About this policy
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Upper Gastrointestinal Endoscopy and Visualization L34434. All unlisted procedure codes billed for services are subject to development and medical review.
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 |
|---|---|---|
| 0652T | HCPCS | Covered |
| 0653T | HCPCS | Covered |
| 0654T | HCPCS | Covered |
| 43191 | HCPCS | Covered |
| 43192 | HCPCS | Covered |
| 43193 | HCPCS | Covered |
| 43194 | HCPCS | Covered |
| 43195 | HCPCS | Covered |
| 43196 | HCPCS | Covered |
| 43197 | HCPCS | Covered |
| 43198 | HCPCS | Covered |
| 43200 | HCPCS | Covered |
| 43201 | HCPCS | Covered |
| 43202 | HCPCS | Covered |
| 43204 | HCPCS | Covered |
| 43205 | HCPCS | Covered |
| 43206 | HCPCS | Covered |
| 43210 | HCPCS | Covered |
| 43211 | HCPCS | Covered |
| 43212 | HCPCS | Covered |
| 43213 | HCPCS | Covered |
| 43214 | HCPCS | Covered |
| 43215 | HCPCS | Covered |
| 43216 | HCPCS | Covered |
| 43217 | HCPCS | Covered |
| 43220 | HCPCS | Covered |
| 43226 | HCPCS | Covered |
| 43227 | HCPCS | Covered |
| 43229 | HCPCS | Covered |
| 43231 | HCPCS | Covered |
| 43232 | HCPCS | Covered |
| 43233 | HCPCS | Covered |
| 43235 | HCPCS | Covered |
| 43236 | HCPCS | Covered |
| 43237 | HCPCS | Covered |
| 43238 | HCPCS | Covered |
| 43239 | HCPCS | Covered |
| 43240 | HCPCS | Covered |
| 43241 | HCPCS | Covered |
| 43242 | HCPCS | Covered |
| 43243 | HCPCS | Covered |
| 43244 | HCPCS | Covered |
| 43245 | HCPCS | Covered |
| 43246 | HCPCS | Covered |
| 43247 | HCPCS | Covered |
| 43248 | HCPCS | Covered |
| 43249 | HCPCS | Covered |
| 43250 | HCPCS | Covered |
| 43251 | HCPCS | Covered |
| 43252 | HCPCS | Covered |
| 43253 | HCPCS | Covered |
| 43254 | HCPCS | Covered |
| 43255 | HCPCS | Covered |
| 43259 | HCPCS | Covered |
| 43260 | HCPCS | Covered |
| 43261 | HCPCS | Covered |
| 43262 | HCPCS | Covered |
| 43263 | HCPCS | Covered |
| 43264 | HCPCS | Covered |
| 43265 | HCPCS | Covered |
| 43266 | HCPCS | Covered |
| 43270 | HCPCS | Covered |
| 43274 | HCPCS | Covered |
| 43275 | HCPCS | Covered |
| 43276 | HCPCS | Covered |
| 43277 | HCPCS | Covered |
| 43278 | HCPCS | Covered |
| 43499 | HCPCS | Covered |
| 74235 | HCPCS | Covered |
| J0585 | HCPCS | Covered |
| B37.81 | ICD10CM | Covered |
| C01 | ICD10CM | Covered |
| C02.0 | ICD10CM | Covered |
| C02.1 | ICD10CM | Covered |
| C02.2 | ICD10CM | Covered |
| C02.3 | ICD10CM | Covered |
| C02.4 | ICD10CM | Covered |
| C02.8 | ICD10CM | Covered |
| C09.0 | ICD10CM | Covered |
| C09.1 | ICD10CM | Covered |
| C09.8 | 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 |
| C15.3 | ICD10CM | Covered |
| C15.4 | ICD10CM | Covered |
