S11.025S | ICD10CM | Covered |
| S11.029A | ICD10CM | Covered |
| S11.029D | ICD10CM | Covered |
| S11.029S | ICD10CM | Covered |
| S11.031A | ICD10CM | Covered |
| S11.031D | ICD10CM | Covered |
| S11.031S | ICD10CM | Covered |
| S11.032A | ICD10CM | Covered |
| S11.032D | ICD10CM | Covered |
| S11.032S | ICD10CM | Covered |
| S11.034A | ICD10CM | Covered |
| S11.034D | ICD10CM | Covered |
| S11.034S | ICD10CM | Covered |
| S11.035A | ICD10CM | Covered |
| S11.035D | ICD10CM | Covered |
| S11.035S | ICD10CM | Covered |
| S11.039A | ICD10CM | Covered |
| S11.039D | ICD10CM | Covered |
| S11.039S | ICD10CM | Covered |
| S11.10XA | ICD10CM | Covered |
| S11.10XD | ICD10CM | Covered |
| S11.10XS | ICD10CM | Covered |
| S11.11XA | ICD10CM | Covered |
| S11.11XD | ICD10CM | Covered |
| S11.11XS | ICD10CM | Covered |
| S11.12XA | ICD10CM | Covered |
| S11.12XD | ICD10CM | Covered |
| S11.12XS | ICD10CM | Covered |
| S11.13XA | ICD10CM | Covered |
| S11.13XD | ICD10CM | Covered |
| S11.13XS | ICD10CM | Covered |
| S11.14XA | ICD10CM | Covered |
| S11.14XD | ICD10CM | Covered |
| S11.14XS | ICD10CM | Covered |
| S11.15XA | ICD10CM | Covered |
| S11.15XD | ICD10CM | Covered |
| S11.15XS | ICD10CM | Covered |
| S11.20XA | ICD10CM | Covered |
| S11.20XD | ICD10CM | Covered |
| S11.20XS | ICD10CM | Covered |
| S11.21XA | ICD10CM | Covered |
| S11.21XD | ICD10CM | Covered |
| S11.21XS | ICD10CM | Covered |
| S11.22XA | ICD10CM | Covered |
| S11.22XD | ICD10CM | Covered |
| S11.22XS | ICD10CM | Covered |
| S11.23XA | ICD10CM | Covered |
| S11.23XD | ICD10CM | Covered |
| S11.23XS | ICD10CM | Covered |
| S11.24XA | ICD10CM | Covered |
| S11.24XD | ICD10CM | Covered |
| S11.24XS | ICD10CM | Covered |
| S11.25XA | ICD10CM | Covered |
| S11.25XD | ICD10CM | Covered |
| S11.25XS | ICD10CM | Covered |
| S11.80XA | ICD10CM | Covered |
| S11.80XD | ICD10CM | Covered |
| S11.80XS | ICD10CM | Covered |
| S11.81XA | ICD10CM | Covered |
| S11.81XD | ICD10CM | Covered |
| S11.81XS | ICD10CM | Covered |
| S11.82XA | ICD10CM | Covered |
| S11.82XD | ICD10CM | Covered |
| S11.82XS | ICD10CM | Covered |
| S11.83XA | ICD10CM | Covered |
| S11.83XD | ICD10CM | Covered |
| S11.83XS | ICD10CM | Covered |
| S11.84XA | ICD10CM | Covered |
| S11.84XD | ICD10CM | Covered |
| S11.84XS | ICD10CM | Covered |
| S11.85XA | ICD10CM | Covered |
| S11.85XD | ICD10CM | Covered |
| S11.85XS | ICD10CM | Covered |
| S11.90XA | ICD10CM | Covered |
| S11.90XD | ICD10CM | Covered |
| S11.90XS | ICD10CM | Covered |
| S11.91XA | ICD10CM | Covered |
| S11.91XD | ICD10CM | Covered |
| S11.91XS | ICD10CM | Covered |
| S11.92XA | ICD10CM | Covered |
| S11.92XD | ICD10CM | Covered |
| S11.92XS | ICD10CM | Covered |
| S11.93XA | ICD10CM | Covered |
| S11.93XD | ICD10CM | Covered |
| S11.93XS | ICD10CM | Covered |
| S11.94XA | ICD10CM | Covered |
| S11.94XD | ICD10CM | Covered |
| S11.94XS | ICD10CM | Covered |
| S11.95XA | ICD10CM | Covered |
| S11.95XD | ICD10CM | Covered |
| S11.95XS | ICD10CM | Covered |
| S12.000B | ICD10CM | Covered |
