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 1,318 codes. The source has the full list.
| Code | Code system | Status in this policy |
|---|---|---|
| 80305 | HCPCS | Covered |
| 80306 | HCPCS | Covered |
| 80307 | HCPCS | Covered |
| G0480 | HCPCS | Covered |
| G0481 | HCPCS | Covered |
| G0482 | HCPCS | Covered |
| G0483 | HCPCS | Covered |
| G0659 | HCPCS | Covered |
| E03.5 | ICD10CM | Covered |
| E87.21 | ICD10CM | Covered |
| E87.22 | ICD10CM | Covered |
| E87.29 | ICD10CM | Covered |
| F10.11 | ICD10CM | Covered |
| F10.120 | ICD10CM | Covered |
| F10.121 | ICD10CM | Covered |
| F10.129 | ICD10CM | Covered |
| F10.130 | ICD10CM | Covered |
| F10.131 | ICD10CM | Covered |
| F10.132 | ICD10CM | Covered |
| F10.14 | ICD10CM | Covered |
| F10.150 | ICD10CM | Covered |
| F10.151 | ICD10CM | Covered |
| F10.159 | ICD10CM | Covered |
| F10.180 | ICD10CM | Covered |
| F10.181 | ICD10CM | Covered |
| F10.182 | ICD10CM | Covered |
| F10.188 | ICD10CM | Covered |
| F10.19 | ICD10CM | Covered |
| F10.20 | ICD10CM | Covered |
| F10.21 | ICD10CM | Covered |
| F10.220 | ICD10CM | Covered |
| F10.221 | ICD10CM | Covered |
| F10.229 | ICD10CM | Covered |
| F10.230 | ICD10CM | Covered |
| F10.231 | ICD10CM | Covered |
| F10.232 | ICD10CM | Covered |
| F10.239 | ICD10CM | Covered |
| F10.24 | ICD10CM | Covered |
| F10.250 | ICD10CM | Covered |
| F10.251 | ICD10CM | Covered |
| F10.259 | ICD10CM | Covered |
| F10.26 | ICD10CM | Covered |
| F10.27 | ICD10CM | Covered |
| F10.280 | ICD10CM | Covered |
| F10.281 | ICD10CM | Covered |
| F10.282 | ICD10CM | Covered |
| F10.288 | ICD10CM | Covered |
| F10.29 | ICD10CM | Covered |
| F10.920 | ICD10CM | Covered |
| F10.921 | ICD10CM | Covered |
| F10.929 | ICD10CM | Covered |
| F10.94 | ICD10CM | Covered |
| F10.950 | ICD10CM | Covered |
| F10.951 | ICD10CM | Covered |
| F10.959 | ICD10CM | Covered |
| F10.96 | ICD10CM | Covered |
| F10.97 | ICD10CM | Covered |
| F10.980 | ICD10CM | Covered |
| F10.981 | ICD10CM | Covered |
| F10.982 | ICD10CM | Covered |
| F10.988 | ICD10CM | Covered |
| F10.99 | ICD10CM | Covered |
| F11.11 | ICD10CM | Covered |
| F11.120 | ICD10CM | Covered |
| F11.121 | ICD10CM | Covered |
| F11.122 | ICD10CM | Covered |
| F11.129 | ICD10CM | Covered |
| F11.13 | ICD10CM | Covered |
| F11.14 | ICD10CM | Covered |
| F11.150 | ICD10CM | Covered |
| F11.151 | ICD10CM | Covered |
| F11.159 | ICD10CM | Covered |
| F11.181 | ICD10CM | Covered |
| F11.182 | ICD10CM | Covered |
| F11.188 | ICD10CM | Covered |
| F11.19 | ICD10CM | Covered |
| F11.20 | ICD10CM | Covered |
| F11.21 | ICD10CM | Covered |
| F11.220 | ICD10CM | Covered |
| F11.221 | ICD10CM | Covered |
| F11.222 | ICD10CM | Covered |
| F11.229 | ICD10CM | Covered |
| F11.23 | ICD10CM | Covered |