| C15.5 | ICD10CM | Covered |
| C15.8 | ICD10CM | Covered |
| C15.9 | ICD10CM | Covered |
| C16.0 | ICD10CM | Covered |
| C16.1 | ICD10CM | Covered |
| C16.2 | ICD10CM | Covered |
| C16.3 | ICD10CM | Covered |
| C16.4 | ICD10CM | Covered |
| C16.5 | ICD10CM | Covered |
| C16.6 | ICD10CM | Covered |
| C16.8 | ICD10CM | Covered |
| C16.9 | ICD10CM | Covered |
| C17.0 | ICD10CM | Covered |
| C17.1 | ICD10CM | Covered |
| C17.2 | ICD10CM | Covered |
| C17.3 | ICD10CM | Covered |
| C17.8 | ICD10CM | Covered |
| C17.9 | ICD10CM | Covered |
| C24.1 | 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 |
| C32.0 | ICD10CM | Covered |
| C32.1 | ICD10CM | Covered |
| C32.2 | ICD10CM | Covered |
| C32.3 | ICD10CM | Covered |
| C32.8 | ICD10CM | Covered |
| C33 | ICD10CM | Covered |
| C7A.010 | ICD10CM | Covered |
| C7A.092 | ICD10CM | Covered |
| C81.01 | ICD10CM | Covered |
| C81.02 | ICD10CM | Covered |
| C81.03 | ICD10CM | Covered |
| C81.0A | ICD10CM | Covered |
| C81.11 | ICD10CM | Covered |
| C81.12 | ICD10CM | Covered |
| C81.13 | ICD10CM | Covered |
| C81.1A | ICD10CM | Covered |
| C81.21 | ICD10CM | Covered |
| C81.22 | ICD10CM | Covered |
| C81.23 | ICD10CM | Covered |
| C81.2A | ICD10CM | Covered |
| C81.31 | ICD10CM | Covered |
| C81.32 | ICD10CM | Covered |
| C81.33 | ICD10CM | Covered |
| C81.3A | ICD10CM | Covered |
| C81.41 | ICD10CM | Covered |
| C81.42 | ICD10CM | Covered |
| C81.43 | ICD10CM | Covered |
| C81.4A | ICD10CM | Covered |
| C81.71 | ICD10CM | Covered |
| C81.72 | ICD10CM | Covered |
| C81.73 | ICD10CM | Covered |
| C81.7A | ICD10CM | Covered |
| C81.91 | ICD10CM | Covered |
| C81.92 | ICD10CM | Covered |
| C81.93 | ICD10CM | Covered |
| C81.9A | ICD10CM | Covered |
| C82.0A | ICD10CM | Covered |
| C82.1A | ICD10CM | Covered |
| C82.2A | ICD10CM | Covered |
| C82.3A | ICD10CM | Covered |
| C82.4A | ICD10CM | Covered |
| C82.51 | ICD10CM | Covered |
| C82.52 | ICD10CM | Covered |
| C82.53 | ICD10CM | Covered |
| C82.5A | ICD10CM | Covered |
| C82.61 | ICD10CM | Covered |
| C82.62 | ICD10CM | Covered |
| C82.63 | ICD10CM | Covered |
| C82.6A | ICD10CM | Covered |
| C82.81 | ICD10CM | Covered |
| C82.82 | ICD10CM | Covered |
| C82.83 | ICD10CM | Covered |
| C82.8A | ICD10CM | Covered |
| C83.01 | ICD10CM | Covered |
| C83.02 | ICD10CM | Covered |
| C83.03 | ICD10CM | Covered |
| C83.0A | ICD10CM | Covered |
| C83.11 | ICD10CM | Covered |
| C83.12 | ICD10CM | Covered |
| C83.13 | ICD10CM | Covered |
| C83.1A | ICD10CM | Covered |
| C83.31 | ICD10CM | Covered |
| C83.32 | ICD10CM | Covered |
| C83.33 | ICD10CM | Covered |
| C83.390 | ICD10CM | Covered |
| C83.398 | ICD10CM | Covered |
| C83.3A | ICD10CM | Covered |
