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 1,383 codes. The source has the full list.
| Code | Code system | Status in this policy |
|---|---|---|
| 11000 | HCPCS | Covered |
| 11001 | HCPCS | Covered |
| 11004 | HCPCS | Covered |
| 11005 | HCPCS | Covered |
| 11006 | HCPCS | Covered |
| 11042 | HCPCS | Covered |
| 11043 | HCPCS | Covered |
| 11044 | HCPCS | Covered |
| 11045 | HCPCS | Covered |
| 11046 | HCPCS | Covered |
| 11047 | HCPCS | Covered |
| 97597 | HCPCS | Covered |
| 97598 | HCPCS | Covered |
| 97602 | HCPCS | Covered |
| 97605 | HCPCS | Covered |
| 97606 | HCPCS | Covered |
| 97607 | HCPCS | Covered |
| 97608 | HCPCS | Covered |
| 97610 | HCPCS | Covered |
| G0281 | HCPCS | Covered |
| G0329 | HCPCS | Covered |
| A48.0 | ICD10CM | Covered |
| B78.1 | ICD10CM | Covered |
| E08.51 | ICD10CM | Covered |
| E08.52 | ICD10CM | Covered |
| E08.621 | ICD10CM | Covered |
| E08.622 | ICD10CM | Covered |
| E09.51 | ICD10CM | Covered |
| E09.52 | ICD10CM | Covered |
| E09.621 | ICD10CM | Covered |
| E09.622 | ICD10CM | Covered |
| E10.51 | ICD10CM | Covered |
| E10.52 | ICD10CM | Covered |
| E10.621 | ICD10CM | Covered |
| E10.622 | ICD10CM | Covered |
| E11.51 | ICD10CM | Covered |
| E11.52 | ICD10CM | Covered |
| E11.621 | ICD10CM | Covered |
| E11.622 | ICD10CM | Covered |
| E13.51 | ICD10CM | Covered |
| E13.52 | ICD10CM | Covered |
| E13.621 | ICD10CM | Covered |
| E13.622 | 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 |
| I70.241 | ICD10CM | Covered |
| I70.242 | ICD10CM | Covered |
| I70.243 | ICD10CM | Covered |
| I70.244 | ICD10CM | Covered |
| I70.245 | ICD10CM | Covered |
| I70.248 | 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 |
| I70.341 | ICD10CM | Covered |
| I70.342 | ICD10CM | Covered |
| I70.343 | ICD10CM | Covered |
| I70.344 | ICD10CM | Covered |
| I70.345 | ICD10CM | Covered |
| I70.348 | 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 |
| I70.441 | ICD10CM | Covered |
| I70.442 | ICD10CM | Covered |
| I70.443 | ICD10CM | Covered |
| I70.444 | ICD10CM | Covered |
| I70.445 | ICD10CM | Covered |
| I70.448 | 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 |
| I70.541 | ICD10CM | Covered |
| I70.542 | ICD10CM | Covered |
| I70.543 | ICD10CM | Covered |
| I70.544 | ICD10CM | Covered |
| I70.545 | ICD10CM | Covered |
| I70.548 | 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 |
| I70.641 | ICD10CM | Covered |
| I70.642 | ICD10CM | Covered |
| I70.643 | ICD10CM | Covered |
| I70.644 | ICD10CM | Covered |
| I70.645 | ICD10CM | Covered |
| I70.648 | 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 |
| I70.741 | ICD10CM | Covered |
| I70.742 | ICD10CM | Covered |
| I70.743 | ICD10CM | Covered |
| I70.744 | ICD10CM | Covered |
| I70.745 | ICD10CM | Covered |
| I70.748 | ICD10CM | Covered |
| I70.75 | ICD10CM | Covered |
| I70.761 | ICD10CM | Covered |
| I70.762 | ICD10CM | Covered |
| I70.763 | ICD10CM | Covered |
| I70.768 | ICD10CM | Covered |
| I73.01 | ICD10CM | Covered |
| I83.011 | ICD10CM | Covered |
| I83.012 | ICD10CM | Covered |
| I83.013 | ICD10CM | Covered |
| I83.014 | ICD10CM | Covered |
| I83.015 | ICD10CM | Covered |
| I83.018 | ICD10CM | Covered |
| I83.021 | ICD10CM | Covered |
| I83.022 | ICD10CM | Covered |
| I83.023 | ICD10CM | Covered |
| I83.024 | ICD10CM | Covered |
| I83.025 | ICD10CM | Covered |
| I83.028 | ICD10CM | Covered |
| I83.211 | ICD10CM | Covered |
| I83.212 | ICD10CM | Covered |
| I83.213 | ICD10CM | Covered |
