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 |
|---|---|---|
| 0165U | HCPCS | Covered |
| 0178U | HCPCS | Covered |
| 82785 | HCPCS | Covered |
| 86001 | HCPCS | Covered |
| 86003 | HCPCS | Covered |
| 86005 | HCPCS | Covered |
| 86008 | HCPCS | Covered |
| 95004 | HCPCS | Covered |
| 95017 | HCPCS | Covered |
| 95018 | HCPCS | Covered |
| 95024 | HCPCS | Covered |
| 95027 | HCPCS | Covered |
| 95028 | HCPCS | Covered |
| 95044 | HCPCS | Covered |
| 95052 | HCPCS | Covered |
| 95056 | HCPCS | Covered |
| 95060 | HCPCS | Covered |
| 95065 | HCPCS | Covered |
| 95070 | HCPCS | Covered |
| 95076 | HCPCS | Covered |
| 95079 | HCPCS | Covered |
| B44.0 | ICD10CM | Covered |
| H10.411 | ICD10CM | Covered |
| H10.412 | ICD10CM | Covered |
| H10.413 | ICD10CM | Covered |
| H10.44 | ICD10CM | Covered |
| H10.45 | ICD10CM | Covered |
| H65.411 | ICD10CM | Covered |
| H65.412 | ICD10CM | Covered |
| H65.413 | ICD10CM | Covered |
| J30.1 | ICD10CM | Covered |
| J30.2 | ICD10CM | Covered |
| J30.5 | ICD10CM | Covered |
| J30.81 | ICD10CM | Covered |
| J30.89 | ICD10CM | Covered |
| J30.9 | ICD10CM | Covered |
| J31.0 | ICD10CM | Covered |
| J32.0 | ICD10CM | Covered |
| J32.1 | ICD10CM | Covered |
| J32.2 | ICD10CM | Covered |
| J32.3 | ICD10CM | Covered |
| J45.20 | ICD10CM | Covered |
| J45.21 | ICD10CM | Covered |
| J45.22 | ICD10CM | Covered |
| J45.30 | ICD10CM | Covered |
| J45.31 | ICD10CM | Covered |
| J45.32 | ICD10CM | Covered |
| J45.40 | ICD10CM | Covered |
| J45.41 | ICD10CM | Covered |
| J45.42 | ICD10CM | Covered |
| J45.50 | ICD10CM | Covered |
| J45.51 | ICD10CM | Covered |
| J45.52 | ICD10CM | Covered |
| J45.901 | ICD10CM | Covered |
| J45.902 | ICD10CM | Covered |
| J45.909 | ICD10CM | Covered |
| J45.991 | ICD10CM | Covered |
| J45.998 | ICD10CM | Covered |
| L20.0 | ICD10CM | Covered |
| L20.81 | ICD10CM | Covered |
| L20.82 | ICD10CM | Covered |
| L20.84 | ICD10CM | Covered |
| L20.89 | ICD10CM | Covered |
| L23.0 | ICD10CM | Covered |
| L23.1 | ICD10CM | Covered |
| L23.2 | ICD10CM | Covered |
| L23.3 | ICD10CM | Covered |
| L23.4 | ICD10CM | Covered |
| L23.5 | ICD10CM | Covered |
| L23.6 | ICD10CM | Covered |
| L23.7 | ICD10CM | Covered |
| L23.81 | ICD10CM | Covered |
| L23.89 | ICD10CM | Covered |
| L23.9 | ICD10CM | Covered |
| L24.0 | ICD10CM | Covered |
| L24.1 | ICD10CM | Covered |
| L24.2 | ICD10CM | Covered |
| L24.3 | ICD10CM | Covered |
| L24.4 | ICD10CM | Covered |
| L24.5 | ICD10CM | Covered |
| L24.6 | ICD10CM | Covered |
| L24.7 | ICD10CM | Covered |
| L24.81 | ICD10CM | Covered |
| L24.89 | ICD10CM | Covered |
| L24.9 | ICD10CM | Covered |
| L25.0 | ICD10CM | Covered |
| L25.1 | ICD10CM | Covered |
| L25.2 | ICD10CM | Covered |
| L25.3 | ICD10CM | Covered |