| C83.51 | ICD10CM | Covered |
| C83.52 | ICD10CM | Covered |
| C83.53 | ICD10CM | Covered |
| C83.5A | ICD10CM | Covered |
| C83.71 | ICD10CM | Covered |
| C83.72 | ICD10CM | Covered |
| C83.73 | ICD10CM | Covered |
| C83.7A | ICD10CM | Covered |
| C83.81 | ICD10CM | Covered |
| C83.82 | ICD10CM | Covered |
| C83.83 | ICD10CM | Covered |
| C83.8A | ICD10CM | Covered |
| C83.91 | ICD10CM | Covered |
| C83.92 | ICD10CM | Covered |
| C83.93 | ICD10CM | Covered |
| C83.9A | ICD10CM | Covered |
| C84.01 | ICD10CM | Covered |
| C84.02 | ICD10CM | Covered |
| C84.03 | ICD10CM | Covered |
| C84.0A | ICD10CM | Covered |
| C84.11 | ICD10CM | Covered |
| C84.12 | ICD10CM | Covered |
| C84.13 | ICD10CM | Covered |
| C84.1A | ICD10CM | Covered |
| C84.41 | ICD10CM | Covered |
| C84.42 | ICD10CM | Covered |
| C84.43 | ICD10CM | Covered |
| C84.4A | ICD10CM | Covered |
| C84.61 | ICD10CM | Covered |
| C84.62 | ICD10CM | Covered |
| C84.63 | ICD10CM | Covered |
| C84.6A | ICD10CM | Covered |
| C84.71 | ICD10CM | Covered |
| C84.72 | ICD10CM | Covered |
| C84.73 | ICD10CM | Covered |
| C84.7B | ICD10CM | Covered |
| C84.91 | ICD10CM | Covered |
| C84.92 | ICD10CM | Covered |
| C84.93 | ICD10CM | Covered |
| C84.9A | ICD10CM | Covered |
| C84.A1 | ICD10CM | Covered |
| C84.A2 | ICD10CM | Covered |
| C84.A3 | ICD10CM | Covered |
| C84.AA | ICD10CM | Covered |
| C84.Z1 | ICD10CM | Covered |
| C84.Z2 | ICD10CM | Covered |
| C84.Z3 | ICD10CM | Covered |
| C84.ZA | ICD10CM | Covered |
| C85.11 | ICD10CM | Covered |
| C85.12 | ICD10CM | Covered |
| C85.13 | ICD10CM | Covered |
| C85.1A | ICD10CM | Covered |
| C85.21 | ICD10CM | Covered |
| C85.22 | ICD10CM | Covered |
| C85.23 | ICD10CM | Covered |
| C85.2A | ICD10CM | Covered |
| C85.81 | ICD10CM | Covered |
| C85.82 | ICD10CM | Covered |
| C85.83 | ICD10CM | Covered |
| C85.8A | ICD10CM | Covered |
| C85.91 | ICD10CM | Covered |
| C85.92 | ICD10CM | Covered |
| C85.93 | ICD10CM | Covered |
| C85.9A | ICD10CM | Covered |
| C86.00 | ICD10CM | Covered |
| C86.01 | ICD10CM | Covered |
| C86.10 | ICD10CM | Covered |
| C86.11 | ICD10CM | Covered |
| C86.20 | ICD10CM | Covered |
| C86.21 | ICD10CM | Covered |
| C86.30 | ICD10CM | Covered |
| C86.31 | ICD10CM | Covered |
| C86.40 | ICD10CM | Covered |
| C86.41 | ICD10CM | Covered |
| C86.50 | ICD10CM | Covered |
| C86.51 | ICD10CM | Covered |
| C86.60 | ICD10CM | Covered |
| C86.61 | ICD10CM | Covered |
| C88.00 | ICD10CM | Covered |
| C88.01 | ICD10CM | Covered |
| C88.20 | ICD10CM | Covered |
| C88.21 | ICD10CM | Covered |
| C88.30 | ICD10CM | Covered |
| C88.31 | ICD10CM | Covered |
| C88.40 | ICD10CM | Covered |
| C88.41 | ICD10CM | Covered |