| I83.214 | ICD10CM | Covered |
| I83.215 | ICD10CM | Covered |
| I83.218 | ICD10CM | Covered |
| I83.221 | ICD10CM | Covered |
| I83.222 | ICD10CM | Covered |
| I83.223 | ICD10CM | Covered |
| I83.224 | ICD10CM | Covered |
| I83.225 | ICD10CM | Covered |
| I83.228 | ICD10CM | Covered |
| I87.011 | ICD10CM | Covered |
| I87.012 | ICD10CM | Covered |
| I87.013 | ICD10CM | Covered |
| I87.2 | ICD10CM | Covered |
| I96 | ICD10CM | Covered |
| L02.01 | ICD10CM | Covered |
| L02.11 | ICD10CM | Covered |
| L02.211 | ICD10CM | Covered |
| L02.212 | ICD10CM | Covered |
| L02.213 | ICD10CM | Covered |
| L02.214 | ICD10CM | Covered |
| L02.215 | ICD10CM | Covered |
| L02.216 | ICD10CM | Covered |
| L02.217 | ICD10CM | Covered |
| L02.31 | ICD10CM | Covered |
| L02.411 | ICD10CM | Covered |
| L02.412 | ICD10CM | Covered |
| L02.413 | ICD10CM | Covered |
| L02.414 | ICD10CM | Covered |
| L02.415 | ICD10CM | Covered |
| L02.416 | ICD10CM | Covered |
| L02.511 | ICD10CM | Covered |
| L02.512 | ICD10CM | Covered |
| L02.611 | ICD10CM | Covered |
| L02.612 | ICD10CM | Covered |
| L02.811 | ICD10CM | Covered |
| L02.818 | ICD10CM | Covered |
| L03.011 | ICD10CM | Covered |
| L03.012 | ICD10CM | Covered |
| L03.021 | ICD10CM | Covered |
| L03.022 | ICD10CM | Covered |
| L03.031 | ICD10CM | Covered |
| L03.032 | ICD10CM | Covered |
| L03.041 | ICD10CM | Covered |
| L03.042 | ICD10CM | Covered |
| L03.111 | ICD10CM | Covered |
| L03.112 | ICD10CM | Covered |
| L03.113 | ICD10CM | Covered |
| L03.114 | ICD10CM | Covered |
| L03.115 | ICD10CM | Covered |
| L03.116 | ICD10CM | Covered |
| L03.121 | ICD10CM | Covered |
| L03.122 | ICD10CM | Covered |
| L03.123 | ICD10CM | Covered |
| L03.124 | ICD10CM | Covered |
| L03.125 | ICD10CM | Covered |
| L03.126 | ICD10CM | Covered |
| L03.211 | ICD10CM | Covered |
| L03.212 | ICD10CM | Covered |
| L03.221 | ICD10CM | Covered |
| L03.222 | ICD10CM | Covered |
| L03.311 | ICD10CM | Covered |
| L03.312 | ICD10CM | Covered |
| L03.313 | ICD10CM | Covered |
| L03.314 | ICD10CM | Covered |
| L03.315 | ICD10CM | Covered |
| L03.316 | ICD10CM | Covered |
| L03.317 | ICD10CM | Covered |
| L03.31A | ICD10CM | Covered |
| L03.321 | ICD10CM | Covered |
| L03.322 | ICD10CM | Covered |
| L03.323 | ICD10CM | Covered |
| L03.324 | ICD10CM | Covered |
| L03.325 | ICD10CM | Covered |
| L03.326 | ICD10CM | Covered |
| L03.327 | ICD10CM | Covered |
| L03.32A | ICD10CM | Covered |
| L03.811 | ICD10CM | Covered |
| L03.818 | ICD10CM | Covered |
| L03.891 | ICD10CM | Covered |
| L03.898 | ICD10CM | Covered |
| L08.81 | ICD10CM | Covered |
| L08.82 | ICD10CM | Covered |
| L88 | ICD10CM | Covered |
| L89.010 | ICD10CM | Covered |
| L89.012 | ICD10CM | Covered |
| L89.013 | ICD10CM | Covered |
| L89.014 | ICD10CM | Covered |
| L89.020 | ICD10CM | Covered |
| L89.022 | ICD10CM | Covered |
| L89.023 | ICD10CM | Covered |
| L89.024 | ICD10CM | Covered |
| L89.110 | ICD10CM | Covered |
| L89.112 | ICD10CM | Covered |
| L89.113 | ICD10CM | Covered |
| L89.114 | ICD10CM | Covered |
| L89.120 | ICD10CM | Covered |
| L89.122 | ICD10CM | Covered |
| L89.123 | ICD10CM | Covered |
| L89.124 | ICD10CM | Covered |
| L89.130 | ICD10CM | Covered |
| L89.132 | ICD10CM | Covered |
| L89.133 | ICD10CM | Covered |
| L89.134 | ICD10CM | Covered |
| L89.140 | ICD10CM | Covered |
| L89.142 | ICD10CM | Covered |
| L89.143 | ICD10CM | Covered |
| L89.144 | ICD10CM | Covered |
| L89.150 | ICD10CM | Covered |
| L89.152 | ICD10CM | Covered |
| L89.153 | ICD10CM | Covered |
