Policy source
The recorded policy does not contain a public text excerpt. Read the official source for details.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| 76770 | HCPCS | Covered |
| 76775 | HCPCS | Covered |
| 76776 | HCPCS | Covered |
| B25.2 | ICD10CM | Covered |
| B52.0 | ICD10CM | Covered |
| C25.0 | ICD10CM | Covered |
| C25.1 | ICD10CM | Covered |
| C25.2 | ICD10CM | Covered |
| C25.3 | ICD10CM | Covered |
| C25.4 | ICD10CM | Covered |
| C25.7 | ICD10CM | Covered |
| C25.8 | ICD10CM | Covered |
| C25.9 | ICD10CM | Covered |
| C48.0 | ICD10CM | Covered |
| C48.8 | ICD10CM | Covered |
| C61 | ICD10CM | Covered |
| C64.1 | ICD10CM | Covered |
| C64.2 | ICD10CM | Covered |
| C65.1 | ICD10CM | Covered |
| C65.2 | ICD10CM | Covered |
| C66.1 | ICD10CM | Covered |
| C66.2 | ICD10CM | Covered |
| C67.9 | ICD10CM | Covered |
| C68.0 | ICD10CM | Covered |
| C68.1 | ICD10CM | Covered |
| C68.8 | ICD10CM | Covered |
| C78.6 | ICD10CM | Covered |
| C79.01 | ICD10CM | Covered |
| C79.02 | ICD10CM | Covered |
| C79.11 | ICD10CM | Covered |
| C79.19 | ICD10CM | Covered |
| C79.71 | ICD10CM | Covered |
| C79.72 | ICD10CM | Covered |
| C7A.093 | ICD10CM | Covered |
| C7B.09 | ICD10CM | Covered |
| C7B.8 | ICD10CM | Covered |
| C81.00 | ICD10CM | Covered |
| C81.03 | ICD10CM | Covered |
| C81.07 | ICD10CM | Covered |
| C81.08 | ICD10CM | Covered |
| C81.09 | ICD10CM | Covered |
| C81.10 | ICD10CM | Covered |
| C81.13 | ICD10CM | Covered |
| C81.17 | ICD10CM | Covered |
| C81.18 | ICD10CM | Covered |
| C81.19 | ICD10CM | Covered |
| C81.20 | ICD10CM | Covered |
| C81.23 | ICD10CM | Covered |
| C81.27 | ICD10CM | Covered |
| C81.28 | ICD10CM | Covered |
| C81.29 | ICD10CM | Covered |
| C81.30 | ICD10CM | Covered |
| C81.33 | ICD10CM | Covered |
| C81.37 | ICD10CM | Covered |
| C81.38 | ICD10CM | Covered |
| C81.39 | ICD10CM | Covered |
| C81.40 | ICD10CM | Covered |
| C81.43 | ICD10CM | Covered |
| C81.47 | ICD10CM | Covered |
| C81.48 | ICD10CM | Covered |
| C81.49 | ICD10CM | Covered |
| C81.70 | ICD10CM | Covered |
| C81.73 | ICD10CM | Covered |
| C81.77 | ICD10CM | Covered |
| C81.78 | ICD10CM | Covered |
| C81.79 | ICD10CM | Covered |
| C81.90 | ICD10CM | Covered |
| C81.93 | ICD10CM | Covered |
| C81.97 | ICD10CM | Covered |
| C81.98 | ICD10CM | Covered |
| C81.99 | ICD10CM | Covered |
| C82.00 | ICD10CM | Covered |
| C82.03 | ICD10CM | Covered |
| C82.07 | ICD10CM | Covered |
| C82.08 | ICD10CM | Covered |
| C82.09 | ICD10CM | Covered |
| C82.10 | ICD10CM | Covered |
| C82.13 | ICD10CM | Covered |
| C82.17 | ICD10CM | Covered |
| C82.18 | ICD10CM | Covered |
| C82.19 | ICD10CM | Covered |
| C82.20 | ICD10CM | Covered |
| C82.23 | ICD10CM | Covered |
| C82.27 | ICD10CM | Covered |
| C82.28 | ICD10CM | Covered |
| C82.29 | ICD10CM | Covered |
| C82.30 | ICD10CM | Covered |
| C82.33 | ICD10CM | Covered |
| C82.37 | ICD10CM | Covered |
| C82.38 | ICD10CM | Covered |
| C82.39 | ICD10CM | Covered |
| C82.40 | ICD10CM | Covered |
| C82.43 | ICD10CM | Covered |
| C82.47 | ICD10CM | Covered |
| C82.48 | ICD10CM | Covered |
| C82.49 | ICD10CM | Covered |
| C82.50 | ICD10CM | Covered |