| S12.001B | ICD10CM | Covered |
| S12.01XB | ICD10CM | Covered |
| S12.02XB | ICD10CM | Covered |
| S12.040B | ICD10CM | Covered |
| S12.041B | ICD10CM | Covered |
| S12.090B | ICD10CM | Covered |
| S12.091B | ICD10CM | Covered |
| S12.100B | ICD10CM | Covered |
| S12.101B | ICD10CM | Covered |
| S12.110B | ICD10CM | Covered |
| S12.111B | ICD10CM | Covered |
| S12.112B | ICD10CM | Covered |
| S12.120B | ICD10CM | Covered |
| S12.121B | ICD10CM | Covered |
| S12.14XB | ICD10CM | Covered |
| S12.150B | ICD10CM | Covered |
| S12.151B | ICD10CM | Covered |
| S12.190B | ICD10CM | Covered |
| S12.191B | ICD10CM | Covered |
| S12.200B | ICD10CM | Covered |
| S12.201B | ICD10CM | Covered |
| S12.24XB | ICD10CM | Covered |
| S12.250B | ICD10CM | Covered |
| S12.251B | ICD10CM | Covered |
| S12.290B | ICD10CM | Covered |
| S12.291B | ICD10CM | Covered |
| S12.400B | ICD10CM | Covered |
| S12.401B | ICD10CM | Covered |
| S12.44XB | ICD10CM | Covered |
| S12.450B | ICD10CM | Covered |
| S12.451B | ICD10CM | Covered |
| S12.490B | ICD10CM | Covered |
| S12.491B | ICD10CM | Covered |
| S12.500B | ICD10CM | Covered |
| S12.501B | ICD10CM | Covered |
| S12.54XB | ICD10CM | Covered |
| S12.550B | ICD10CM | Covered |
| S12.551B | ICD10CM | Covered |
| S12.590B | ICD10CM | Covered |
| S12.591B | ICD10CM | Covered |
| S12.600B | ICD10CM | Covered |
| S12.601B | ICD10CM | Covered |
| S12.650B | ICD10CM | Covered |
| S12.651B | ICD10CM | Covered |
| S12.690B | ICD10CM | Covered |
| S12.691B | ICD10CM | Covered |
| S20.111A | ICD10CM | Covered |
| S20.112A | ICD10CM | Covered |
| S20.171A | ICD10CM | Covered |
| S20.172A | ICD10CM | Covered |
| S20.303A | ICD10CM | Covered |
| S20.304A | ICD10CM | Covered |
| S20.311A | ICD10CM | Covered |
| S20.312A | ICD10CM | Covered |
| S20.313A | ICD10CM | Covered |
| S20.314A | ICD10CM | Covered |
| S20.351A | ICD10CM | Covered |
| S20.352A | ICD10CM | Covered |
| S20.353A | ICD10CM | Covered |
| S20.354A | ICD10CM | Covered |
| S20.371A | ICD10CM | Covered |
| S20.372A | ICD10CM | Covered |
| S20.373A | ICD10CM | Covered |
| S20.374A | ICD10CM | Covered |
| S20.411A | ICD10CM | Covered |
| S20.412A | ICD10CM | Covered |
| S20.451A | ICD10CM | Covered |
| S20.452A | ICD10CM | Covered |
| S20.471A | ICD10CM | Covered |
| S20.472A | ICD10CM | Covered |
| S21.001A | ICD10CM | Covered |
| S21.001D | ICD10CM | Covered |
| S21.001S | ICD10CM | Covered |
| S21.002A | ICD10CM | Covered |
| S21.002D | ICD10CM | Covered |
| S21.002S | ICD10CM | Covered |
| S21.011A | ICD10CM | Covered |
| S21.011D | ICD10CM | Covered |
| S21.011S | ICD10CM | Covered |
| S21.012A | ICD10CM | Covered |
| S21.012D | ICD10CM | Covered |
| S21.012S | ICD10CM | Covered |
| S21.021A | ICD10CM | Covered |
| S21.021D | ICD10CM | Covered |
| S21.021S | ICD10CM | Covered |
| S21.022A | ICD10CM | Covered |
| S21.022D | ICD10CM | Covered |
| S21.022S | ICD10CM | Covered |
| S21.031A | ICD10CM | Covered |
| S21.031D | ICD10CM | Covered |
| S21.031S | ICD10CM | Covered |
| S21.032A | ICD10CM | Covered |