| L89.154 | ICD10CM | Covered |
| L89.210 | ICD10CM | Covered |
| L89.212 | ICD10CM | Covered |
| L89.213 | ICD10CM | Covered |
| L89.214 | ICD10CM | Covered |
| L89.220 | ICD10CM | Covered |
| L89.222 | ICD10CM | Covered |
| L89.223 | ICD10CM | Covered |
| L89.224 | ICD10CM | Covered |
| L89.310 | ICD10CM | Covered |
| L89.312 | ICD10CM | Covered |
| L89.313 | ICD10CM | Covered |
| L89.314 | ICD10CM | Covered |
| L89.320 | ICD10CM | Covered |
| L89.322 | ICD10CM | Covered |
| L89.323 | ICD10CM | Covered |
| L89.324 | ICD10CM | Covered |
| L89.42 | ICD10CM | Covered |
| L89.43 | ICD10CM | Covered |
| L89.44 | ICD10CM | Covered |
| L89.45 | ICD10CM | Covered |
| L89.510 | ICD10CM | Covered |
| L89.512 | ICD10CM | Covered |
| L89.513 | ICD10CM | Covered |
| L89.514 | ICD10CM | Covered |
| L89.520 | ICD10CM | Covered |
| L89.522 | ICD10CM | Covered |
| L89.523 | ICD10CM | Covered |
| L89.524 | ICD10CM | Covered |
| L89.610 | ICD10CM | Covered |
| L89.612 | ICD10CM | Covered |
| L89.613 | ICD10CM | Covered |
| L89.614 | ICD10CM | Covered |
| L89.620 | ICD10CM | Covered |
| L89.622 | ICD10CM | Covered |
| L89.623 | ICD10CM | Covered |
| L89.624 | ICD10CM | Covered |
| L89.810 | ICD10CM | Covered |
| L89.812 | ICD10CM | Covered |
| L89.813 | ICD10CM | Covered |
| L89.814 | ICD10CM | Covered |
| L89.892 | ICD10CM | Covered |
| L89.893 | ICD10CM | Covered |
| L89.894 | ICD10CM | Covered |
| L92.3 | ICD10CM | Covered |
| L97.111 | 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 |
| L97.121 | 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 |
| L97.211 | 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 |
| L97.221 | 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 |
| L97.311 | 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 |
| L97.321 | 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 |
| L97.411 | 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 |
| L97.421 | 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 |
| L97.511 | 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 |
| L97.521 | 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 |
| L97.811 | 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 |
| L97.821 | 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 |
| L98.3 | ICD10CM | Covered |
| L98.411 | 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 |
| L98.421 | 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 |
| L98.435 | ICD10CM | Covered |
| L98.436 | ICD10CM | Covered |
| L98.438 | ICD10CM | Covered |
| L98.439 | ICD10CM | Covered |
| L98.441 | ICD10CM | Covered |
| L98.442 | ICD10CM | Covered |
| L98.443 | ICD10CM | Covered |
| L98.444 | ICD10CM | Covered |
| L98.445 | ICD10CM | Covered |
| L98.446 | ICD10CM | Covered |
| L98.448 | ICD10CM | Covered |
| L98.449 | ICD10CM | Covered |
| L98.451 | ICD10CM | Covered |
| L98.452 | ICD10CM | Covered |
| L98.453 | ICD10CM | Covered |
| L98.454 | ICD10CM | Covered |
| L98.455 | ICD10CM | Covered |
| L98.456 | ICD10CM | Covered |
| L98.458 | ICD10CM | Covered |
| L98.459 | ICD10CM | Covered |
| L98.461 | ICD10CM | Covered |
| L98.462 | ICD10CM | Covered |
| L98.463 | ICD10CM | Covered |
| L98.464 | ICD10CM | Covered |
| L98.465 | ICD10CM | Covered |
| L98.466 | ICD10CM | Covered |
| L98.468 | ICD10CM | Covered |
| L98.471 | ICD10CM | Covered |
| L98.472 | ICD10CM | Covered |
| L98.473 | ICD10CM | Covered |
| L98.474 | ICD10CM | Covered |
| L98.475 | ICD10CM | Covered |
| L98.476 | ICD10CM | Covered |
| L98.478 | ICD10CM | Covered |