| F11.24 | ICD10CM | Covered |
| F11.250 | ICD10CM | Covered |
| F11.251 | ICD10CM | Covered |
| F11.281 | ICD10CM | Covered |
| F11.282 | ICD10CM | Covered |
| F11.288 | ICD10CM | Covered |
| F11.29 | ICD10CM | Covered |
| F11.90 | ICD10CM | Covered |
| F11.920 | ICD10CM | Covered |
| F11.921 | ICD10CM | Covered |
| F11.922 | ICD10CM | Covered |
| F11.929 | ICD10CM | Covered |
| F11.93 | ICD10CM | Covered |
| F11.94 | ICD10CM | Covered |
| F11.950 | ICD10CM | Covered |
| F11.951 | ICD10CM | Covered |
| F11.959 | ICD10CM | Covered |
| F11.981 | ICD10CM | Covered |
| F11.982 | ICD10CM | Covered |
| F11.988 | ICD10CM | Covered |
| F11.99 | ICD10CM | Covered |
| F12.11 | ICD10CM | Covered |
| F12.120 | ICD10CM | Covered |
| F12.121 | ICD10CM | Covered |
| F12.122 | ICD10CM | Covered |
| F12.129 | ICD10CM | Covered |
| F12.13 | ICD10CM | Covered |
| F12.150 | ICD10CM | Covered |
| F12.151 | ICD10CM | Covered |
| F12.159 | ICD10CM | Covered |
| F12.180 | ICD10CM | Covered |
| F12.188 | ICD10CM | Covered |
| F12.19 | ICD10CM | Covered |
| F12.20 | ICD10CM | Covered |
| F12.21 | ICD10CM | Covered |
| F12.220 | ICD10CM | Covered |
| F12.221 | ICD10CM | Covered |
| F12.222 | ICD10CM | Covered |
| F12.229 | ICD10CM | Covered |
| F12.23 | ICD10CM | Covered |
| F12.250 | ICD10CM | Covered |
| F12.251 | ICD10CM | Covered |
| F12.259 | ICD10CM | Covered |
| F12.280 | ICD10CM | Covered |
| F12.288 | ICD10CM | Covered |
| F12.29 | ICD10CM | Covered |
| F12.90 | ICD10CM | Covered |
| F12.920 | ICD10CM | Covered |
| F12.921 | ICD10CM | Covered |
| F12.922 | ICD10CM | Covered |
| F12.929 | ICD10CM | Covered |
| F12.93 | ICD10CM | Covered |
| F12.950 | ICD10CM | Covered |
| F12.951 | ICD10CM | Covered |
| F12.959 | ICD10CM | Covered |
| F12.980 | ICD10CM | Covered |
| F12.988 | ICD10CM | Covered |
| F12.99 | ICD10CM | Covered |
| F13.10 | ICD10CM | Covered |
| F13.11 | ICD10CM | Covered |
| F13.120 | ICD10CM | Covered |
| F13.121 | ICD10CM | Covered |
| F13.129 | ICD10CM | Covered |
| F13.130 | ICD10CM | Covered |
| F13.131 | ICD10CM | Covered |
| F13.132 | ICD10CM | Covered |
| F13.14 | ICD10CM | Covered |
| F13.150 | ICD10CM | Covered |
| F13.151 | ICD10CM | Covered |
| F13.159 | ICD10CM | Covered |
| F13.180 | ICD10CM | Covered |
| F13.181 | ICD10CM | Covered |
| F13.182 | ICD10CM | Covered |
| F13.188 | ICD10CM | Covered |
| F13.19 | ICD10CM | Covered |
| F13.20 | ICD10CM | Covered |
| F13.21 | ICD10CM | Covered |
| F13.220 | ICD10CM | Covered |
| F13.221 | ICD10CM | Covered |
| F13.229 | ICD10CM | Covered |
| F13.230 | ICD10CM | Covered |
| F13.231 | ICD10CM | Covered |
| F13.232 | ICD10CM | Covered |
| F13.239 | ICD10CM | Covered |
| F13.24 | ICD10CM | Covered |
| F13.250 | ICD10CM | Covered |
| F13.251 | ICD10CM | Covered |
| F13.259 | ICD10CM | Covered |