| C88.80 | ICD10CM | Covered |
| C88.81 | ICD10CM | Covered |
| C88.90 | ICD10CM | Covered |
| C88.91 | ICD10CM | Covered |
| D00.1 | ICD10CM | Covered |
| D00.2 | ICD10CM | Covered |
| D01.7 | ICD10CM | Covered |
| D13.0 | ICD10CM | Covered |
| D13.1 | ICD10CM | Covered |
| D13.2 | ICD10CM | Covered |
| D13.39 | ICD10CM | Covered |
| D13.4 | ICD10CM | Covered |
| D13.5 | ICD10CM | Covered |
| D13.6 | ICD10CM | Covered |
| D13.7 | ICD10CM | Covered |
| D17.5 | ICD10CM | Covered |
| D37.1 | ICD10CM | Covered |
| D37.2 | ICD10CM | Covered |
| D37.3 | ICD10CM | Covered |
| D37.4 | ICD10CM | Covered |
| D37.5 | ICD10CM | Covered |
| D37.6 | ICD10CM | Covered |
| D37.8 | ICD10CM | Covered |
| D3A.010 | ICD10CM | Covered |
| D3A.092 | ICD10CM | Covered |
| D3A.8 | ICD10CM | Covered |
| D49.0 | ICD10CM | Covered |
| D50.0 | ICD10CM | Covered |
| D50.9 | ICD10CM | Covered |
| D51.0 | ICD10CM | Covered |
| D62 | ICD10CM | Covered |
| E41 | ICD10CM | Covered |
| E43 | ICD10CM | Covered |
| E44.0 | ICD10CM | Covered |
| E46 | ICD10CM | Covered |
| E64.0 | ICD10CM | Covered |
| I69.091 | ICD10CM | Covered |
| I69.191 | ICD10CM | Covered |
| I69.291 | ICD10CM | Covered |
| I69.391 | ICD10CM | Covered |
| I69.891 | ICD10CM | Covered |
| I69.991 | ICD10CM | Covered |
| I77.2 | ICD10CM | Covered |
| I78.0 | ICD10CM | Covered |
| I85.00 | ICD10CM | Covered |
| I85.01 | ICD10CM | Covered |
| I85.10 | ICD10CM | Covered |
| I85.11 | ICD10CM | Covered |
| J86.0 | ICD10CM | Covered |
| K20.0 | ICD10CM | Covered |
| K20.80 | ICD10CM | Covered |
| K20.81 | ICD10CM | Covered |
| K20.90 | ICD10CM | Covered |
| K20.91 | ICD10CM | Covered |
| K21.00 | ICD10CM | Covered |
| K21.01 | ICD10CM | Covered |
| K21.9 | ICD10CM | Covered |
| K22.0 | ICD10CM | Covered |
| K22.10 | ICD10CM | Covered |
| K22.11 | ICD10CM | Covered |
| K22.2 | ICD10CM | Covered |
| K22.3 | ICD10CM | Covered |
| K22.4 | ICD10CM | Covered |
| K22.5 | ICD10CM | Covered |
| K22.6 | ICD10CM | Covered |
| K22.70 | ICD10CM | Covered |
| K22.710 | ICD10CM | Covered |
| K22.711 | ICD10CM | Covered |
| K22.719 | ICD10CM | Covered |
| K22.81 | ICD10CM | Covered |
| K22.82 | ICD10CM | Covered |
| K22.89 | ICD10CM | Covered |
| K25.0 | ICD10CM | Covered |
| K25.1 | ICD10CM | Covered |
| K25.2 | ICD10CM | Covered |
| K25.3 | ICD10CM | Covered |
| K25.4 | ICD10CM | Covered |
| K25.7 | ICD10CM | Covered |
| K25.9 | ICD10CM | Covered |
| K26.0 | ICD10CM | Covered |
| K26.3 | ICD10CM | Covered |
| K26.4 | ICD10CM | Covered |
| K26.7 | ICD10CM | Covered |
| K26.9 | ICD10CM | Covered |
| K27.0 | ICD10CM | Covered |
| K27.3 | ICD10CM | Covered |
| K27.4 | ICD10CM | Covered |
| K27.7 | ICD10CM | Covered |