| C82.53 | ICD10CM | Covered |
| C82.57 | ICD10CM | Covered |
| C82.58 | ICD10CM | Covered |
| C82.59 | ICD10CM | Covered |
| C82.60 | ICD10CM | Covered |
| C82.63 | ICD10CM | Covered |
| C82.67 | ICD10CM | Covered |
| C82.68 | ICD10CM | Covered |
| C82.69 | ICD10CM | Covered |
| C82.80 | ICD10CM | Covered |
| C82.83 | ICD10CM | Covered |
| C82.87 | ICD10CM | Covered |
| C82.88 | ICD10CM | Covered |
| C82.89 | ICD10CM | Covered |
| C82.90 | ICD10CM | Covered |
| C82.93 | ICD10CM | Covered |
| C82.97 | ICD10CM | Covered |
| C82.98 | ICD10CM | Covered |
| C82.99 | ICD10CM | Covered |
| C83.00 | ICD10CM | Covered |
| C83.03 | ICD10CM | Covered |
| C83.07 | ICD10CM | Covered |
| C83.08 | ICD10CM | Covered |
| C83.09 | ICD10CM | Covered |
| C83.10 | ICD10CM | Covered |
| C83.13 | ICD10CM | Covered |
| C83.17 | ICD10CM | Covered |
| C83.18 | ICD10CM | Covered |
| C83.19 | ICD10CM | Covered |
| C83.30 | ICD10CM | Covered |
| C83.33 | ICD10CM | Covered |
| C83.37 | ICD10CM | Covered |
| C83.38 | ICD10CM | Covered |
| C83.390 | ICD10CM | Covered |
| C83.398 | ICD10CM | Covered |
| C83.50 | ICD10CM | Covered |
| C83.53 | ICD10CM | Covered |
| C83.57 | ICD10CM | Covered |
| C83.58 | ICD10CM | Covered |
| C83.59 | ICD10CM | Covered |
| C83.70 | ICD10CM | Covered |
| C83.73 | ICD10CM | Covered |
| C83.77 | ICD10CM | Covered |
| C83.78 | ICD10CM | Covered |
| C83.79 | ICD10CM | Covered |
| C83.80 | ICD10CM | Covered |
| C83.83 | ICD10CM | Covered |
| C83.87 | ICD10CM | Covered |
| C83.88 | ICD10CM | Covered |
| C83.89 | ICD10CM | Covered |
| C83.90 | ICD10CM | Covered |
| C83.93 | ICD10CM | Covered |
| C83.97 | ICD10CM | Covered |
| C83.98 | ICD10CM | Covered |
| C83.99 | ICD10CM | Covered |
| C84.00 | ICD10CM | Covered |
| C84.03 | ICD10CM | Covered |
| C84.07 | ICD10CM | Covered |
| C84.08 | ICD10CM | Covered |
| C84.09 | ICD10CM | Covered |
| C84.10 | ICD10CM | Covered |
| C84.13 | ICD10CM | Covered |
| C84.17 | ICD10CM | Covered |
| C84.18 | ICD10CM | Covered |
| C84.19 | ICD10CM | Covered |
| C84.40 | ICD10CM | Covered |
| C84.43 | ICD10CM | Covered |
| C84.47 | ICD10CM | Covered |
| C84.48 | ICD10CM | Covered |
| C84.49 | ICD10CM | Covered |
| C84.60 | ICD10CM | Covered |
| C84.63 | ICD10CM | Covered |
| C84.67 | ICD10CM | Covered |
| C84.68 | ICD10CM | Covered |
| C84.69 | ICD10CM | Covered |
| C84.70 | ICD10CM | Covered |
| C84.73 | ICD10CM | Covered |
| C84.77 | ICD10CM | Covered |
| C84.78 | ICD10CM | Covered |
| C84.79 | ICD10CM | Covered |
| C84.90 | ICD10CM | Covered |
| C84.93 | ICD10CM | Covered |
| C84.97 | ICD10CM | Covered |
| C84.98 | ICD10CM | Covered |
| C84.99 | ICD10CM | Covered |
| C84.A0 | ICD10CM | Covered |
| C84.A3 | ICD10CM | Covered |
| C84.A7 | ICD10CM | Covered |
| C84.A8 | ICD10CM | Covered |
| C84.A9 | ICD10CM | Covered |
| C84.Z0 | ICD10CM | Covered |
| C84.Z3 | ICD10CM | Covered |
| C84.Z7 | ICD10CM | Covered |
| C84.Z8 | ICD10CM | Covered |
| C84.Z9 | ICD10CM | Covered |
| C85.10 | ICD10CM | Covered |
| C85.13 | ICD10CM | Covered |
| C85.17 | ICD10CM | Covered |
| C85.18 | ICD10CM | Covered |
| C85.19 | ICD10CM | Covered |
| C85.20 | ICD10CM | Covered |
| C85.23 | ICD10CM | Covered |