| F13.26 | ICD10CM | Covered |
| F13.27 | ICD10CM | Covered |
| F13.280 | ICD10CM | Covered |
| F13.281 | ICD10CM | Covered |
| F13.282 | ICD10CM | Covered |
| F13.288 | ICD10CM | Covered |
| F13.29 | ICD10CM | Covered |
| F13.90 | ICD10CM | Covered |
| F13.920 | ICD10CM | Covered |
| F13.921 | ICD10CM | Covered |
| F13.929 | ICD10CM | Covered |
| F13.930 | ICD10CM | Covered |
| F13.931 | ICD10CM | Covered |
| F13.932 | ICD10CM | Covered |
| F13.939 | ICD10CM | Covered |
| F13.94 | ICD10CM | Covered |
| F13.950 | ICD10CM | Covered |
| F13.951 | ICD10CM | Covered |
| F13.959 | ICD10CM | Covered |
| F13.96 | ICD10CM | Covered |
| F13.97 | ICD10CM | Covered |
| F13.980 | ICD10CM | Covered |
| F13.981 | ICD10CM | Covered |
| F13.982 | ICD10CM | Covered |
| F13.988 | ICD10CM | Covered |
| F13.99 | ICD10CM | Covered |
| F14.10 | ICD10CM | Covered |
| F14.11 | ICD10CM | Covered |
| F14.120 | ICD10CM | Covered |
| F14.121 | ICD10CM | Covered |
| F14.122 | ICD10CM | Covered |
| F14.13 | ICD10CM | Covered |
| F14.14 | ICD10CM | Covered |
| F14.150 | ICD10CM | Covered |
| F14.151 | ICD10CM | Covered |
| F14.159 | ICD10CM | Covered |
| F14.180 | ICD10CM | Covered |
| F14.181 | ICD10CM | Covered |
| F14.182 | ICD10CM | Covered |
| F14.188 | ICD10CM | Covered |
| F14.19 | ICD10CM | Covered |
| F14.20 | ICD10CM | Covered |
| F14.220 | ICD10CM | Covered |
| F14.221 | ICD10CM | Covered |
| F14.222 | ICD10CM | Covered |
| F14.229 | ICD10CM | Covered |
| F14.250 | ICD10CM | Covered |
| F14.251 | ICD10CM | Covered |
| F14.259 | ICD10CM | Covered |
| F14.280 | ICD10CM | Covered |
| F14.281 | ICD10CM | Covered |
| F14.282 | ICD10CM | Covered |
| F14.288 | ICD10CM | Covered |
| F14.29 | ICD10CM | Covered |
| F14.90 | ICD10CM | Covered |
| F14.920 | ICD10CM | Covered |
| F14.921 | ICD10CM | Covered |
| F14.922 | ICD10CM | Covered |
| F14.929 | ICD10CM | Covered |
| F14.93 | ICD10CM | Covered |
| F14.94 | ICD10CM | Covered |
| F14.950 | ICD10CM | Covered |
| F14.951 | ICD10CM | Covered |
| F14.959 | ICD10CM | Covered |
| F14.980 | ICD10CM | Covered |
| F14.981 | ICD10CM | Covered |
| F14.982 | ICD10CM | Covered |
| F14.988 | ICD10CM | Covered |
| F14.99 | ICD10CM | Covered |
| F15.10 | ICD10CM | Covered |
| F15.11 | ICD10CM | Covered |
| F15.120 | ICD10CM | Covered |
| F15.121 | ICD10CM | Covered |
| F15.122 | ICD10CM | Covered |
| F15.129 | ICD10CM | Covered |
| F15.13 | ICD10CM | Covered |
| F15.14 | ICD10CM | Covered |
| F15.150 | ICD10CM | Covered |
| F15.151 | ICD10CM | Covered |
| F15.159 | ICD10CM | Covered |
| F15.180 | ICD10CM | Covered |
| F15.181 | ICD10CM | Covered |
| F15.182 | ICD10CM | Covered |
| F15.188 | ICD10CM | Covered |
| F15.19 | ICD10CM | Covered |
| F15.20 | ICD10CM | Covered |
| F15.21 | ICD10CM | Covered |