| K27.9 | ICD10CM | Covered |
| K28.0 | ICD10CM | Covered |
| K28.3 | ICD10CM | Covered |
| K28.4 | ICD10CM | Covered |
| K28.7 | ICD10CM | Covered |
| K28.9 | ICD10CM | Covered |
| K29.00 | ICD10CM | Covered |
| K29.01 | ICD10CM | Covered |
| K29.20 | ICD10CM | Covered |
| K29.21 | ICD10CM | Covered |
| K29.30 | ICD10CM | Covered |
| K29.31 | ICD10CM | Covered |
| K29.40 | ICD10CM | Covered |
| K29.41 | ICD10CM | Covered |
| K29.50 | ICD10CM | Covered |
| K29.51 | ICD10CM | Covered |
| K29.60 | ICD10CM | Covered |
| K29.61 | ICD10CM | Covered |
| K29.70 | ICD10CM | Covered |
| K29.71 | ICD10CM | Covered |
| K29.80 | ICD10CM | Covered |
| K29.81 | ICD10CM | Covered |
| K29.90 | ICD10CM | Covered |
| K29.91 | ICD10CM | Covered |
| K30 | ICD10CM | Covered |
| K31.0 | ICD10CM | Covered |
| K31.1 | ICD10CM | Covered |
| K31.2 | ICD10CM | Covered |
| K31.3 | ICD10CM | Covered |
| K31.4 | ICD10CM | Covered |
| K31.5 | ICD10CM | Covered |
| K31.6 | ICD10CM | Covered |
| K31.7 | ICD10CM | Covered |
| K31.811 | ICD10CM | Covered |
| K31.819 | ICD10CM | Covered |
| K31.82 | ICD10CM | Covered |
| K31.89 | ICD10CM | Covered |
| K31.A11 | ICD10CM | Covered |
| K31.A12 | ICD10CM | Covered |
| K31.A13 | ICD10CM | Covered |
| K31.A14 | ICD10CM | Covered |
| K31.A15 | ICD10CM | Covered |
| K31.A21 | ICD10CM | Covered |
| K31.A22 | ICD10CM | Covered |
| K44.0 | ICD10CM | Covered |
| K50.00 | ICD10CM | Covered |
| K50.011 | ICD10CM | Covered |
| K50.014 | ICD10CM | Covered |
| K50.018 | ICD10CM | Covered |
| K50.80 | ICD10CM | Covered |
| K50.811 | ICD10CM | Covered |
| K50.813 | ICD10CM | Covered |
| K50.814 | ICD10CM | Covered |
| K50.818 | ICD10CM | Covered |
| K52.0 | ICD10CM | Covered |
| K52.1 | ICD10CM | Covered |
| K52.21 | ICD10CM | Covered |
| K52.22 | ICD10CM | Covered |
| K52.29 | ICD10CM | Covered |
| K52.3 | ICD10CM | Covered |
| K52.81 | ICD10CM | Covered |
| K52.831 | ICD10CM | Covered |
| K52.832 | ICD10CM | Covered |
| K52.838 | ICD10CM | Covered |
| K52.839 | ICD10CM | Covered |
| K52.89 | ICD10CM | Covered |
| K52.9 | ICD10CM | Covered |
| K55.011 | ICD10CM | Covered |
| K55.012 | ICD10CM | Covered |
| K55.019 | ICD10CM | Covered |
| K55.021 | ICD10CM | Covered |
| K55.022 | ICD10CM | Covered |
| K55.029 | ICD10CM | Covered |
| K55.051 | ICD10CM | Covered |
| K55.052 | ICD10CM | Covered |
| K55.059 | ICD10CM | Covered |
| K55.061 | ICD10CM | Covered |
| K55.062 | ICD10CM | Covered |
| K55.069 | ICD10CM | Covered |
| K55.1 | ICD10CM | Covered |
| K55.20 | ICD10CM | Covered |
| K55.21 | ICD10CM | Covered |
| K55.30 | ICD10CM | Covered |
| K55.31 | ICD10CM | Covered |
| K55.32 | ICD10CM | Covered |
| K55.33 | ICD10CM | Covered |
| K55.8 | ICD10CM | Covered |