| C85.27 | ICD10CM | Covered |
| C85.28 | ICD10CM | Covered |
| C85.29 | ICD10CM | Covered |
| C85.80 | ICD10CM | Covered |
| C85.83 | ICD10CM | Covered |
| C85.87 | ICD10CM | Covered |
| C85.88 | ICD10CM | Covered |
| C85.89 | ICD10CM | Covered |
| C85.90 | ICD10CM | Covered |
| C85.93 | ICD10CM | Covered |
| C85.97 | ICD10CM | Covered |
| C85.98 | ICD10CM | Covered |
| C85.99 | ICD10CM | Covered |
| C86.10 | ICD10CM | Covered |
| C96.Z | ICD10CM | Covered |
| D30.01 | ICD10CM | Covered |
| D30.02 | ICD10CM | Covered |
| D30.11 | ICD10CM | Covered |
| D30.12 | ICD10CM | Covered |
| D30.21 | ICD10CM | Covered |
| D30.22 | ICD10CM | Covered |
| D30.3 | ICD10CM | Covered |
| D30.4 | ICD10CM | Covered |
| D30.8 | ICD10CM | Covered |
| D3A.093 | ICD10CM | Covered |
| D47.Z1 | ICD10CM | Covered |
| D47.Z2 | ICD10CM | Covered |
| D49.511 | ICD10CM | Covered |
| D49.512 | ICD10CM | Covered |
| D49.519 | ICD10CM | Covered |
| D49.59 | ICD10CM | Covered |
| E08.21 | ICD10CM | Covered |
| E08.22 | ICD10CM | Covered |
| E08.29 | ICD10CM | Covered |
| E09.21 | ICD10CM | Covered |
| E09.22 | ICD10CM | Covered |
| E09.29 | ICD10CM | Covered |
| E25.0 | ICD10CM | Covered |
| E25.8 | ICD10CM | Covered |
| E25.9 | ICD10CM | Covered |
| E26.01 | ICD10CM | Covered |
| E26.02 | ICD10CM | Covered |
| E26.09 | ICD10CM | Covered |
| E26.1 | ICD10CM | Covered |
| E26.81 | ICD10CM | Covered |
| E26.89 | ICD10CM | Covered |
| E26.9 | ICD10CM | Covered |
| E85.0 | ICD10CM | Covered |
| E85.1 | ICD10CM | Covered |
| E85.2 | ICD10CM | Covered |
| E85.3 | ICD10CM | Covered |
| E85.4 | ICD10CM | Covered |
| E85.81 | ICD10CM | Covered |
| E85.82 | ICD10CM | Covered |
| E85.89 | ICD10CM | Covered |
| E85.9 | ICD10CM | Covered |
| I12.0 | ICD10CM | Covered |
| I12.9 | ICD10CM | Covered |
| I15.0 | ICD10CM | Covered |
| I71.02 | ICD10CM | Covered |
| I71.03 | ICD10CM | Covered |
| I71.30 | ICD10CM | Covered |
| I71.31 | ICD10CM | Covered |
| I71.32 | ICD10CM | Covered |
| I71.33 | ICD10CM | Covered |
| I71.40 | ICD10CM | Covered |
| I71.41 | ICD10CM | Covered |
| I71.42 | ICD10CM | Covered |
| I71.43 | ICD10CM | Covered |
| I71.50 | ICD10CM | Covered |
| I71.51 | ICD10CM | Covered |
| I71.52 | ICD10CM | Covered |
| I71.60 | ICD10CM | Covered |
| I71.61 | ICD10CM | Covered |
| I71.62 | ICD10CM | Covered |
| I72.2 | ICD10CM | Covered |
| I74.01 | ICD10CM | Covered |
| I74.09 | ICD10CM | Covered |
| I82.3 | ICD10CM | Covered |
| I97.620 | ICD10CM | Covered |
| I97.621 | ICD10CM | Covered |
| I97.622 | ICD10CM | Covered |
| I97.638 | ICD10CM | Covered |
| I97.648 | ICD10CM | Covered |
| K35.200 | ICD10CM | Covered |
| K35.201 | ICD10CM | Covered |
| K35.209 | ICD10CM | Covered |
| K35.210 | ICD10CM | Covered |
| K35.211 | ICD10CM | Covered |
| K35.219 | ICD10CM | Covered |
| K35.30 | ICD10CM | Covered |
| K35.31 | ICD10CM | Covered |
| K35.32 | ICD10CM | Covered |
| K35.33 | ICD10CM | Covered |
| K35.890 | ICD10CM | Covered |
| K35.891 | ICD10CM | Covered |
| K56.3 | ICD10CM | Covered |
| K61.31 | ICD10CM | Covered |
| K61.39 | ICD10CM | Covered |
| K61.5 | ICD10CM | Covered |
| K68.3 | ICD10CM | Covered |