| F15.220 | ICD10CM | Covered |
| F15.221 | ICD10CM | Covered |
| F15.222 | ICD10CM | Covered |
| F15.229 | ICD10CM | Covered |
| F15.23 | ICD10CM | Covered |
| F15.24 | ICD10CM | Covered |
| F15.250 | ICD10CM | Covered |
| F15.251 | ICD10CM | Covered |
| F15.259 | ICD10CM | Covered |
| F15.280 | ICD10CM | Covered |
| F15.281 | ICD10CM | Covered |
| F15.282 | ICD10CM | Covered |
| F15.288 | ICD10CM | Covered |
| F15.29 | ICD10CM | Covered |
| F15.90 | ICD10CM | Covered |
| F15.920 | ICD10CM | Covered |
| F15.921 | ICD10CM | Covered |
| F15.922 | ICD10CM | Covered |
| F15.929 | ICD10CM | Covered |
| F15.93 | ICD10CM | Covered |
| F15.94 | ICD10CM | Covered |
| F15.950 | ICD10CM | Covered |
| F15.951 | ICD10CM | Covered |
| F15.959 | ICD10CM | Covered |
| F15.980 | ICD10CM | Covered |
| F15.981 | ICD10CM | Covered |
| F15.982 | ICD10CM | Covered |
| F15.988 | ICD10CM | Covered |
| F15.99 | ICD10CM | Covered |
| F16.10 | ICD10CM | Covered |
| F16.11 | ICD10CM | Covered |
| F16.120 | ICD10CM | Covered |
| F16.121 | ICD10CM | Covered |
| F16.122 | ICD10CM | Covered |
| F16.129 | ICD10CM | Covered |
| F16.150 | ICD10CM | Covered |
| F16.151 | ICD10CM | Covered |
| F16.159 | ICD10CM | Covered |
| F16.180 | ICD10CM | Covered |
| F16.183 | ICD10CM | Covered |
| F16.188 | ICD10CM | Covered |
| F16.19 | ICD10CM | Covered |
| F16.20 | ICD10CM | Covered |
| F16.21 | ICD10CM | Covered |
| F16.220 | ICD10CM | Covered |
| F16.221 | ICD10CM | Covered |
| F16.229 | ICD10CM | Covered |
| F16.24 | ICD10CM | Covered |
| F16.250 | ICD10CM | Covered |
| F16.251 | ICD10CM | Covered |
| F16.259 | ICD10CM | Covered |
| F16.280 | ICD10CM | Covered |
| F16.283 | ICD10CM | Covered |
| F16.288 | ICD10CM | Covered |
| F16.29 | ICD10CM | Covered |
| F16.90 | ICD10CM | Covered |
| F16.920 | ICD10CM | Covered |
| F16.921 | ICD10CM | Covered |
| F16.929 | ICD10CM | Covered |
| F16.94 | ICD10CM | Covered |
| F16.950 | ICD10CM | Covered |
| F16.951 | ICD10CM | Covered |
| F16.959 | ICD10CM | Covered |
| F16.980 | ICD10CM | Covered |
| F16.983 | ICD10CM | Covered |
| F16.988 | ICD10CM | Covered |
| F16.99 | ICD10CM | Covered |
| F18.10 | ICD10CM | Covered |
| F18.11 | ICD10CM | Covered |
| F18.120 | ICD10CM | Covered |
| F18.121 | ICD10CM | Covered |
| F18.129 | ICD10CM | Covered |
| F18.14 | ICD10CM | Covered |
| F18.150 | ICD10CM | Covered |
| F18.151 | ICD10CM | Covered |
| F18.159 | ICD10CM | Covered |
| F18.17 | ICD10CM | Covered |
| F18.180 | ICD10CM | Covered |
| F18.188 | ICD10CM | Covered |
| F18.19 | ICD10CM | Covered |
| F18.20 | ICD10CM | Covered |
| F18.21 | ICD10CM | Covered |
| F18.220 | ICD10CM | Covered |
| F18.221 | ICD10CM | Covered |
| F18.229 | ICD10CM | Covered |
| F18.24 | ICD10CM | Covered |
| F18.250 | ICD10CM | Covered |