| L25.4 | ICD10CM | Covered |
| L25.5 | ICD10CM | Covered |
| L25.8 | ICD10CM | Covered |
| L25.9 | ICD10CM | Covered |
| L27.2 | ICD10CM | Covered |
| L30.8 | ICD10CM | Covered |
| L50.0 | ICD10CM | Covered |
| L50.1 | ICD10CM | Covered |
| L50.3 | ICD10CM | Covered |
| L50.6 | ICD10CM | Covered |
| L50.8 | ICD10CM | Covered |
| R05.3 | ICD10CM | Covered |
| T36.0X5A | ICD10CM | Covered |
| T36.0X5D | ICD10CM | Covered |
| T36.0X5S | ICD10CM | Covered |
| T36.1X5A | ICD10CM | Covered |
| T36.1X5D | ICD10CM | Covered |
| T36.1X5S | ICD10CM | Covered |
| T36.2X5A | ICD10CM | Covered |
| T36.2X5D | ICD10CM | Covered |
| T36.2X5S | ICD10CM | Covered |
| T36.3X5A | ICD10CM | Covered |
| T36.3X5D | ICD10CM | Covered |
| T36.3X5S | ICD10CM | Covered |
| T36.4X5A | ICD10CM | Covered |
| T36.4X5D | ICD10CM | Covered |
| T36.4X5S | ICD10CM | Covered |
| T36.5X5A | ICD10CM | Covered |
| T36.5X5D | ICD10CM | Covered |
| T36.5X5S | ICD10CM | Covered |
| T36.6X5A | ICD10CM | Covered |
| T36.6X5D | ICD10CM | Covered |
| T36.6X5S | ICD10CM | Covered |
| T36.7X5A | ICD10CM | Covered |
| T36.7X5D | ICD10CM | Covered |
| T36.7X5S | ICD10CM | Covered |
| T36.8X5A | ICD10CM | Covered |
| T36.8X5D | ICD10CM | Covered |
| T36.8X5S | ICD10CM | Covered |
| T36.AX5A | ICD10CM | Covered |
| T36.AX5D | ICD10CM | Covered |
| T36.AX5S | ICD10CM | Covered |
| T37.0X5A | ICD10CM | Covered |
| T37.0X5D | ICD10CM | Covered |
| T37.0X5S | ICD10CM | Covered |
| T37.1X5A | ICD10CM | Covered |
| T37.1X5D | ICD10CM | Covered |
| T37.1X5S | ICD10CM | Covered |
| T37.2X5A | ICD10CM | Covered |
| T37.2X5D | ICD10CM | Covered |
| T37.2X5S | ICD10CM | Covered |
| T37.3X5A | ICD10CM | Covered |
| T37.3X5D | ICD10CM | Covered |
| T37.3X5S | ICD10CM | Covered |
| T37.4X5A | ICD10CM | Covered |
| T37.4X5D | ICD10CM | Covered |
| T37.4X5S | ICD10CM | Covered |
| T37.5X5A | ICD10CM | Covered |
| T37.5X5D | ICD10CM | Covered |
| T37.5X5S | ICD10CM | Covered |
| T37.8X5A | ICD10CM | Covered |
| T37.8X5D | ICD10CM | Covered |
| T37.8X5S | ICD10CM | Covered |
| T38.0X5A | ICD10CM | Covered |
| T38.0X5D | ICD10CM | Covered |
| T38.0X5S | ICD10CM | Covered |
| T38.1X5A | ICD10CM | Covered |
| T38.1X5D | ICD10CM | Covered |
| T38.1X5S | ICD10CM | Covered |
| T38.2X5A | ICD10CM | Covered |
| T38.2X5D | ICD10CM | Covered |
| T38.2X5S | ICD10CM | Covered |
| T38.3X5A | ICD10CM | Covered |
| T38.3X5D | ICD10CM | Covered |
| T38.3X5S | ICD10CM | Covered |
| T38.4X5A | ICD10CM | Covered |
| T38.4X5D | ICD10CM | Covered |
| T38.4X5S | ICD10CM | Covered |
| T38.5X5A | ICD10CM | Covered |
| T38.5X5D | ICD10CM | Covered |
| T38.5X5S | ICD10CM | Covered |
| T38.6X5A | ICD10CM | Covered |
| T38.6X5D | ICD10CM | Covered |
| T38.6X5S | ICD10CM | Covered |