| K80.00 | ICD10CM | Covered |
| K80.01 | ICD10CM | Covered |
| K80.10 | ICD10CM | Covered |
| K80.11 | ICD10CM | Covered |
| K80.12 | ICD10CM | Covered |
| K80.13 | ICD10CM | Covered |
| K80.18 | ICD10CM | Covered |
| K80.19 | ICD10CM | Covered |
| K80.20 | ICD10CM | Covered |
| K80.21 | ICD10CM | Covered |
| K80.60 | ICD10CM | Covered |
| K80.61 | ICD10CM | Covered |
| K80.62 | ICD10CM | Covered |
| K80.63 | ICD10CM | Covered |
| K80.64 | ICD10CM | Covered |
| K80.65 | ICD10CM | Covered |
| K80.66 | ICD10CM | Covered |
| K80.67 | ICD10CM | Covered |
| K80.70 | ICD10CM | Covered |
| K80.71 | ICD10CM | Covered |
| K82.0 | ICD10CM | Covered |
| K82.1 | ICD10CM | Covered |
| K82.2 | ICD10CM | Covered |
| K82.3 | ICD10CM | Covered |
| K82.4 | ICD10CM | Covered |
| K82.A1 | ICD10CM | Covered |
| K82.A2 | ICD10CM | Covered |
| K83.01 | ICD10CM | Covered |
| K83.09 | ICD10CM | Covered |
| K85.00 | ICD10CM | Covered |
| K85.01 | ICD10CM | Covered |
| K85.02 | ICD10CM | Covered |
| K85.10 | ICD10CM | Covered |
| K85.11 | ICD10CM | Covered |
| K85.12 | ICD10CM | Covered |
| K85.20 | ICD10CM | Covered |
| K85.21 | ICD10CM | Covered |
| K85.22 | ICD10CM | Covered |
| K85.30 | ICD10CM | Covered |
| K85.31 | ICD10CM | Covered |
| K85.32 | ICD10CM | Covered |
| K85.80 | ICD10CM | Covered |
| K85.81 | ICD10CM | Covered |
| K85.82 | ICD10CM | Covered |
| K85.90 | ICD10CM | Covered |
| K85.91 | ICD10CM | Covered |
| K85.92 | ICD10CM | Covered |
| K86.81 | ICD10CM | Covered |
| K87 | ICD10CM | Covered |
| M32.14 | ICD10CM | Covered |
| M32.15 | ICD10CM | Covered |
| M35.04 | ICD10CM | Covered |
| M35.0A | ICD10CM | Covered |
| N00.0 | ICD10CM | Covered |
| N00.1 | ICD10CM | Covered |
| N00.2 | ICD10CM | Covered |
| N00.3 | ICD10CM | Covered |
| N00.4 | ICD10CM | Covered |
| N00.5 | ICD10CM | Covered |
| N00.6 | ICD10CM | Covered |
| N00.7 | ICD10CM | Covered |
| N00.8 | ICD10CM | Covered |
| N00.9 | ICD10CM | Covered |
| N01.0 | ICD10CM | Covered |
| N01.1 | ICD10CM | Covered |
| N01.2 | ICD10CM | Covered |
| N01.3 | ICD10CM | Covered |
| N01.4 | ICD10CM | Covered |
| N01.5 | ICD10CM | Covered |
| N01.6 | ICD10CM | Covered |
| N01.7 | ICD10CM | Covered |
| N01.8 | ICD10CM | Covered |
| N01.9 | ICD10CM | Covered |
| N02.0 | ICD10CM | Covered |
| N02.1 | ICD10CM | Covered |
| N02.2 | ICD10CM | Covered |
| N02.3 | ICD10CM | Covered |
| N02.4 | ICD10CM | Covered |
| N02.5 | ICD10CM | Covered |
| N02.6 | ICD10CM | Covered |
| N02.7 | ICD10CM | Covered |
| N02.8 | ICD10CM | Covered |
| N02.9 | ICD10CM | Covered |
| N03.0 | ICD10CM | Covered |
| N03.1 | ICD10CM | Covered |
| N03.2 | ICD10CM | Covered |
| N03.3 | ICD10CM | Covered |
| N03.4 | ICD10CM | Covered |
| N03.5 | ICD10CM | Covered |
| N03.6 | ICD10CM | Covered |
| N03.7 | ICD10CM | Covered |
| N03.8 | ICD10CM | Covered |
| N03.9 | ICD10CM | Covered |
| N04.0 | ICD10CM | Covered |
| N04.1 | ICD10CM | Covered |
| N04.20 | ICD10CM | Covered |
| N04.21 | ICD10CM | Covered |
| N04.22 | ICD10CM | Covered |
| N04.29 | ICD10CM | Covered |
| N04.3 | ICD10CM | Covered |
| N04.4 | ICD10CM | Covered |
| N04.5 | ICD10CM | Covered |
| N04.6 | ICD10CM | Covered |