| S21.032D | ICD10CM | Covered |
| S21.032S | ICD10CM | Covered |
| S21.041A | ICD10CM | Covered |
| S21.041D | ICD10CM | Covered |
| S21.041S | ICD10CM | Covered |
| S21.042A | ICD10CM | Covered |
| S21.042D | ICD10CM | Covered |
| S21.042S | ICD10CM | Covered |
| S21.051A | ICD10CM | Covered |
| S21.051D | ICD10CM | Covered |
| S21.051S | ICD10CM | Covered |
| S21.052A | ICD10CM | Covered |
| S21.052D | ICD10CM | Covered |
| S21.052S | ICD10CM | Covered |
| S21.101A | ICD10CM | Covered |
| S21.101D | ICD10CM | Covered |
| S21.101S | ICD10CM | Covered |
| S21.102A | ICD10CM | Covered |
| S21.102D | ICD10CM | Covered |
| S21.102S | ICD10CM | Covered |
| S21.111A | ICD10CM | Covered |
| S21.111D | ICD10CM | Covered |
| S21.111S | ICD10CM | Covered |
| S21.112A | ICD10CM | Covered |
| S21.112D | ICD10CM | Covered |
| S21.112S | ICD10CM | Covered |
| S21.121A | ICD10CM | Covered |
| S21.121D | ICD10CM | Covered |
| S21.121S | ICD10CM | Covered |
| S21.122A | ICD10CM | Covered |
| S21.122D | ICD10CM | Covered |
| S21.122S | ICD10CM | Covered |
| S21.131A | ICD10CM | Covered |
| S21.131D | ICD10CM | Covered |
| S21.131S | ICD10CM | Covered |
| S21.132A | ICD10CM | Covered |
| S21.132D | ICD10CM | Covered |
| S21.132S | ICD10CM | Covered |
| S21.141A | ICD10CM | Covered |
| S21.141D | ICD10CM | Covered |
| S21.141S | ICD10CM | Covered |
| S21.142A | ICD10CM | Covered |
| S21.142D | ICD10CM | Covered |
| S21.142S | ICD10CM | Covered |
| S21.151A | ICD10CM | Covered |
| S21.151D | ICD10CM | Covered |
| S21.151S | ICD10CM | Covered |
| S21.152A | ICD10CM | Covered |
| S21.152D | ICD10CM | Covered |
| S21.152S | ICD10CM | Covered |
| S21.201A | ICD10CM | Covered |
| S21.201D | ICD10CM | Covered |
| S21.201S | ICD10CM | Covered |
| S21.202A | ICD10CM | Covered |
| S21.202D | ICD10CM | Covered |
| S21.202S | ICD10CM | Covered |
| S21.211A | ICD10CM | Covered |
| S21.211D | ICD10CM | Covered |
| S21.211S | ICD10CM | Covered |
| S21.212A | ICD10CM | Covered |
| S21.212D | ICD10CM | Covered |
| S21.212S | ICD10CM | Covered |
| S21.221A | ICD10CM | Covered |
| S21.221D | ICD10CM | Covered |
| S21.221S | ICD10CM | Covered |
| S21.222A | ICD10CM | Covered |
| S21.222D | ICD10CM | Covered |
| S21.222S | ICD10CM | Covered |
| S21.231A | ICD10CM | Covered |
| S21.231D | ICD10CM | Covered |
| S21.231S | ICD10CM | Covered |
| S21.232A | ICD10CM | Covered |
| S21.232D | ICD10CM | Covered |
| S21.232S | ICD10CM | Covered |
| S21.241A | ICD10CM | Covered |
| S21.241D | ICD10CM | Covered |
| S21.241S | ICD10CM | Covered |
| S21.242A | ICD10CM | Covered |
| S21.242D | ICD10CM | Covered |
| S21.242S | ICD10CM | Covered |
| S21.251A | ICD10CM | Covered |
| S21.251D | ICD10CM | Covered |
| S21.251S | ICD10CM | Covered |
| S21.252A | ICD10CM | Covered |
| S21.252D | ICD10CM | Covered |
| S21.252S | ICD10CM | Covered |
| S21.301A | ICD10CM | Covered |
| S21.301D | ICD10CM | Covered |
| S21.301S | ICD10CM | Covered |
| S21.302A | ICD10CM | Covered |
| S21.302D | ICD10CM | Covered |
| S21.302S | ICD10CM | Covered |
| S21.311A | ICD10CM | Covered |