| L98.479 | ICD10CM | Covered |
| L98.491 | ICD10CM | Covered |
| L98.492 | ICD10CM | Covered |
| L98.493 | ICD10CM | Covered |
| L98.494 | ICD10CM | Covered |
| L98.495 | ICD10CM | Covered |
| L98.496 | ICD10CM | Covered |
| L98.498 | ICD10CM | Covered |
| L98.8 | ICD10CM | Covered |
| L98.A111 | ICD10CM | Covered |
| L98.A112 | ICD10CM | Covered |
| L98.A113 | ICD10CM | Covered |
| L98.A114 | ICD10CM | Covered |
| L98.A115 | ICD10CM | Covered |
| L98.A116 | ICD10CM | Covered |
| L98.A118 | ICD10CM | Covered |
| L98.A121 | ICD10CM | Covered |
| L98.A122 | ICD10CM | Covered |
| L98.A123 | ICD10CM | Covered |
| L98.A124 | ICD10CM | Covered |
| L98.A125 | ICD10CM | Covered |
| L98.A126 | ICD10CM | Covered |
| L98.A128 | ICD10CM | Covered |
| L98.A211 | ICD10CM | Covered |
| L98.A212 | ICD10CM | Covered |
| L98.A213 | ICD10CM | Covered |
| L98.A214 | ICD10CM | Covered |
| L98.A215 | ICD10CM | Covered |
| L98.A216 | ICD10CM | Covered |
| L98.A218 | ICD10CM | Covered |
| L98.A221 | ICD10CM | Covered |
| L98.A222 | ICD10CM | Covered |
| L98.A223 | ICD10CM | Covered |
| L98.A224 | ICD10CM | Covered |
| L98.A225 | ICD10CM | Covered |
| L98.A226 | ICD10CM | Covered |
| L98.A228 | ICD10CM | Covered |
| L98.A311 | ICD10CM | Covered |
| L98.A312 | ICD10CM | Covered |
| L98.A313 | ICD10CM | Covered |
| L98.A314 | ICD10CM | Covered |
| L98.A315 | ICD10CM | Covered |
| L98.A316 | ICD10CM | Covered |
| L98.A318 | ICD10CM | Covered |
| L98.A321 | ICD10CM | Covered |
| L98.A322 | ICD10CM | Covered |
| L98.A323 | ICD10CM | Covered |
| L98.A324 | ICD10CM | Covered |
| L98.A325 | ICD10CM | Covered |
| L98.A326 | ICD10CM | Covered |
| L98.A328 | ICD10CM | Covered |
| M72.6 | ICD10CM | Covered |
| M79.5 | ICD10CM | Covered |
| M86.411 | ICD10CM | Covered |
| M86.412 | ICD10CM | Covered |
| M86.421 | ICD10CM | Covered |
| M86.422 | ICD10CM | Covered |
| M86.431 | ICD10CM | Covered |
| M86.432 | ICD10CM | Covered |
| M86.441 | ICD10CM | Covered |
| M86.442 | ICD10CM | Covered |
| M86.451 | ICD10CM | Covered |
| M86.452 | ICD10CM | Covered |
| M86.461 | ICD10CM | Covered |
| M86.462 | ICD10CM | Covered |
| S00.04XA | ICD10CM | Covered |
| S00.06XA | ICD10CM | Covered |
| S00.241A | ICD10CM | Covered |
| S00.242A | ICD10CM | Covered |
| S00.261A | ICD10CM | Covered |
| S00.262A | ICD10CM | Covered |
| S00.34XA | ICD10CM | Covered |
| S00.36XA | ICD10CM | Covered |
| S00.441A | ICD10CM | Covered |
| S00.442A | ICD10CM | Covered |
| S00.461A | ICD10CM | Covered |
| S00.462A | ICD10CM | Covered |
| S00.541A | ICD10CM | Covered |
| S00.561A | ICD10CM | Covered |
| S00.84XA | ICD10CM | Covered |
| S00.86XA | ICD10CM | Covered |
| S01.01XA | ICD10CM | Covered |
| S01.02XA | ICD10CM | Covered |
| S01.03XA | ICD10CM | Covered |
| S01.04XA | ICD10CM | Covered |
| S01.05XA | ICD10CM | Covered |
| S01.111A | ICD10CM | Covered |
| S01.112A | ICD10CM | Covered |
| S01.121A | ICD10CM | Covered |
| S01.122A | ICD10CM | Covered |
| S01.131A | ICD10CM | Covered |
| S01.132A | ICD10CM | Covered |
| S01.141A | ICD10CM | Covered |
| S01.142A | ICD10CM | Covered |
| S01.151A | ICD10CM | Covered |
| S01.152A | ICD10CM | Covered |
| S01.21XA | ICD10CM | Covered |
| S01.22XA | ICD10CM | Covered |
| S01.23XA | ICD10CM | Covered |
| S01.24XA | ICD10CM | Covered |
| S01.25XA | ICD10CM | Covered |
| S01.311A | ICD10CM | Covered |
| S01.312A | ICD10CM | Covered |
| S01.321A | ICD10CM | Covered |
| S01.322A | ICD10CM | Covered |
| S01.331A | ICD10CM | Covered |