| N04.7 | ICD10CM | Covered |
| N04.8 | ICD10CM | Covered |
| N04.9 | ICD10CM | Covered |
| N05.0 | ICD10CM | Covered |
| N05.1 | ICD10CM | Covered |
| N05.2 | ICD10CM | Covered |
| N05.3 | ICD10CM | Covered |
| N05.4 | ICD10CM | Covered |
| N05.5 | ICD10CM | Covered |
| N05.6 | ICD10CM | Covered |
| N05.7 | ICD10CM | Covered |
| N05.8 | ICD10CM | Covered |
| N05.9 | ICD10CM | Covered |
| N06.0 | ICD10CM | Covered |
| N06.1 | ICD10CM | Covered |
| N06.20 | ICD10CM | Covered |
| N06.21 | ICD10CM | Covered |
| N06.22 | ICD10CM | Covered |
| N06.29 | ICD10CM | Covered |
| N06.3 | ICD10CM | Covered |
| N06.4 | ICD10CM | Covered |
| N06.5 | ICD10CM | Covered |
| N06.6 | ICD10CM | Covered |
| N06.7 | ICD10CM | Covered |
| N06.8 | ICD10CM | Covered |
| N06.9 | ICD10CM | Covered |
| N07.0 | ICD10CM | Covered |
| N07.1 | ICD10CM | Covered |
| N07.2 | ICD10CM | Covered |
| N07.3 | ICD10CM | Covered |
| N07.4 | ICD10CM | Covered |
| N07.5 | ICD10CM | Covered |
| N07.6 | ICD10CM | Covered |
| N07.7 | ICD10CM | Covered |
| N07.8 | ICD10CM | Covered |
| N07.9 | ICD10CM | Covered |
| N08 | ICD10CM | Covered |
| N10 | ICD10CM | Covered |
| N11.0 | ICD10CM | Covered |
| N11.1 | ICD10CM | Covered |
| N11.8 | ICD10CM | Covered |
| N11.9 | ICD10CM | Covered |
| N12 | ICD10CM | Covered |
| N13.0 | ICD10CM | Covered |
| N13.1 | ICD10CM | Covered |
| N13.2 | ICD10CM | Covered |
| N13.30 | ICD10CM | Covered |
| N13.39 | ICD10CM | Covered |
| N13.4 | ICD10CM | Covered |
| N13.6 | ICD10CM | Covered |
| N13.8 | ICD10CM | Covered |
| N13.9 | ICD10CM | Covered |
| N14.0 | ICD10CM | Covered |
| N14.11 | ICD10CM | Covered |
| N14.19 | ICD10CM | Covered |
| N14.2 | ICD10CM | Covered |
| N14.3 | ICD10CM | Covered |
| N14.4 | ICD10CM | Covered |
| N15.0 | ICD10CM | Covered |
| N15.1 | ICD10CM | Covered |
| N15.8 | ICD10CM | Covered |
| N15.9 | ICD10CM | Covered |
| N16 | ICD10CM | Covered |
| N17.0 | ICD10CM | Covered |
| N17.1 | ICD10CM | Covered |
| N17.2 | ICD10CM | Covered |
| N17.8 | ICD10CM | Covered |
| N17.9 | ICD10CM | Covered |
| N18.1 | ICD10CM | Covered |
| N18.2 | ICD10CM | Covered |
| N18.30 | ICD10CM | Covered |
| N18.31 | ICD10CM | Covered |
| N18.32 | ICD10CM | Covered |
| N18.4 | ICD10CM | Covered |
| N18.5 | ICD10CM | Covered |
| N18.6 | ICD10CM | Covered |
| N18.9 | ICD10CM | Covered |
| N19 | ICD10CM | Covered |
| N20.0 | ICD10CM | Covered |
| N20.1 | ICD10CM | Covered |
| N20.2 | ICD10CM | Covered |
| N20.9 | ICD10CM | Covered |
| N22 | ICD10CM | Covered |
| N23 | ICD10CM | Covered |
| N26.1 | ICD10CM | Covered |
| N26.9 | ICD10CM | Covered |
| N27.0 | ICD10CM | Covered |
| N27.1 | ICD10CM | Covered |
| N28.0 | ICD10CM | Covered |
| N28.1 | ICD10CM | Covered |
| N28.81 | ICD10CM | Covered |
| N28.82 | ICD10CM | Covered |
| N28.84 | ICD10CM | Covered |
| N28.85 | ICD10CM | Covered |
| N28.86 | ICD10CM | Covered |
| N28.89 | ICD10CM | Covered |
| N29 | ICD10CM | Covered |
| N30.01 | ICD10CM | Covered |
| N30.11 | ICD10CM | Covered |
| N30.21 | ICD10CM | Covered |
| N30.31 | ICD10CM | Covered |
| N30.41 | ICD10CM | Covered |
| N30.81 | ICD10CM | Covered |
| N30.91 | ICD10CM | Covered |
| N31.0 | ICD10CM | Covered |