| S21.311D | ICD10CM | Covered |
| S21.311S | ICD10CM | Covered |
| S21.312A | ICD10CM | Covered |
| S21.312D | ICD10CM | Covered |
| S21.312S | ICD10CM | Covered |
| S21.321A | ICD10CM | Covered |
| S21.321D | ICD10CM | Covered |
| S21.321S | ICD10CM | Covered |
| S21.322A | ICD10CM | Covered |
| S21.322D | ICD10CM | Covered |
| S21.322S | ICD10CM | Covered |
| S21.331A | ICD10CM | Covered |
| S21.331D | ICD10CM | Covered |
| S21.331S | ICD10CM | Covered |
| S21.332A | ICD10CM | Covered |
| S21.332D | ICD10CM | Covered |
| S21.332S | ICD10CM | Covered |
| S21.341A | ICD10CM | Covered |
| S21.341D | ICD10CM | Covered |
| S21.341S | ICD10CM | Covered |
| S21.342A | ICD10CM | Covered |
| S21.342D | ICD10CM | Covered |
| S21.342S | ICD10CM | Covered |
| S21.351A | ICD10CM | Covered |
| S21.351D | ICD10CM | Covered |
| S21.351S | ICD10CM | Covered |
| S21.352A | ICD10CM | Covered |
| S21.352D | ICD10CM | Covered |
| S21.352S | ICD10CM | Covered |
| S21.401A | ICD10CM | Covered |
| S21.401D | ICD10CM | Covered |
| S21.401S | ICD10CM | Covered |
| S21.402A | ICD10CM | Covered |
| S21.402D | ICD10CM | Covered |
| S21.402S | ICD10CM | Covered |
| S21.411A | ICD10CM | Covered |
| S21.411D | ICD10CM | Covered |
| S21.411S | ICD10CM | Covered |
| S21.412A | ICD10CM | Covered |
| S21.412D | ICD10CM | Covered |
| S21.412S | ICD10CM | Covered |
| S21.421A | ICD10CM | Covered |
| S21.421D | ICD10CM | Covered |
| S21.421S | ICD10CM | Covered |
| S21.422A | ICD10CM | Covered |
| S21.422D | ICD10CM | Covered |
| S21.422S | ICD10CM | Covered |
| S21.441A | ICD10CM | Covered |
| S21.441D | ICD10CM | Covered |
| S21.441S | ICD10CM | Covered |
| S21.442A | ICD10CM | Covered |
| S21.442D | ICD10CM | Covered |
| S21.442S | ICD10CM | Covered |
| S21.451A | ICD10CM | Covered |
| S21.451D | ICD10CM | Covered |
| S21.451S | ICD10CM | Covered |
| S21.452A | ICD10CM | Covered |
| S21.452D | ICD10CM | Covered |
| S21.452S | ICD10CM | Covered |
| S22.001B | ICD10CM | Covered |
| S22.002B | ICD10CM | Covered |
| S22.010B | ICD10CM | Covered |
| S22.011B | ICD10CM | Covered |
| S22.012B | ICD10CM | Covered |
| S22.018B | ICD10CM | Covered |
| S22.019B | ICD10CM | Covered |
| S22.020B | ICD10CM | Covered |
| S22.021B | ICD10CM | Covered |
| S22.022B | ICD10CM | Covered |
| S22.028B | ICD10CM | Covered |
| S22.029B | ICD10CM | Covered |
| S22.040B | ICD10CM | Covered |
| S22.041B | ICD10CM | Covered |
| S22.042B | ICD10CM | Covered |
| S22.048B | ICD10CM | Covered |
| S22.049B | ICD10CM | Covered |
| S22.050B | ICD10CM | Covered |
| S22.051B | ICD10CM | Covered |
| S22.052B | ICD10CM | Covered |
| S22.058B | ICD10CM | Covered |
| S22.059B | ICD10CM | Covered |
| S22.060B | ICD10CM | Covered |
| S22.061B | ICD10CM | Covered |
| S22.062B | ICD10CM | Covered |
| S22.068B | ICD10CM | Covered |
| S22.069B | ICD10CM | Covered |
| S22.070B | ICD10CM | Covered |
| S22.071B | ICD10CM | Covered |
| S22.072B | ICD10CM | Covered |
| S22.078B | ICD10CM | Covered |
| S22.079B | ICD10CM | Covered |
| S22.080B | ICD10CM | Covered |