| T38.7X5A | ICD10CM | Covered |
| T38.7X5D | ICD10CM | Covered |
| T38.7X5S | ICD10CM | Covered |
| T38.815A | ICD10CM | Covered |
| T38.815D | ICD10CM | Covered |
| T38.815S | ICD10CM | Covered |
| T38.895A | ICD10CM | Covered |
| T38.895D | ICD10CM | Covered |
| T38.895S | ICD10CM | Covered |
| T38.995A | ICD10CM | Covered |
| T38.995D | ICD10CM | Covered |
| T38.995S | ICD10CM | Covered |
| T39.015A | ICD10CM | Covered |
| T39.015D | ICD10CM | Covered |
| T39.015S | ICD10CM | Covered |
| T39.095A | ICD10CM | Covered |
| T39.095D | ICD10CM | Covered |
| T39.095S | ICD10CM | Covered |
| T39.1X5A | ICD10CM | Covered |
| T39.1X5D | ICD10CM | Covered |
| T39.1X5S | ICD10CM | Covered |
| T39.2X5A | ICD10CM | Covered |
| T39.2X5D | ICD10CM | Covered |
| T39.2X5S | ICD10CM | Covered |
| T39.315A | ICD10CM | Covered |
| T39.315D | ICD10CM | Covered |
| T39.315S | ICD10CM | Covered |
| T39.395A | ICD10CM | Covered |
| T39.395D | ICD10CM | Covered |
| T39.395S | ICD10CM | Covered |
| T39.4X5A | ICD10CM | Covered |
| T39.4X5D | ICD10CM | Covered |
| T39.4X5S | ICD10CM | Covered |
| T39.8X5A | ICD10CM | Covered |
| T39.8X5D | ICD10CM | Covered |
| T39.8X5S | ICD10CM | Covered |
| T44.3X5A | ICD10CM | Covered |
| T44.3X5D | ICD10CM | Covered |
| T44.3X5S | ICD10CM | Covered |
| T44.4X5A | ICD10CM | Covered |
| T44.4X5D | ICD10CM | Covered |
| T44.4X5S | ICD10CM | Covered |
| T44.5X5A | ICD10CM | Covered |
| T44.5X5D | ICD10CM | Covered |
| T44.5X5S | ICD10CM | Covered |
| T44.6X5A | ICD10CM | Covered |
| T44.6X5D | ICD10CM | Covered |
| T44.6X5S | ICD10CM | Covered |
| T44.7X5A | ICD10CM | Covered |
| T44.7X5D | ICD10CM | Covered |
| T44.7X5S | ICD10CM | Covered |
| T44.8X5A | ICD10CM | Covered |
| T44.8X5D | ICD10CM | Covered |
| T44.8X5S | ICD10CM | Covered |
| T44.995A | ICD10CM | Covered |
| T44.995D | ICD10CM | Covered |
| T44.995S | ICD10CM | Covered |
| T45.0X5A | ICD10CM | Covered |
| T45.0X5D | ICD10CM | Covered |
| T45.0X5S | ICD10CM | Covered |
| T45.1X5A | ICD10CM | Covered |
| T45.1X5D | ICD10CM | Covered |
| T45.1X5S | ICD10CM | Covered |
| T45.2X5A | ICD10CM | Covered |
| T45.2X5D | ICD10CM | Covered |
| T45.2X5S | ICD10CM | Covered |
| T45.3X5A | ICD10CM | Covered |
| T45.3X5D | ICD10CM | Covered |
| T45.3X5S | ICD10CM | Covered |
| T45.4X5A | ICD10CM | Covered |
| T45.4X5D | ICD10CM | Covered |
| T45.4X5S | ICD10CM | Covered |
| T45.515A | ICD10CM | Covered |
| T45.515D | ICD10CM | Covered |
| T45.515S | ICD10CM | Covered |
| T45.525A | ICD10CM | Covered |
| T45.525D | ICD10CM | Covered |
| T45.525S | ICD10CM | Covered |
| T45.615A | ICD10CM | Covered |
| T45.615D | ICD10CM | Covered |
| T45.615S | ICD10CM | Covered |
| T45.625A | ICD10CM | Covered |
| T45.625D | ICD10CM | Covered |