| N31.1 | ICD10CM | Covered |
| N31.2 | ICD10CM | Covered |
| N31.8 | ICD10CM | Covered |
| N31.9 | ICD10CM | Covered |
| N39.0 | ICD10CM | Covered |
| N80.A41 | ICD10CM | Covered |
| N80.A42 | ICD10CM | Covered |
| N80.A43 | ICD10CM | Covered |
| N80.A51 | ICD10CM | Covered |
| N80.A52 | ICD10CM | Covered |
| N80.A53 | ICD10CM | Covered |
| N80.A61 | ICD10CM | Covered |
| N80.A62 | ICD10CM | Covered |
| N80.A63 | ICD10CM | Covered |
| O08.4 | ICD10CM | Covered |
| Q25.42 | ICD10CM | Covered |
| Q25.43 | ICD10CM | Covered |
| Q25.44 | ICD10CM | Covered |
| Q44.0 | ICD10CM | Covered |
| Q44.1 | ICD10CM | Covered |
| Q53.111 | ICD10CM | Covered |
| Q53.112 | ICD10CM | Covered |
| Q53.211 | ICD10CM | Covered |
| Q53.212 | ICD10CM | Covered |
| Q61.00 | ICD10CM | Covered |
| Q61.01 | ICD10CM | Covered |
| Q61.02 | ICD10CM | Covered |
| Q61.11 | ICD10CM | Covered |
| Q61.19 | ICD10CM | Covered |
| Q61.2 | ICD10CM | Covered |
| Q61.3 | ICD10CM | Covered |
| Q61.4 | ICD10CM | Covered |
| Q61.5 | ICD10CM | Covered |
| Q61.8 | ICD10CM | Covered |
| Q61.9 | ICD10CM | Covered |
| Q62.0 | ICD10CM | Covered |
| Q62.10 | ICD10CM | Covered |
| Q62.11 | ICD10CM | Covered |
| Q62.12 | ICD10CM | Covered |
| Q62.2 | ICD10CM | Covered |
| Q62.39 | ICD10CM | Covered |
| R10.11 | ICD10CM | Covered |
| R10.12 | ICD10CM | Covered |
| R10.13 | ICD10CM | Covered |
| R10.20 | ICD10CM | Covered |
| R10.21 | ICD10CM | Covered |
| R10.22 | ICD10CM | Covered |
| R10.23 | ICD10CM | Covered |
| R10.24 | ICD10CM | Covered |
| R10.31 | ICD10CM | Covered |
| R10.32 | ICD10CM | Covered |
| R10.33 | ICD10CM | Covered |
| R10.85 | ICD10CM | Covered |
| R10.9 | ICD10CM | Covered |
| R10.A1 | ICD10CM | Covered |
| R10.A2 | ICD10CM | Covered |
| R10.A3 | ICD10CM | Covered |
| R31.0 | ICD10CM | Covered |
| R31.1 | ICD10CM | Covered |
| R31.21 | ICD10CM | Covered |
| R31.29 | ICD10CM | Covered |
| R31.9 | ICD10CM | Covered |
| R34 | ICD10CM | Covered |
| R74.8 | ICD10CM | Covered |
| R80.0 | ICD10CM | Covered |
| R80.1 | ICD10CM | Covered |
| R80.3 | ICD10CM | Covered |
| R80.8 | ICD10CM | Covered |
| R80.9 | ICD10CM | Covered |
| R82.991 | ICD10CM | Covered |
| R82.992 | ICD10CM | Covered |
| R82.993 | ICD10CM | Covered |
| R82.994 | ICD10CM | Covered |
| R93.41 | ICD10CM | Covered |
| R93.421 | ICD10CM | Covered |
| R93.422 | ICD10CM | Covered |
| R93.429 | ICD10CM | Covered |
| R93.49 | ICD10CM | Covered |
| R93.5 | ICD10CM | Covered |
| R93.811 | ICD10CM | Covered |
| R93.812 | ICD10CM | Covered |
| R93.813 | ICD10CM | Covered |
| R93.89 | ICD10CM | Covered |
| R94.4 | ICD10CM | Covered |
| S31.001A | ICD10CM | Covered |
| S31.001D | ICD10CM | Covered |
| S31.001S | ICD10CM | Covered |
| S36.892A | ICD10CM | Covered |
| S36.892D | ICD10CM | Covered |
| S36.892S | ICD10CM | Covered |
| S36.893A | ICD10CM | Covered |
| S36.893D | ICD10CM | Covered |
| S36.893S | ICD10CM | Covered |
| S36.898A | ICD10CM | Covered |
| S36.898D | ICD10CM | Covered |
| S36.898S | ICD10CM | Covered |
| S37.001A | ICD10CM | Covered |
| S37.001D | ICD10CM | Covered |
| S37.001S | ICD10CM | Covered |
| S37.002A | ICD10CM | Covered |
| S37.002D | ICD10CM | Covered |