| S22.081B | ICD10CM | Covered |
| S22.082B | ICD10CM | Covered |
| S22.088B | ICD10CM | Covered |
| S22.089B | ICD10CM | Covered |
| S22.20XB | ICD10CM | Covered |
| S22.21XB | ICD10CM | Covered |
| S22.22XB | ICD10CM | Covered |
| S22.24XB | ICD10CM | Covered |
| S22.41XB | ICD10CM | Covered |
| S22.42XB | ICD10CM | Covered |
| S22.5XXB | ICD10CM | Covered |
| S22.9XXB | ICD10CM | Covered |
| S28.0XXA | ICD10CM | Covered |
| S28.0XXD | ICD10CM | Covered |
| S28.0XXS | ICD10CM | Covered |
| S28.1XXA | ICD10CM | Covered |
| S28.1XXD | ICD10CM | Covered |
| S28.1XXS | ICD10CM | Covered |
| S28.211A | ICD10CM | Covered |
| S28.211D | ICD10CM | Covered |
| S28.211S | ICD10CM | Covered |
| S28.212A | ICD10CM | Covered |
| S28.212D | ICD10CM | Covered |
| S28.212S | ICD10CM | Covered |
| S28.221A | ICD10CM | Covered |
| S28.221D | ICD10CM | Covered |
| S28.221S | ICD10CM | Covered |
| S28.222A | ICD10CM | Covered |
| S28.222D | ICD10CM | Covered |
| S28.222S | ICD10CM | Covered |
| S30.810A | ICD10CM | Covered |
| S30.811A | ICD10CM | Covered |
| S30.812A | ICD10CM | Covered |
| S30.813A | ICD10CM | Covered |
| S30.814A | ICD10CM | Covered |
| S30.817A | ICD10CM | Covered |
| S30.81AA | ICD10CM | Covered |
| S30.81AD | ICD10CM | Covered |
| S30.81AS | ICD10CM | Covered |
| S30.82AA | ICD10CM | Covered |
| S30.82AD | ICD10CM | Covered |
| S30.82AS | ICD10CM | Covered |
| S30.84AA | ICD10CM | Covered |
| S30.84AD | ICD10CM | Covered |
| S30.84AS | ICD10CM | Covered |
| S30.850A | ICD10CM | Covered |
| S30.851A | ICD10CM | Covered |
| S30.852A | ICD10CM | Covered |
| S30.853A | ICD10CM | Covered |
| S30.854A | ICD10CM | Covered |
| S30.857A | ICD10CM | Covered |
| S30.85AA | ICD10CM | Covered |
| S30.85AD | ICD10CM | Covered |
| S30.85AS | ICD10CM | Covered |
| S30.86AA | ICD10CM | Covered |
| S30.86AD | ICD10CM | Covered |
| S30.86AS | ICD10CM | Covered |
| S30.870A | ICD10CM | Covered |
| S30.871A | ICD10CM | Covered |
| S30.872A | ICD10CM | Covered |
| S30.873A | ICD10CM | Covered |
| S30.874A | ICD10CM | Covered |
| S30.877A | ICD10CM | Covered |
| S30.87AA | ICD10CM | Covered |
| S30.87AD | ICD10CM | Covered |
| S30.87AS | ICD10CM | Covered |
| S31.000A | ICD10CM | Covered |
| S31.000D | ICD10CM | Covered |
| S31.000S | ICD10CM | Covered |
| S31.001A | ICD10CM | Covered |
| S31.001D | ICD10CM | Covered |
| S31.001S | ICD10CM | Covered |
| S31.010A | ICD10CM | Covered |
| S31.010D | ICD10CM | Covered |
| S31.010S | ICD10CM | Covered |
| S31.011A | ICD10CM | Covered |
| S31.011D | ICD10CM | Covered |
| S31.011S | ICD10CM | Covered |
| S31.020A | ICD10CM | Covered |
| S31.020D | ICD10CM | Covered |
| S31.020S | ICD10CM | Covered |
| S31.021A | ICD10CM | Covered |
| S31.021D | ICD10CM | Covered |
| S31.021S | ICD10CM | Covered |
| S31.030A | ICD10CM | Covered |
| S31.030D | ICD10CM | Covered |
| S31.030S | ICD10CM | Covered |
| S31.031A | ICD10CM | Covered |
| S31.031D | ICD10CM | Covered |
| S31.031S | ICD10CM | Covered |
| S31.040A | ICD10CM | Covered |
| S31.040D | ICD10CM | Covered |