| T45.625S | ICD10CM | Covered |
| T45.695A | ICD10CM | Covered |
| T45.695D | ICD10CM | Covered |
| T45.695S | ICD10CM | Covered |
| T45.7X5A | ICD10CM | Covered |
| T45.7X5D | ICD10CM | Covered |
| T45.7X5S | ICD10CM | Covered |
| T45.8X5A | ICD10CM | Covered |
| T45.8X5D | ICD10CM | Covered |
| T45.8X5S | ICD10CM | Covered |
| T45.AX5A | ICD10CM | Covered |
| T45.AX5D | ICD10CM | Covered |
| T45.AX5S | ICD10CM | Covered |
| T46.0X5A | ICD10CM | Covered |
| T46.0X5D | ICD10CM | Covered |
| T46.0X5S | ICD10CM | Covered |
| T46.1X5A | ICD10CM | Covered |
| T46.1X5D | ICD10CM | Covered |
| T46.1X5S | ICD10CM | Covered |
| T46.2X5A | ICD10CM | Covered |
| T46.2X5D | ICD10CM | Covered |
| T46.2X5S | ICD10CM | Covered |
| T46.3X5A | ICD10CM | Covered |
| T46.3X5D | ICD10CM | Covered |
| T46.3X5S | ICD10CM | Covered |
| T46.4X5A | ICD10CM | Covered |
| T46.4X5D | ICD10CM | Covered |
| T46.4X5S | ICD10CM | Covered |
| T46.5X5A | ICD10CM | Covered |
| T46.5X5D | ICD10CM | Covered |
| T46.5X5S | ICD10CM | Covered |
| T46.6X5A | ICD10CM | Covered |
| T46.6X5D | ICD10CM | Covered |
| T46.6X5S | ICD10CM | Covered |
| T46.7X5A | ICD10CM | Covered |
| T46.7X5D | ICD10CM | Covered |
| T46.7X5S | ICD10CM | Covered |
| T46.8X5A | ICD10CM | Covered |
| T46.8X5D | ICD10CM | Covered |
| T46.8X5S | ICD10CM | Covered |
| T46.995A | ICD10CM | Covered |
| T46.995D | ICD10CM | Covered |
| T46.995S | ICD10CM | Covered |
| T47.0X5A | ICD10CM | Covered |
| T47.0X5D | ICD10CM | Covered |
| T47.0X5S | ICD10CM | Covered |
| T47.1X5A | ICD10CM | Covered |
| T47.1X5D | ICD10CM | Covered |
| T47.1X5S | ICD10CM | Covered |
| T47.2X5A | ICD10CM | Covered |
| T47.2X5D | ICD10CM | Covered |
| T47.2X5S | ICD10CM | Covered |
| T47.3X5A | ICD10CM | Covered |
| T47.3X5D | ICD10CM | Covered |
| T47.3X5S | ICD10CM | Covered |
| T47.4X5A | ICD10CM | Covered |
| T47.4X5D | ICD10CM | Covered |
| T47.4X5S | ICD10CM | Covered |
| T47.5X5A | ICD10CM | Covered |
| T47.5X5D | ICD10CM | Covered |
| T47.5X5S | ICD10CM | Covered |
| T47.6X5A | ICD10CM | Covered |
| T47.6X5D | ICD10CM | Covered |
| T47.6X5S | ICD10CM | Covered |
| T47.7X5A | ICD10CM | Covered |
| T47.7X5D | ICD10CM | Covered |
| T47.7X5S | ICD10CM | Covered |
| T47.8X5A | ICD10CM | Covered |
| T47.8X5D | ICD10CM | Covered |
| T47.8X5S | ICD10CM | Covered |
| T48.0X5A | ICD10CM | Covered |
| T48.0X5D | ICD10CM | Covered |
| T48.0X5S | ICD10CM | Covered |
| T48.1X5A | ICD10CM | Covered |
| T48.1X5D | ICD10CM | Covered |
| T48.1X5S | ICD10CM | Covered |
| T48.295A | ICD10CM | Covered |
| T48.295D | ICD10CM | Covered |
| T48.295S | ICD10CM | Covered |
| T48.3X5A | ICD10CM | Covered |
| T48.3X5D | ICD10CM | Covered |
| T48.3X5S | ICD10CM | Covered |
| T48.4X5A | ICD10CM | Covered |
| T48.4X5D | ICD10CM | Covered |