| S37.002S | ICD10CM | Covered |
| S37.011A | ICD10CM | Covered |
| S37.011D | ICD10CM | Covered |
| S37.011S | ICD10CM | Covered |
| S37.012A | ICD10CM | Covered |
| S37.012D | ICD10CM | Covered |
| S37.012S | ICD10CM | Covered |
| S37.021A | ICD10CM | Covered |
| S37.021D | ICD10CM | Covered |
| S37.021S | ICD10CM | Covered |
| S37.022A | ICD10CM | Covered |
| S37.022D | ICD10CM | Covered |
| S37.022S | ICD10CM | Covered |
| S37.031A | ICD10CM | Covered |
| S37.031D | ICD10CM | Covered |
| S37.031S | ICD10CM | Covered |
| S37.032A | ICD10CM | Covered |
| S37.032D | ICD10CM | Covered |
| S37.032S | ICD10CM | Covered |
| S37.041A | ICD10CM | Covered |
| S37.041D | ICD10CM | Covered |
| S37.041S | ICD10CM | Covered |
| S37.042A | ICD10CM | Covered |
| S37.042D | ICD10CM | Covered |
| S37.042S | ICD10CM | Covered |
| S37.051A | ICD10CM | Covered |
| S37.051D | ICD10CM | Covered |
| S37.051S | ICD10CM | Covered |
| S37.052A | ICD10CM | Covered |
| S37.052D | ICD10CM | Covered |
| S37.052S | ICD10CM | Covered |
| S37.061A | ICD10CM | Covered |
| S37.061D | ICD10CM | Covered |
| S37.061S | ICD10CM | Covered |
| S37.062A | ICD10CM | Covered |
| S37.062D | ICD10CM | Covered |
| S37.062S | ICD10CM | Covered |
| S37.091A | ICD10CM | Covered |
| S37.091D | ICD10CM | Covered |
| S37.091S | ICD10CM | Covered |
| S37.092A | ICD10CM | Covered |
| S37.092D | ICD10CM | Covered |
| S37.092S | ICD10CM | Covered |
| S37.10XA | ICD10CM | Covered |
| S37.10XD | ICD10CM | Covered |
| S37.10XS | ICD10CM | Covered |
| S37.12XA | ICD10CM | Covered |
| S37.12XD | ICD10CM | Covered |
| S37.12XS | ICD10CM | Covered |
| S37.13XA | ICD10CM | Covered |
| S37.13XD | ICD10CM | Covered |
| S37.13XS | ICD10CM | Covered |
| S37.19XA | ICD10CM | Covered |
| S37.19XD | ICD10CM | Covered |
| S37.19XS | ICD10CM | Covered |
| S37.30XA | ICD10CM | Covered |
| S37.30XD | ICD10CM | Covered |
| S37.30XS | ICD10CM | Covered |
| S37.32XA | ICD10CM | Covered |
| S37.32XD | ICD10CM | Covered |
| S37.32XS | ICD10CM | Covered |
| S37.33XA | ICD10CM | Covered |
| S37.33XD | ICD10CM | Covered |
| S37.33XS | ICD10CM | Covered |
| S37.39XA | ICD10CM | Covered |
| S37.39XD | ICD10CM | Covered |
| S37.39XS | ICD10CM | Covered |
| S37.812A | ICD10CM | Covered |
| S37.812D | ICD10CM | Covered |
| S37.812S | ICD10CM | Covered |
| S37.813A | ICD10CM | Covered |
| S37.813D | ICD10CM | Covered |
| S37.813S | ICD10CM | Covered |
| S37.818A | ICD10CM | Covered |
| S37.818D | ICD10CM | Covered |
| S37.818S | ICD10CM | Covered |
| S37.819A | ICD10CM | Covered |
| S37.819D | ICD10CM | Covered |
| S37.819S | ICD10CM | Covered |
| S37.892A | ICD10CM | Covered |
| S37.892D | ICD10CM | Covered |
| S37.892S | ICD10CM | Covered |
| S37.893A | ICD10CM | Covered |
| S37.893D | ICD10CM | Covered |
| S37.893S | ICD10CM | Covered |
| S37.898A | ICD10CM | Covered |
| S37.898D | ICD10CM | Covered |
| S37.898S | ICD10CM | Covered |
| S37.899A | ICD10CM | Covered |
| S37.899D | ICD10CM | Covered |
| S37.899S | ICD10CM | Covered |
| S39.81XA | ICD10CM | Covered |
| S39.81XD | ICD10CM | Covered |
| S39.81XS | ICD10CM | Covered |
| S39.82XA | ICD10CM | Covered |