| S01.332A | ICD10CM | Covered |
| S01.341A | ICD10CM | Covered |
| S01.342A | ICD10CM | Covered |
| S01.351A | ICD10CM | Covered |
| S01.352A | ICD10CM | Covered |
| S01.411A | ICD10CM | Covered |
| S01.412A | ICD10CM | Covered |
| S01.421A | ICD10CM | Covered |
| S01.422A | ICD10CM | Covered |
| S01.431A | ICD10CM | Covered |
| S01.432A | ICD10CM | Covered |
| S01.441A | ICD10CM | Covered |
| S01.442A | ICD10CM | Covered |
| S01.451A | ICD10CM | Covered |
| S01.452A | ICD10CM | Covered |
| S01.511A | ICD10CM | Covered |
| S01.521A | ICD10CM | Covered |
| S01.531A | ICD10CM | Covered |
| S01.541A | ICD10CM | Covered |
| S01.551A | ICD10CM | Covered |
| S01.81XA | ICD10CM | Covered |
| S01.82XA | ICD10CM | Covered |
| S01.83XA | ICD10CM | Covered |
| S01.84XA | ICD10CM | Covered |
| S01.85XA | ICD10CM | Covered |
| S08.0XXA | ICD10CM | Covered |
| S08.111A | ICD10CM | Covered |
| S08.112A | ICD10CM | Covered |
| S08.121A | ICD10CM | Covered |
| S08.122A | ICD10CM | Covered |
| S08.811A | ICD10CM | Covered |
| S08.812A | ICD10CM | Covered |
| S08.89XA | ICD10CM | Covered |
| S09.12XA | ICD10CM | Covered |
| S09.311A | ICD10CM | Covered |
| S09.312A | ICD10CM | Covered |
| S09.313A | ICD10CM | Covered |
| S10.84XA | ICD10CM | Covered |
| S10.86XA | ICD10CM | Covered |
| S11.11XA | ICD10CM | Covered |
| S11.12XA | ICD10CM | Covered |
| S11.13XA | ICD10CM | Covered |
| S11.14XA | ICD10CM | Covered |
| S11.15XA | ICD10CM | Covered |
| S11.81XA | ICD10CM | Covered |
| S11.82XA | ICD10CM | Covered |
| S11.83XA | ICD10CM | Covered |
| S11.84XA | ICD10CM | Covered |
| S11.85XA | ICD10CM | Covered |
| S11.89XA | ICD10CM | Covered |
| S16.2XXA | ICD10CM | Covered |
| S20.141A | ICD10CM | Covered |
| S20.142A | ICD10CM | Covered |
| S20.161A | ICD10CM | Covered |
| S20.162A | ICD10CM | Covered |
| S20.341A | ICD10CM | Covered |
| S20.342A | ICD10CM | Covered |
| S20.343A | ICD10CM | Covered |
| S20.344A | ICD10CM | Covered |
| S20.361A | ICD10CM | Covered |
| S20.362A | ICD10CM | Covered |
| S20.363A | ICD10CM | Covered |
| S20.364A | ICD10CM | Covered |
| S20.441A | ICD10CM | Covered |
| S20.442A | ICD10CM | Covered |
| S20.461A | ICD10CM | Covered |
| S20.462A | ICD10CM | Covered |
| S21.011A | ICD10CM | Covered |
| S21.012A | ICD10CM | Covered |
| S21.021A | ICD10CM | Covered |
| S21.022A | ICD10CM | Covered |
| S21.031A | ICD10CM | Covered |
| S21.032A | ICD10CM | Covered |
| S21.041A | ICD10CM | Covered |
| S21.042A | ICD10CM | Covered |
| S21.051A | ICD10CM | Covered |
| S21.052A | ICD10CM | Covered |
| S21.111A | ICD10CM | Covered |
| S21.112A | ICD10CM | Covered |
| S21.121A | ICD10CM | Covered |
| S21.122A | ICD10CM | Covered |
| S21.131A | ICD10CM | Covered |
| S21.132A | ICD10CM | Covered |
| S21.141A | ICD10CM | Covered |
| S21.142A | ICD10CM | Covered |
| S21.151A | ICD10CM | Covered |
| S21.152A | ICD10CM | Covered |
| S21.211A | ICD10CM | Covered |
| S21.212A | ICD10CM | Covered |
| S21.221A | ICD10CM | Covered |
| S21.222A | ICD10CM | Covered |
| S21.231A | ICD10CM | Covered |
| S21.232A | ICD10CM | Covered |
| S21.241A | ICD10CM | Covered |
| S21.242A | ICD10CM | Covered |
| S21.251A | ICD10CM | Covered |
| S21.252A | ICD10CM | Covered |
| S21.311A | ICD10CM | Covered |
| S21.312A | ICD10CM | Covered |
| S21.321A | ICD10CM | Covered |
| S21.322A | ICD10CM | Covered |
| S21.331A | ICD10CM | Covered |
| S21.332A | ICD10CM | Covered |
| S21.341A | ICD10CM | Covered |
| S21.342A | ICD10CM | Covered |
| S21.351A | ICD10CM | Covered |