| T48.4X5S | ICD10CM | Covered |
| T48.5X5A | ICD10CM | Covered |
| T48.5X5D | ICD10CM | Covered |
| T48.5X5S | ICD10CM | Covered |
| T48.6X5A | ICD10CM | Covered |
| T48.6X5D | ICD10CM | Covered |
| T48.6X5S | ICD10CM | Covered |
| T48.995A | ICD10CM | Covered |
| T48.995D | ICD10CM | Covered |
| T48.995S | ICD10CM | Covered |
| T49.5X5A | ICD10CM | Covered |
| T49.5X5D | ICD10CM | Covered |
| T49.5X5S | ICD10CM | Covered |
| T50.0X5A | ICD10CM | Covered |
| T50.0X5D | ICD10CM | Covered |
| T50.0X5S | ICD10CM | Covered |
| T50.1X5A | ICD10CM | Covered |
| T50.1X5D | ICD10CM | Covered |
| T50.1X5S | ICD10CM | Covered |
| T50.2X5A | ICD10CM | Covered |
| T50.2X5D | ICD10CM | Covered |
| T50.2X5S | ICD10CM | Covered |
| T50.3X5A | ICD10CM | Covered |
| T50.3X5D | ICD10CM | Covered |
| T50.3X5S | ICD10CM | Covered |
| T50.4X5A | ICD10CM | Covered |
| T50.4X5D | ICD10CM | Covered |
| T50.4X5S | ICD10CM | Covered |
| T50.5X5A | ICD10CM | Covered |
| T50.5X5D | ICD10CM | Covered |
| T50.5X5S | ICD10CM | Covered |
| T50.7X5A | ICD10CM | Covered |
| T50.7X5D | ICD10CM | Covered |
| T50.7X5S | ICD10CM | Covered |
| T50.8X5A | ICD10CM | Covered |
| T50.8X5D | ICD10CM | Covered |
| T50.8X5S | ICD10CM | Covered |
| T50.995A | ICD10CM | Covered |
| T50.995D | ICD10CM | Covered |
| T50.995S | ICD10CM | Covered |
| T50.A15A | ICD10CM | Covered |
| T50.A15D | ICD10CM | Covered |
| T50.A15S | ICD10CM | Covered |
| T50.A25A | ICD10CM | Covered |
| T50.A25D | ICD10CM | Covered |
| T50.A25S | ICD10CM | Covered |
| T50.A95A | ICD10CM | Covered |
| T50.A95D | ICD10CM | Covered |
| T50.A95S | ICD10CM | Covered |
| T50.B95A | ICD10CM | Covered |
| T50.B95D | ICD10CM | Covered |
| T50.B95S | ICD10CM | Covered |
| T50.Z15A | ICD10CM | Covered |
| T50.Z15D | ICD10CM | Covered |
| T50.Z15S | ICD10CM | Covered |
| T50.Z95A | ICD10CM | Covered |
| T50.Z95D | ICD10CM | Covered |
| T50.Z95S | ICD10CM | Covered |
| T63.421A | ICD10CM | Covered |
| T63.421D | ICD10CM | Covered |
| T63.421S | ICD10CM | Covered |
| T63.422A | ICD10CM | Covered |
| T63.422D | ICD10CM | Covered |
| T63.422S | ICD10CM | Covered |
| T63.423A | ICD10CM | Covered |
| T63.423D | ICD10CM | Covered |
| T63.423S | ICD10CM | Covered |
| T63.424A | ICD10CM | Covered |
| T63.424D | ICD10CM | Covered |
| T63.424S | ICD10CM | Covered |
| T63.431A | ICD10CM | Covered |
| T63.431D | ICD10CM | Covered |
| T63.431S | ICD10CM | Covered |
| T63.432A | ICD10CM | Covered |
| T63.432D | ICD10CM | Covered |
| T63.432S | ICD10CM | Covered |
| T63.433A | ICD10CM | Covered |
| T63.433D | ICD10CM | Covered |
| T63.433S | ICD10CM | Covered |
| T63.434A | ICD10CM | Covered |
| T63.434D | ICD10CM | Covered |
| T63.434S | ICD10CM | Covered |
| T63.441A | ICD10CM | Covered |