| S31.040S | ICD10CM | Covered |
| S31.041A | ICD10CM | Covered |
| S31.041D | ICD10CM | Covered |
| S31.041S | ICD10CM | Covered |
| S31.050A | ICD10CM | Covered |
| S31.050D | ICD10CM | Covered |
| S31.050S | ICD10CM | Covered |
| S31.051A | ICD10CM | Covered |
| S31.051D | ICD10CM | Covered |
| S31.051S | ICD10CM | Covered |
| S31.100A | ICD10CM | Covered |
| S31.100D | ICD10CM | Covered |
| S31.100S | ICD10CM | Covered |
| S31.101A | ICD10CM | Covered |
| S31.101D | ICD10CM | Covered |
| S31.101S | ICD10CM | Covered |
| S31.102A | ICD10CM | Covered |
| S31.102D | ICD10CM | Covered |
| S31.102S | ICD10CM | Covered |
| S31.103A | ICD10CM | Covered |
| S31.103D | ICD10CM | Covered |
| S31.103S | ICD10CM | Covered |
| S31.104A | ICD10CM | Covered |
| S31.104D | ICD10CM | Covered |
| S31.104S | ICD10CM | Covered |
| S31.105A | ICD10CM | Covered |
| S31.105D | ICD10CM | Covered |
| S31.105S | ICD10CM | Covered |
| S31.106A | ICD10CM | Covered |
| S31.106D | ICD10CM | Covered |
| S31.106S | ICD10CM | Covered |
| S31.107A | ICD10CM | Covered |
| S31.107D | ICD10CM | Covered |
| S31.107S | ICD10CM | Covered |
| S31.10AA | ICD10CM | Covered |
| S31.10AD | ICD10CM | Covered |
| S31.10AS | ICD10CM | Covered |
| S31.110A | ICD10CM | Covered |
| S31.110D | ICD10CM | Covered |
| S31.110S | ICD10CM | Covered |
| S31.111A | ICD10CM | Covered |
| S31.111D | ICD10CM | Covered |
| S31.111S | ICD10CM | Covered |
| S31.112A | ICD10CM | Covered |
| S31.112D | ICD10CM | Covered |
| S31.112S | ICD10CM | Covered |
| S31.113A | ICD10CM | Covered |
| S31.113D | ICD10CM | Covered |
| S31.113S | ICD10CM | Covered |
| S31.114A | ICD10CM | Covered |
| S31.114D | ICD10CM | Covered |
| S31.114S | ICD10CM | Covered |
| S31.115A | ICD10CM | Covered |
| S31.115D | ICD10CM | Covered |
| S31.115S | ICD10CM | Covered |
| S31.116A | ICD10CM | Covered |
| S31.116D | ICD10CM | Covered |
| S31.116S | ICD10CM | Covered |
| S31.117A | ICD10CM | Covered |
| S31.117D | ICD10CM | Covered |
| S31.117S | ICD10CM | Covered |
| S31.11AA | ICD10CM | Covered |
| S31.11AD | ICD10CM | Covered |
| S31.11AS | ICD10CM | Covered |
| S31.120A | ICD10CM | Covered |
| S31.120D | ICD10CM | Covered |
| S31.120S | ICD10CM | Covered |
| S31.121A | ICD10CM | Covered |
| S31.121D | ICD10CM | Covered |
| S31.121S | ICD10CM | Covered |
| S31.122A | ICD10CM | Covered |
| S31.122D | ICD10CM | Covered |
| S31.122S | ICD10CM | Covered |
| S31.123A | ICD10CM | Covered |
| S31.123D | ICD10CM | Covered |
| S31.123S | ICD10CM | Covered |
| S31.124A | ICD10CM | Covered |
| S31.124D | ICD10CM | Covered |
| S31.124S | ICD10CM | Covered |
| S31.125A | ICD10CM | Covered |
| S31.125D | ICD10CM | Covered |
| S31.125S | ICD10CM | Covered |
| S31.126A | ICD10CM | Covered |
| S31.126D | ICD10CM | Covered |
| S31.126S | ICD10CM | Covered |
| S31.127A | ICD10CM | Covered |
| S31.127D | ICD10CM | Covered |
| S31.127S | ICD10CM | Covered |
| S31.12AA | ICD10CM | Covered |
| S31.12AD | ICD10CM | Covered |
| S31.12AS | ICD10CM | Covered |
| S31.130A | ICD10CM | Covered |