| K55.9 | ICD10CM | Covered |
| K63.3 | ICD10CM | Covered |
| K70.0 | ICD10CM | Covered |
| K74.60 | ICD10CM | Covered |
| K76.6 | ICD10CM | Covered |
| K76.81 | ICD10CM | Covered |
| K76.82 | ICD10CM | Covered |
| K76.89 | ICD10CM | Covered |
| K80.00 | ICD10CM | Covered |
| K80.01 | ICD10CM | Covered |
| K80.10 | ICD10CM | Covered |
| K80.11 | ICD10CM | Covered |
| K80.18 | ICD10CM | Covered |
| K80.19 | ICD10CM | Covered |
| K80.20 | ICD10CM | Covered |
| K80.21 | ICD10CM | Covered |
| K80.30 | ICD10CM | Covered |
| K80.31 | ICD10CM | Covered |
| K80.32 | ICD10CM | Covered |
| K80.33 | ICD10CM | Covered |
| K80.34 | ICD10CM | Covered |
| K80.35 | ICD10CM | Covered |
| K80.40 | ICD10CM | Covered |
| K80.41 | ICD10CM | Covered |
| K80.42 | ICD10CM | Covered |
| K80.43 | ICD10CM | Covered |
| K80.44 | ICD10CM | Covered |
| K80.45 | ICD10CM | Covered |
| K80.50 | ICD10CM | Covered |
| K80.51 | 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 |
| K80.80 | ICD10CM | Covered |
| K80.81 | ICD10CM | Covered |
| K83.01 | ICD10CM | Covered |
| K83.09 | ICD10CM | Covered |
| K83.1 | ICD10CM | Covered |
| K83.2 | ICD10CM | Covered |
| K83.3 | ICD10CM | Covered |
| K83.4 | ICD10CM | Covered |
| K83.5 | ICD10CM | Covered |
| K83.8 | ICD10CM | Covered |
| K83.9 | 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 |
| K86.0 | ICD10CM | Covered |
| K86.1 | ICD10CM | Covered |
| K86.2 | ICD10CM | Covered |
| K86.3 | ICD10CM | Covered |
| K86.81 | ICD10CM | Covered |
| K86.89 | ICD10CM | Covered |
| K86.9 | ICD10CM | Covered |
| K87 | ICD10CM | Covered |
| K90.0 | ICD10CM | Covered |
| K90.1 | ICD10CM | Covered |
| K90.41 | ICD10CM | Covered |
| K90.49 | ICD10CM | Covered |
| K90.81 | ICD10CM | Covered |
| K90.821 | ICD10CM | Covered |
| K90.822 | ICD10CM | Covered |
| K90.829 | ICD10CM | Covered |
| K90.83 | ICD10CM | Covered |
| K90.89 | ICD10CM | Covered |
| K90.9 | ICD10CM | Covered |
| K91.30 | ICD10CM | Covered |
| K91.31 | ICD10CM | Covered |
| K91.32 | ICD10CM | Covered |
| K91.5 | ICD10CM | Covered |
| K91.81 | ICD10CM | Covered |
| K91.82 | ICD10CM | Covered |
| K91.83 | ICD10CM | Covered |
| K91.86 | ICD10CM | Covered |
| K91.870 | ICD10CM | Covered |
| K91.871 | ICD10CM | Covered |
| K91.872 | ICD10CM | Covered |
| K91.873 | ICD10CM | Covered |
| K91.89 | ICD10CM | Covered |
| K92.0 | ICD10CM | Covered |
| K92.1 | ICD10CM | Covered |
| K92.2 | ICD10CM | Covered |
| K92.81 | ICD10CM | Covered |
| K94.20 | ICD10CM | Covered |
| K94.23 | ICD10CM | Covered |
| K94.30 | ICD10CM | Covered |
| K94.31 | ICD10CM | Covered |
| K94.33 | ICD10CM | Covered |
| K94.39 | ICD10CM | Covered |
| Q26.5 | ICD10CM | Covered |