| T63.441D | ICD10CM | Covered |
| T63.441S | ICD10CM | Covered |
| T63.442A | ICD10CM | Covered |
| T63.442D | ICD10CM | Covered |
| T63.442S | ICD10CM | Covered |
| T63.443A | ICD10CM | Covered |
| T63.443D | ICD10CM | Covered |
| T63.443S | ICD10CM | Covered |
| T63.444A | ICD10CM | Covered |
| T63.444D | ICD10CM | Covered |
| T63.444S | ICD10CM | Covered |
| T63.451A | ICD10CM | Covered |
| T63.451D | ICD10CM | Covered |
| T63.451S | ICD10CM | Covered |
| T63.452A | ICD10CM | Covered |
| T63.452D | ICD10CM | Covered |
| T63.452S | ICD10CM | Covered |
| T63.453A | ICD10CM | Covered |
| T63.453D | ICD10CM | Covered |
| T63.453S | ICD10CM | Covered |
| T63.454A | ICD10CM | Covered |
| T63.454D | ICD10CM | Covered |
| T63.454S | ICD10CM | Covered |
| T63.461A | ICD10CM | Covered |
| T63.461D | ICD10CM | Covered |
| T63.461S | ICD10CM | Covered |
| T63.462A | ICD10CM | Covered |
| T63.462D | ICD10CM | Covered |
| T63.462S | ICD10CM | Covered |
| T63.463A | ICD10CM | Covered |
| T63.463D | ICD10CM | Covered |
| T63.463S | ICD10CM | Covered |
| T63.464A | ICD10CM | Covered |
| T63.464D | ICD10CM | Covered |
| T63.464S | ICD10CM | Covered |
| T63.481A | ICD10CM | Covered |
| T63.481D | ICD10CM | Covered |
| T63.481S | ICD10CM | Covered |
| T63.482A | ICD10CM | Covered |
| T63.482D | ICD10CM | Covered |
| T63.482S | ICD10CM | Covered |
| T63.483A | ICD10CM | Covered |
| T63.483D | ICD10CM | Covered |
| T63.483S | ICD10CM | Covered |
| T63.484A | ICD10CM | Covered |
| T63.484D | ICD10CM | Covered |
| T63.484S | ICD10CM | Covered |
| T63.91XA | ICD10CM | Covered |
| T63.91XD | ICD10CM | Covered |
| T63.91XS | ICD10CM | Covered |
| T63.92XA | ICD10CM | Covered |
| T63.92XD | ICD10CM | Covered |
| T63.92XS | ICD10CM | Covered |
| T63.93XA | ICD10CM | Covered |
| T63.93XD | ICD10CM | Covered |
| T63.93XS | ICD10CM | Covered |
| T63.94XA | ICD10CM | Covered |
| T63.94XD | ICD10CM | Covered |
| T63.94XS | ICD10CM | Covered |
| T65.811A | ICD10CM | Covered |
| T65.811D | ICD10CM | Covered |
| T65.811S | ICD10CM | Covered |
| T65.812A | ICD10CM | Covered |
| T65.812D | ICD10CM | Covered |
| T65.812S | ICD10CM | Covered |
| T65.813A | ICD10CM | Covered |
| T65.813D | ICD10CM | Covered |
| T65.813S | ICD10CM | Covered |
| T65.814A | ICD10CM | Covered |
| T65.814D | ICD10CM | Covered |
| T65.814S | ICD10CM | Covered |
| T78.01XA | ICD10CM | Covered |
| T78.01XD | ICD10CM | Covered |
| T78.01XS | ICD10CM | Covered |
| T78.02XA | ICD10CM | Covered |
| T78.02XD | ICD10CM | Covered |
| T78.02XS | ICD10CM | Covered |
| T78.03XA | ICD10CM | Covered |
| T78.03XD | ICD10CM | Covered |
| T78.03XS | ICD10CM | Covered |
| T78.04XA | ICD10CM | Covered |
| T78.04XD | ICD10CM | Covered |
| T78.04XS | ICD10CM | Covered |