| S21.352A | ICD10CM | Covered |
| S21.411A | ICD10CM | Covered |
| S21.412A | ICD10CM | Covered |
| S21.421A | ICD10CM | Covered |
| S21.422A | ICD10CM | Covered |
| S21.431A | ICD10CM | Covered |
| S21.432A | ICD10CM | Covered |
| S21.441A | ICD10CM | Covered |
| S21.442A | ICD10CM | Covered |
| S21.451A | ICD10CM | Covered |
| S21.452A | ICD10CM | Covered |
| S28.1XXA | ICD10CM | Covered |
| S28.211A | ICD10CM | Covered |
| S28.212A | ICD10CM | Covered |
| S28.221A | ICD10CM | Covered |
| S28.222A | ICD10CM | Covered |
| S29.021A | ICD10CM | Covered |
| S29.022A | ICD10CM | Covered |
| S30.81AA | ICD10CM | Covered |
| S30.81AD | ICD10CM | Covered |
| S30.81AS | ICD10CM | Covered |
| S30.840A | ICD10CM | Covered |
| S30.841A | ICD10CM | Covered |
| S30.842A | ICD10CM | Covered |
| S30.843A | ICD10CM | Covered |
| S30.844A | ICD10CM | Covered |
| S30.85AA | ICD10CM | Covered |
| S30.85AD | ICD10CM | Covered |
| S30.85AS | ICD10CM | Covered |
| S30.860A | ICD10CM | Covered |
| S30.861A | ICD10CM | Covered |
| S30.862A | ICD10CM | Covered |
| S30.863A | ICD10CM | Covered |
| S30.864A | ICD10CM | Covered |
| S30.867A | ICD10CM | Covered |
| S30.86AA | ICD10CM | Covered |
| S30.86AD | ICD10CM | Covered |
| S30.86AS | ICD10CM | Covered |
| S30.87AA | ICD10CM | Covered |
| S30.87AD | ICD10CM | Covered |
| S30.87AS | ICD10CM | Covered |
| S31.010A | ICD10CM | Covered |
| S31.011A | ICD10CM | Covered |
| S31.020A | ICD10CM | Covered |
| S31.021A | ICD10CM | Covered |
| S31.030A | ICD10CM | Covered |
| S31.031A | ICD10CM | Covered |
| S31.040A | ICD10CM | Covered |
| S31.041A | ICD10CM | Covered |
| S31.050A | ICD10CM | Covered |
| S31.051A | ICD10CM | Covered |
| S31.110A | ICD10CM | Covered |
| S31.111A | ICD10CM | Covered |
| S31.112A | ICD10CM | Covered |
| S31.113A | ICD10CM | Covered |
| S31.114A | ICD10CM | Covered |
| S31.115A | 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 |
| S31.121A | ICD10CM | Covered |
| S31.122A | ICD10CM | Covered |
| S31.123A | ICD10CM | Covered |
| S31.124A | ICD10CM | Covered |
| S31.125A | 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 |
| S31.131A | ICD10CM | Covered |
| S31.132A | ICD10CM | Covered |
| S31.133A | ICD10CM | Covered |
| S31.134A | ICD10CM | Covered |
| S31.135A | ICD10CM | Covered |
| S31.136A | ICD10CM | Covered |
| S31.136D | ICD10CM | Covered |
| S31.136S | ICD10CM | Covered |
| S31.137A | ICD10CM | Covered |
| S31.137D | ICD10CM | Covered |
| S31.137S | ICD10CM | Covered |
| S31.13AA | ICD10CM | Covered |
| S31.13AD | ICD10CM | Covered |
| S31.13AS | ICD10CM | Covered |
| S31.140A | ICD10CM | Covered |
| S31.141A | ICD10CM | Covered |
| S31.142A | ICD10CM | Covered |
| S31.143A | ICD10CM | Covered |
| S31.144A | ICD10CM | Covered |
| S31.145A | ICD10CM | Covered |
| S31.146A | ICD10CM | Covered |
| S31.146D | ICD10CM | Covered |
| S31.146S | ICD10CM | Covered |
| S31.147A | ICD10CM | Covered |
| S31.147D | ICD10CM | Covered |
| S31.147S | ICD10CM | Covered |
| S31.14AA | ICD10CM | Covered |
| S31.14AD | ICD10CM | Covered |
| S31.14AS | ICD10CM | Covered |
| S31.150A | ICD10CM | Covered |
| S31.151A | ICD10CM | Covered |
| S31.152A | ICD10CM | Covered |
| S31.153A | ICD10CM | Covered |
| S31.154A | ICD10CM | Covered |
| S31.155A | ICD10CM | Covered |
| S31.156A | ICD10CM | Covered |
| S31.156D | ICD10CM | Covered |
| S31.156S | ICD10CM | Covered |
| S31.157A | ICD10CM | Covered |
| S31.157D | ICD10CM | Covered |
| S31.157S | ICD10CM | Covered |