| F18.251 | ICD10CM | Covered |
| F18.259 | ICD10CM | Covered |
| F18.27 | ICD10CM | Covered |
| F18.280 | ICD10CM | Covered |
| F18.288 | ICD10CM | Covered |
| F18.29 | ICD10CM | Covered |
| F18.90 | ICD10CM | Covered |
| F18.920 | ICD10CM | Covered |
| F18.921 | ICD10CM | Covered |
| F18.929 | ICD10CM | Covered |
| F18.94 | ICD10CM | Covered |
| F18.950 | ICD10CM | Covered |
| F18.951 | ICD10CM | Covered |
| F18.959 | ICD10CM | Covered |
| F18.980 | ICD10CM | Covered |
| F18.988 | ICD10CM | Covered |
| F18.99 | ICD10CM | Covered |
| F19.10 | ICD10CM | Covered |
| F19.11 | ICD10CM | Covered |
| F19.120 | ICD10CM | Covered |
| F19.121 | ICD10CM | Covered |
| F19.122 | ICD10CM | Covered |
| F19.129 | ICD10CM | Covered |
| F19.130 | ICD10CM | Covered |
| F19.131 | ICD10CM | Covered |
| F19.132 | ICD10CM | Covered |
| F19.14 | ICD10CM | Covered |
| F19.150 | ICD10CM | Covered |
| F19.151 | ICD10CM | Covered |
| F19.159 | ICD10CM | Covered |
| F19.16 | ICD10CM | Covered |
| F19.17 | ICD10CM | Covered |
| F19.180 | ICD10CM | Covered |
| F19.181 | ICD10CM | Covered |
| F19.182 | ICD10CM | Covered |
| F19.188 | ICD10CM | Covered |
| F19.19 | ICD10CM | Covered |
| F19.20 | ICD10CM | Covered |
| F19.21 | ICD10CM | Covered |
| F19.220 | ICD10CM | Covered |
| F19.221 | ICD10CM | Covered |
| F19.222 | ICD10CM | Covered |
| F19.229 | ICD10CM | Covered |
| F19.230 | ICD10CM | Covered |
| F19.231 | ICD10CM | Covered |
| F19.232 | ICD10CM | Covered |
| F19.239 | ICD10CM | Covered |
| F19.24 | ICD10CM | Covered |
| F19.250 | ICD10CM | Covered |
| F19.251 | ICD10CM | Covered |
| F19.259 | ICD10CM | Covered |
| F19.26 | ICD10CM | Covered |
| F19.27 | ICD10CM | Covered |
| F19.280 | ICD10CM | Covered |
| F19.281 | ICD10CM | Covered |
| F19.282 | ICD10CM | Covered |
| F19.288 | ICD10CM | Covered |
| F19.29 | ICD10CM | Covered |
| F19.90 | ICD10CM | Covered |
| F19.920 | ICD10CM | Covered |
| F19.921 | ICD10CM | Covered |
| F19.922 | ICD10CM | Covered |
| F19.929 | ICD10CM | Covered |
| F19.930 | ICD10CM | Covered |
| F19.931 | ICD10CM | Covered |
| F19.932 | ICD10CM | Covered |
| F19.939 | ICD10CM | Covered |
| F19.94 | ICD10CM | Covered |
| F19.950 | ICD10CM | Covered |
| F19.951 | ICD10CM | Covered |
| F19.959 | ICD10CM | Covered |
| F19.96 | ICD10CM | Covered |
| F19.97 | ICD10CM | Covered |
| F19.980 | ICD10CM | Covered |
| F19.981 | ICD10CM | Covered |
| F19.982 | ICD10CM | Covered |
| F19.988 | ICD10CM | Covered |
| F19.99 | ICD10CM | Covered |
| F20.0 | ICD10CM | Covered |
| F20.1 | ICD10CM | Covered |
| F20.2 | ICD10CM | Covered |
| F20.3 | ICD10CM | Covered |
| F20.5 | ICD10CM | Covered |
| F20.81 | ICD10CM | Covered |
| F20.89 | ICD10CM | Covered |
| F20.9 | ICD10CM | Covered |
| F23 | ICD10CM | Covered |
| F25.0 | ICD10CM | Covered |