| Q26.6 | ICD10CM | Covered |
| Q27.33 | ICD10CM | Covered |
| Q39.0 | ICD10CM | Covered |
| Q39.1 | ICD10CM | Covered |
| Q39.2 | ICD10CM | Covered |
| Q39.3 | ICD10CM | Covered |
| Q39.4 | ICD10CM | Covered |
| Q39.5 | ICD10CM | Covered |
| Q39.6 | ICD10CM | Covered |
| Q39.8 | ICD10CM | Covered |
| Q39.9 | ICD10CM | Covered |
| Q40.1 | ICD10CM | Covered |
| Q40.2 | ICD10CM | Covered |
| Q40.3 | ICD10CM | Covered |
| Q44.0 | ICD10CM | Covered |
| Q44.1 | ICD10CM | Covered |
| Q44.4 | ICD10CM | Covered |
| R07.9 | ICD10CM | Covered |
| R10.11 | ICD10CM | Covered |
| R10.12 | ICD10CM | Covered |
| R10.13 | ICD10CM | Covered |
| R10.33 | ICD10CM | Covered |
| R11.0 | ICD10CM | Covered |
| R11.10 | ICD10CM | Covered |
| R11.11 | ICD10CM | Covered |
| R11.12 | ICD10CM | Covered |
| R11.15 | ICD10CM | Covered |
| R11.16 | ICD10CM | Covered |
| R11.2 | ICD10CM | Covered |
| R12 | ICD10CM | Covered |
| R13.0 | ICD10CM | Covered |
| R13.10 | ICD10CM | Covered |
| R13.11 | ICD10CM | Covered |
| R13.12 | ICD10CM | Covered |
| R13.13 | ICD10CM | Covered |
| R13.14 | ICD10CM | Covered |
| R13.19 | ICD10CM | Covered |
| R17 | ICD10CM | Covered |
| R63.0 | ICD10CM | Covered |
| R63.39 | ICD10CM | Covered |
| R63.4 | ICD10CM | Covered |
| R93.2 | ICD10CM | Covered |
| R93.3 | ICD10CM | Covered |
| R93.5 | 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 |
| S27.812A | ICD10CM | Covered |
| S27.812D | ICD10CM | Covered |
| S27.812S | ICD10CM | Covered |
| S27.813A | ICD10CM | Covered |
| S27.813D | ICD10CM | Covered |
| S27.813S | ICD10CM | Covered |
| S27.818A | ICD10CM | Covered |
| S27.818D | ICD10CM | Covered |
| S27.818S | ICD10CM | Covered |
| S27.819A | ICD10CM | Covered |
| S27.819D | ICD10CM | Covered |
| S27.819S | ICD10CM | Covered |
| T18.100A | ICD10CM | Covered |
| T18.100D | ICD10CM | Covered |
| T18.100S | ICD10CM | Covered |
| T18.108A | ICD10CM | Covered |
| T18.108D | ICD10CM | Covered |
| T18.108S | ICD10CM | Covered |
| T18.110A | ICD10CM | Covered |
| T18.110D | ICD10CM | Covered |
| T18.110S | ICD10CM | Covered |
| T18.118A | ICD10CM | Covered |
| T18.118D | ICD10CM | Covered |
| T18.118S | ICD10CM | Covered |
| T18.120A | ICD10CM | Covered |
| T18.120D | ICD10CM | Covered |
| T18.120S | ICD10CM | Covered |
| T18.128A | ICD10CM | Covered |
| T18.128D | ICD10CM | Covered |
| T18.128S | ICD10CM | Covered |
| T18.190A | ICD10CM | Covered |
| T18.190D | ICD10CM | Covered |
| T18.190S | ICD10CM | Covered |
| T18.198A | ICD10CM | Covered |
| T18.198D | ICD10CM | Covered |
| T18.198S | ICD10CM | Covered |
| T18.2XXA | ICD10CM | Covered |
| T18.2XXD | ICD10CM | Covered |
| T18.2XXS | ICD10CM | Covered |
| T18.3XXA | ICD10CM | Covered |