| S31.15AA | ICD10CM | Covered |
| S31.15AD | ICD10CM | Covered |
| S31.15AS | ICD10CM | Covered |
| S31.21XA | ICD10CM | Covered |
| S31.22XA | ICD10CM | Covered |
| S31.23XA | ICD10CM | Covered |
| S31.24XA | ICD10CM | Covered |
| S31.25XA | ICD10CM | Covered |
| S31.31XA | ICD10CM | Covered |
| S31.32XA | ICD10CM | Covered |
| S31.33XA | ICD10CM | Covered |
| S31.34XA | ICD10CM | Covered |
| S31.35XA | ICD10CM | Covered |
| S31.41XA | ICD10CM | Covered |
| S31.42XA | ICD10CM | Covered |
| S31.43XA | ICD10CM | Covered |
| S31.44XA | ICD10CM | Covered |
| S31.45XA | ICD10CM | Covered |
| S31.610A | ICD10CM | Covered |
| S31.611A | ICD10CM | Covered |
| S31.612A | ICD10CM | Covered |
| S31.613A | ICD10CM | Covered |
| S31.614A | ICD10CM | Covered |
| S31.615A | ICD10CM | Covered |
| S31.616A | ICD10CM | Covered |
| S31.616D | ICD10CM | Covered |
| S31.616S | ICD10CM | Covered |
| S31.617A | ICD10CM | Covered |
| S31.617D | ICD10CM | Covered |
| S31.617S | ICD10CM | Covered |
| S31.61AA | ICD10CM | Covered |
| S31.61AD | ICD10CM | Covered |
| S31.61AS | ICD10CM | Covered |
| S31.620A | ICD10CM | Covered |
| S31.621A | ICD10CM | Covered |
| S31.622A | ICD10CM | Covered |
| S31.623A | ICD10CM | Covered |
| S31.624A | ICD10CM | Covered |
| S31.625A | ICD10CM | Covered |
| S31.626A | ICD10CM | Covered |
| S31.626D | ICD10CM | Covered |
| S31.626S | ICD10CM | Covered |
| S31.627A | ICD10CM | Covered |
| S31.627D | ICD10CM | Covered |
| S31.627S | ICD10CM | Covered |
| S31.62AA | ICD10CM | Covered |
| S31.62AD | ICD10CM | Covered |
| S31.62AS | ICD10CM | Covered |
| S31.630A | ICD10CM | Covered |
| S31.631A | ICD10CM | Covered |
| S31.632A | ICD10CM | Covered |
| S31.633A | ICD10CM | Covered |
| S31.634A | ICD10CM | Covered |
| S31.635A | ICD10CM | Covered |
| S31.636A | ICD10CM | Covered |
| S31.636D | ICD10CM | Covered |
| S31.636S | ICD10CM | Covered |
| S31.637A | ICD10CM | Covered |
| S31.637D | ICD10CM | Covered |
| S31.637S | ICD10CM | Covered |
| S31.63AA | ICD10CM | Covered |
| S31.63AD | ICD10CM | Covered |
| S31.63AS | ICD10CM | Covered |
| S31.640A | ICD10CM | Covered |
| S31.641A | ICD10CM | Covered |
| S31.642A | ICD10CM | Covered |
| S31.643A | ICD10CM | Covered |
| S31.644A | ICD10CM | Covered |
| S31.645A | ICD10CM | Covered |
| S31.646A | ICD10CM | Covered |
| S31.646D | ICD10CM | Covered |
| S31.646S | ICD10CM | Covered |
| S31.647A | ICD10CM | Covered |
| S31.647D | ICD10CM | Covered |
| S31.647S | ICD10CM | Covered |
| S31.64AA | ICD10CM | Covered |
| S31.64AD | ICD10CM | Covered |
| S31.64AS | ICD10CM | Covered |
| S31.650A | ICD10CM | Covered |
| S31.651A | ICD10CM | Covered |
| S31.652A | ICD10CM | Covered |
| S31.653A | ICD10CM | Covered |
| S31.654A | ICD10CM | Covered |
| S31.655A | ICD10CM | Covered |
| S31.656A | ICD10CM | Covered |
| S31.656D | ICD10CM | Covered |
| S31.656S | ICD10CM | Covered |
| S31.657A | ICD10CM | Covered |
| S31.657D | ICD10CM | Covered |
| S31.657S | ICD10CM | Covered |
| S31.65AA | ICD10CM | Covered |
| S31.65AD | ICD10CM | Covered |
| S31.65AS | ICD10CM | Covered |
| S31.811A | ICD10CM | Covered |
| S31.812A | ICD10CM | Covered |
| S31.813A | ICD10CM | Covered |
| S31.814A | ICD10CM | Covered |
| S31.815A | ICD10CM | Covered |
| S31.821A | ICD10CM | Covered |
| S31.822A | ICD10CM | Covered |
| S31.823A | ICD10CM | Covered |
| S31.824A | ICD10CM | Covered |
| S31.825A | ICD10CM | Covered |
| S31.831A | ICD10CM | Covered |
| S31.832A | ICD10CM | Covered |
| S31.833A | ICD10CM | Covered |