| S39.82XD | ICD10CM | Covered |
| S39.82XS | ICD10CM | Covered |
| T79.5XXA | ICD10CM | Covered |
| T79.5XXD | ICD10CM | Covered |
| T79.5XXS | ICD10CM | Covered |
| T79.A3XA | ICD10CM | Covered |
| T79.A3XD | ICD10CM | Covered |
| T79.A3XS | ICD10CM | Covered |
| T81.10XA | ICD10CM | Covered |
| T81.10XD | ICD10CM | Covered |
| T81.10XS | ICD10CM | Covered |
| T81.12XA | ICD10CM | Covered |
| T81.12XD | ICD10CM | Covered |
| T81.12XS | ICD10CM | Covered |
| T81.19XA | ICD10CM | Covered |
| T81.19XD | ICD10CM | Covered |
| T81.19XS | ICD10CM | Covered |
| T81.40XA | ICD10CM | Covered |
| T81.40XD | ICD10CM | Covered |
| T81.40XS | ICD10CM | Covered |
| T81.41XA | ICD10CM | Covered |
| T81.41XD | ICD10CM | Covered |
| T81.41XS | ICD10CM | Covered |
| T81.42XA | ICD10CM | Covered |
| T81.42XD | ICD10CM | Covered |
| T81.42XS | ICD10CM | Covered |
| T81.43XA | ICD10CM | Covered |
| T81.43XD | ICD10CM | Covered |
| T81.43XS | ICD10CM | Covered |
| T81.44XA | ICD10CM | Covered |
| T81.44XD | ICD10CM | Covered |
| T81.44XS | ICD10CM | Covered |
| T81.49XA | ICD10CM | Covered |
| T81.49XD | ICD10CM | Covered |
| T81.49XS | ICD10CM | Covered |
| T82.318A | ICD10CM | Covered |
| T82.318D | ICD10CM | Covered |
| T82.318S | ICD10CM | Covered |
| T82.328A | ICD10CM | Covered |
| T82.328D | ICD10CM | Covered |
| T82.328S | ICD10CM | Covered |
| T82.338A | ICD10CM | Covered |
| T82.338D | ICD10CM | Covered |
| T82.338S | ICD10CM | Covered |
| T82.398A | ICD10CM | Covered |
| T82.398D | ICD10CM | Covered |
| T82.398S | ICD10CM | Covered |
| T83.011A | ICD10CM | Covered |
| T83.011D | ICD10CM | Covered |
| T83.011S | ICD10CM | Covered |
| T83.012A | ICD10CM | Covered |
| T83.012D | ICD10CM | Covered |
| T83.012S | ICD10CM | Covered |
| T83.021A | ICD10CM | Covered |
| T83.021D | ICD10CM | Covered |
| T83.021S | ICD10CM | Covered |
| T83.022A | ICD10CM | Covered |
| T83.022D | ICD10CM | Covered |
| T83.022S | ICD10CM | Covered |
| T83.032A | ICD10CM | Covered |
| T83.032D | ICD10CM | Covered |
| T83.032S | ICD10CM | Covered |
| T83.512A | ICD10CM | Covered |
| T83.512D | ICD10CM | Covered |
| T83.512S | ICD10CM | Covered |
| T83.592A | ICD10CM | Covered |
| T83.592D | ICD10CM | Covered |
| T83.592S | ICD10CM | Covered |
| T83.714A | ICD10CM | Covered |
| T83.714D | ICD10CM | Covered |
| T83.714S | ICD10CM | Covered |
| T83.722A | ICD10CM | Covered |
| T83.722D | ICD10CM | Covered |
| T83.722S | ICD10CM | Covered |
| T83.723A | ICD10CM | Covered |
| T83.723D | ICD10CM | Covered |
| T83.723S | ICD10CM | Covered |
| T83.724A | ICD10CM | Covered |
| T83.724D | ICD10CM | Covered |
| T83.724S | ICD10CM | Covered |
| T86.10 | ICD10CM | Covered |
| T86.11 | ICD10CM | Covered |
| T86.12 | ICD10CM | Covered |
| T86.13 | ICD10CM | Covered |
| T86.19 | ICD10CM | Covered |
| T86.890 | ICD10CM | Covered |
| T86.891 | ICD10CM | Covered |
| T86.892 | ICD10CM | Covered |
| T86.898 | ICD10CM | Covered |
| T86.899 | ICD10CM | Covered |
| Z48.22 | ICD10CM | Covered |
| Z85.51 | ICD10CM | Covered |
| Z85.520 | ICD10CM | Covered |
| Z85.528 | ICD10CM | Covered |
| Z85.821 | ICD10CM | Covered |
| Z94.0 | ICD10CM | Covered |