| T18.3XXD | ICD10CM | Covered |
| T18.3XXS | ICD10CM | Covered |
| T18.8XXA | ICD10CM | Covered |
| T18.8XXD | ICD10CM | Covered |
| T18.8XXS | ICD10CM | Covered |
| T28.0XXA | ICD10CM | Covered |
| T28.0XXD | ICD10CM | Covered |
| T28.0XXS | ICD10CM | Covered |
| T28.1XXA | ICD10CM | Covered |
| T28.1XXD | ICD10CM | Covered |
| T28.1XXS | ICD10CM | Covered |
| T28.2XXA | ICD10CM | Covered |
| T28.2XXD | ICD10CM | Covered |
| T28.2XXS | ICD10CM | Covered |
| T28.5XXA | ICD10CM | Covered |
| T28.5XXD | ICD10CM | Covered |
| T28.5XXS | ICD10CM | Covered |
| T28.6XXA | ICD10CM | Covered |
| T28.6XXD | ICD10CM | Covered |
| T28.6XXS | ICD10CM | Covered |
| T28.7XXA | ICD10CM | Covered |
| T28.7XXD | ICD10CM | Covered |
| T28.7XXS | ICD10CM | Covered |
| T54.1X1A | ICD10CM | Covered |
| T54.1X1D | ICD10CM | Covered |
| T54.1X1S | ICD10CM | Covered |
| T54.1X2A | ICD10CM | Covered |
| T54.1X2D | ICD10CM | Covered |
| T54.1X2S | ICD10CM | Covered |
| T54.1X3A | ICD10CM | Covered |
| T54.1X3D | ICD10CM | Covered |
| T54.1X3S | ICD10CM | Covered |
| T54.1X4A | ICD10CM | Covered |
| T54.1X4D | ICD10CM | Covered |
| T54.1X4S | ICD10CM | Covered |
| T54.3X1A | ICD10CM | Covered |
| T54.3X1D | ICD10CM | Covered |
| T54.3X1S | ICD10CM | Covered |
| T54.3X2A | ICD10CM | Covered |
| T54.3X2D | ICD10CM | Covered |
| T54.3X2S | ICD10CM | Covered |
| T54.3X3A | ICD10CM | Covered |
| T54.3X3D | ICD10CM | Covered |
| T54.3X3S | ICD10CM | Covered |
| T54.3X4A | ICD10CM | Covered |
| T54.3X4D | ICD10CM | Covered |
| T54.3X4S | ICD10CM | Covered |
| T54.91XA | ICD10CM | Covered |
| T54.91XD | ICD10CM | Covered |
| T54.91XS | ICD10CM | Covered |
| T54.92XA | ICD10CM | Covered |
| T54.92XD | ICD10CM | Covered |
| T54.92XS | ICD10CM | Covered |
| T54.93XA | ICD10CM | Covered |
| T54.93XD | ICD10CM | Covered |
| T54.93XS | ICD10CM | Covered |
| T54.94XA | ICD10CM | Covered |
| T54.94XD | ICD10CM | Covered |
| T54.94XS | ICD10CM | Covered |
| T57.1X1A | ICD10CM | Covered |
| T57.1X1D | ICD10CM | Covered |
| T57.1X1S | ICD10CM | Covered |
| T57.1X2A | ICD10CM | Covered |
| T57.1X2D | ICD10CM | Covered |
| T57.1X2S | ICD10CM | Covered |
| T57.1X3A | ICD10CM | Covered |
| T57.1X3D | ICD10CM | Covered |
| T57.1X3S | ICD10CM | Covered |
| T57.1X4A | ICD10CM | Covered |
| T57.1X4D | ICD10CM | Covered |
| T57.1X4S | ICD10CM | Covered |
| Z08 | ICD10CM | Covered |
| Z09 | ICD10CM | Covered |
| Z43.1 | ICD10CM | Covered |
| Z46.59 | ICD10CM | Covered |
| Z79.01 | ICD10CM | Covered |
| Z79.82 | ICD10CM | Covered |
| Z79.83 | ICD10CM | Covered |
| Z79.891 | ICD10CM | Covered |
| Z79.899 | ICD10CM | Covered |
| Z85.01 | ICD10CM | Covered |
| Z85.028 | ICD10CM | Covered |