| S31.834A | ICD10CM | Covered |
| S31.835A | ICD10CM | Covered |
| S38.211A | ICD10CM | Covered |
| S38.212A | ICD10CM | Covered |
| S38.221A | ICD10CM | Covered |
| S38.222A | ICD10CM | Covered |
| S38.231A | ICD10CM | Covered |
| S38.232A | ICD10CM | Covered |
| S38.3XXA | ICD10CM | Covered |
| S39.021A | ICD10CM | Covered |
| S39.022A | ICD10CM | Covered |
| S39.023A | ICD10CM | Covered |
| S40.241A | ICD10CM | Covered |
| S40.242A | ICD10CM | Covered |
| S40.261A | ICD10CM | Covered |
| S40.262A | ICD10CM | Covered |
| S40.841A | ICD10CM | Covered |
| S40.842A | ICD10CM | Covered |
| S40.861A | ICD10CM | Covered |
| S40.862A | ICD10CM | Covered |
| S41.011A | ICD10CM | Covered |
| S41.012A | ICD10CM | Covered |
| S41.021A | ICD10CM | Covered |
| S41.022A | ICD10CM | Covered |
| S41.031A | ICD10CM | Covered |
| S41.032A | ICD10CM | Covered |
| S41.041A | ICD10CM | Covered |
| S41.042A | ICD10CM | Covered |
| S41.051A | ICD10CM | Covered |
| S41.052A | ICD10CM | Covered |
| S41.111A | ICD10CM | Covered |
| S41.112A | ICD10CM | Covered |
| S41.121A | ICD10CM | Covered |
| S41.122A | ICD10CM | Covered |
| S41.131A | ICD10CM | Covered |
| S41.132A | ICD10CM | Covered |
| S41.141A | ICD10CM | Covered |
| S41.142A | ICD10CM | Covered |
| S41.151A | ICD10CM | Covered |
| S41.152A | ICD10CM | Covered |
| S46.021A | ICD10CM | Covered |
| S46.022A | ICD10CM | Covered |
| S46.121A | ICD10CM | Covered |
| S46.122A | ICD10CM | Covered |
| S46.221A | ICD10CM | Covered |
| S46.222A | ICD10CM | Covered |
| S46.321A | ICD10CM | Covered |
| S46.322A | ICD10CM | Covered |
| S46.821A | ICD10CM | Covered |
| S46.822A | ICD10CM | Covered |
| S46.921A | ICD10CM | Covered |
| S46.922A | ICD10CM | Covered |
| S50.341A | ICD10CM | Covered |
| S50.342A | ICD10CM | Covered |
| S50.361A | ICD10CM | Covered |
| S50.362A | ICD10CM | Covered |
| S50.841A | ICD10CM | Covered |
| S50.842A | ICD10CM | Covered |
| S50.861A | ICD10CM | Covered |
| S50.862A | ICD10CM | Covered |
| S51.011A | ICD10CM | Covered |
| S51.012A | ICD10CM | Covered |
| S51.021A | ICD10CM | Covered |
| S51.022A | ICD10CM | Covered |
| S51.031A | ICD10CM | Covered |
| S51.032A | ICD10CM | Covered |
| S51.041A | ICD10CM | Covered |
| S51.042A | ICD10CM | Covered |
| S51.051A | ICD10CM | Covered |
| S51.052A | ICD10CM | Covered |
| S51.811A | ICD10CM | Covered |
| S51.812A | ICD10CM | Covered |
| S51.821A | ICD10CM | Covered |
| S51.822A | ICD10CM | Covered |
| S51.831A | ICD10CM | Covered |
| S51.832A | ICD10CM | Covered |
| S51.841A | ICD10CM | Covered |
| S51.842A | ICD10CM | Covered |
| S51.851A | ICD10CM | Covered |
| S51.852A | ICD10CM | Covered |
| S56.021A | ICD10CM | Covered |
| S56.022A | ICD10CM | Covered |
| S56.121A | ICD10CM | Covered |
| S56.122A | ICD10CM | Covered |
| S56.123A | ICD10CM | Covered |
| S56.124A | ICD10CM | Covered |
| S56.125A | ICD10CM | Covered |
| S56.126A | ICD10CM | Covered |
| S56.127A | ICD10CM | Covered |
| S56.128A | ICD10CM | Covered |
| S56.221A | ICD10CM | Covered |
| S56.222A | ICD10CM | Covered |
| S56.321A | ICD10CM | Covered |
| S56.322A | ICD10CM | Covered |
| S56.421A | ICD10CM | Covered |
| S56.422A | ICD10CM | Covered |
| S56.423A | ICD10CM | Covered |
| S56.424A | ICD10CM | Covered |
| S56.425A | ICD10CM | Covered |
| S56.426A | ICD10CM | Covered |
| S56.427A | ICD10CM | Covered |
| S56.428A | ICD10CM | Covered |
| S56.521A | ICD10CM | Covered |
| S56.522A | ICD10CM | Covered |
| S56.821A | ICD10CM | Covered |
| S56.822A | ICD10CM | Covered |