| T78.05XA | ICD10CM | Covered |
| T78.05XD | ICD10CM | Covered |
| T78.05XS | ICD10CM | Covered |
| T78.06XA | ICD10CM | Covered |
| T78.06XD | ICD10CM | Covered |
| T78.06XS | ICD10CM | Covered |
| T78.070A | ICD10CM | Covered |
| T78.070D | ICD10CM | Covered |
| T78.070S | ICD10CM | Covered |
| T78.071A | ICD10CM | Covered |
| T78.071D | ICD10CM | Covered |
| T78.071S | ICD10CM | Covered |
| T78.080A | ICD10CM | Covered |
| T78.080D | ICD10CM | Covered |
| T78.080S | ICD10CM | Covered |
| T78.081A | ICD10CM | Covered |
| T78.081D | ICD10CM | Covered |
| T78.081S | ICD10CM | Covered |
| T78.09XA | ICD10CM | Covered |
| T78.09XD | ICD10CM | Covered |
| T78.09XS | ICD10CM | Covered |
| T78.110A | ICD10CM | Covered |
| T78.110D | ICD10CM | Covered |
| T78.110S | ICD10CM | Covered |
| T78.111A | ICD10CM | Covered |
| T78.111D | ICD10CM | Covered |
| T78.111S | ICD10CM | Covered |
| T78.120A | ICD10CM | Covered |
| T78.120D | ICD10CM | Covered |
| T78.120S | ICD10CM | Covered |
| T78.121A | ICD10CM | Covered |
| T78.121D | ICD10CM | Covered |
| T78.121S | ICD10CM | Covered |
| T78.19XA | ICD10CM | Covered |
| T78.19XD | ICD10CM | Covered |
| T78.19XS | ICD10CM | Covered |
| T78.3XXA | ICD10CM | Covered |
| T78.3XXD | ICD10CM | Covered |
| T78.3XXS | ICD10CM | Covered |
| T78.40XA | ICD10CM | Covered |
| T78.40XD | ICD10CM | Covered |
| T78.40XS | ICD10CM | Covered |
| T78.49XA | ICD10CM | Covered |
| T78.49XD | ICD10CM | Covered |
| T78.49XS | ICD10CM | Covered |
| T80.51XA | ICD10CM | Covered |
| T80.51XD | ICD10CM | Covered |
| T80.51XS | ICD10CM | Covered |
| T80.52XA | ICD10CM | Covered |
| T80.52XD | ICD10CM | Covered |
| T80.52XS | ICD10CM | Covered |
| T80.59XA | ICD10CM | Covered |
| T80.59XD | ICD10CM | Covered |
| T80.59XS | ICD10CM | Covered |
| T80.61XA | ICD10CM | Covered |
| T80.61XD | ICD10CM | Covered |
| T80.61XS | ICD10CM | Covered |
| T80.62XA | ICD10CM | Covered |
| T80.62XD | ICD10CM | Covered |
| T80.62XS | ICD10CM | Covered |
| T80.69XA | ICD10CM | Covered |
| T80.69XD | ICD10CM | Covered |
| T80.69XS | ICD10CM | Covered |
| T84.89XA | ICD10CM | Covered |
| T84.89XD | ICD10CM | Covered |
| T84.89XS | ICD10CM | Covered |
| Z86.19 | ICD10CM | Covered |
| Z88.0 | ICD10CM | Covered |
| Z88.1 | ICD10CM | Covered |
| Z88.2 | ICD10CM | Covered |
| Z88.3 | ICD10CM | Covered |
| Z88.4 | ICD10CM | Covered |
| Z88.5 | ICD10CM | Covered |
| Z88.6 | ICD10CM | Covered |
| Z88.7 | ICD10CM | Covered |
| Z88.8 | ICD10CM | Covered |
| Z91.010 | ICD10CM | Covered |
| Z91.0111 | ICD10CM | Covered |
| Z91.0112 | ICD10CM | Covered |
| Z91.0121 | ICD10CM | Covered |
| Z91.0122 | ICD10CM | Covered |
| Z91.013 | ICD10CM | Covered |
| Z91.014 | ICD10CM | Covered |
| Z91.018 | ICD10CM | Covered |