| F25.1 | ICD10CM | Covered |
| F25.8 | ICD10CM | Covered |
| F25.9 | ICD10CM | Covered |
| F28 | ICD10CM | Covered |
| F29 | ICD10CM | Covered |
| F30.10 | ICD10CM | Covered |
| F30.11 | ICD10CM | Covered |
| F30.12 | ICD10CM | Covered |
| F30.13 | ICD10CM | Covered |
| F30.2 | ICD10CM | Covered |
| F30.3 | ICD10CM | Covered |
| F30.4 | ICD10CM | Covered |
| F30.8 | ICD10CM | Covered |
| F30.9 | ICD10CM | Covered |
| F31.10 | ICD10CM | Covered |
| F31.11 | ICD10CM | Covered |
| F31.12 | ICD10CM | Covered |
| F31.13 | ICD10CM | Covered |
| F31.2 | ICD10CM | Covered |
| F31.30 | ICD10CM | Covered |
| F31.31 | ICD10CM | Covered |
| F31.32 | ICD10CM | Covered |
| F31.4 | ICD10CM | Covered |
| F31.5 | ICD10CM | Covered |
| F31.60 | ICD10CM | Covered |
| F31.61 | ICD10CM | Covered |
| F31.62 | ICD10CM | Covered |
| F31.63 | ICD10CM | Covered |
| F31.64 | ICD10CM | Covered |
| F31.70 | ICD10CM | Covered |
| F31.71 | ICD10CM | Covered |
| F31.72 | ICD10CM | Covered |
| F31.73 | ICD10CM | Covered |
| F31.74 | ICD10CM | Covered |
| F31.75 | ICD10CM | Covered |
| F31.76 | ICD10CM | Covered |
| F31.77 | ICD10CM | Covered |
| F31.78 | ICD10CM | Covered |
| F31.81 | ICD10CM | Covered |
| F31.89 | ICD10CM | Covered |
| F31.9 | ICD10CM | Covered |
| F32.0 | ICD10CM | Covered |
| F32.1 | ICD10CM | Covered |
| F32.2 | ICD10CM | Covered |
| F32.3 | ICD10CM | Covered |
| F32.4 | ICD10CM | Covered |
| F32.5 | ICD10CM | Covered |
| F32.81 | ICD10CM | Covered |
| F32.89 | ICD10CM | Covered |
| F32.9 | ICD10CM | Covered |
| F33.0 | ICD10CM | Covered |
| F33.1 | ICD10CM | Covered |
| F33.2 | ICD10CM | Covered |
| F33.3 | ICD10CM | Covered |
| F33.40 | ICD10CM | Covered |
| F33.41 | ICD10CM | Covered |
| F33.42 | ICD10CM | Covered |
| F33.8 | ICD10CM | Covered |
| F33.9 | ICD10CM | Covered |
| F34.0 | ICD10CM | Covered |
| F34.1 | ICD10CM | Covered |
| F34.81 | ICD10CM | Covered |
| F34.89 | ICD10CM | Covered |
| F34.9 | ICD10CM | Covered |
| F39 | ICD10CM | Covered |
| F43.0 | ICD10CM | Covered |
| F43.10 | ICD10CM | Covered |
| F43.11 | ICD10CM | Covered |
| F43.12 | ICD10CM | Covered |
| F43.20 | ICD10CM | Covered |
| F43.21 | ICD10CM | Covered |
| F43.22 | ICD10CM | Covered |
| F43.23 | ICD10CM | Covered |
| F43.24 | ICD10CM | Covered |
| F43.25 | ICD10CM | Covered |
| F43.29 | ICD10CM | Covered |
| F43.89 | ICD10CM | Covered |
| F43.9 | ICD10CM | Covered |
| F44.0 | ICD10CM | Covered |
| F44.1 | ICD10CM | Covered |
| F44.2 | ICD10CM | Covered |
| F44.4 | ICD10CM | Covered |
| F44.5 | ICD10CM | Covered |
| F44.6 | ICD10CM | Covered |
| F44.7 | ICD10CM | Covered |
| F44.81 | ICD10CM | Covered |
| F44.89 | ICD10CM | Covered |
| F44.9 | ICD10CM | Covered |
| F45.0 | ICD10CM | Covered |
| F45.1 | ICD10CM | Covered |
| F45.20 | ICD10CM | Covered |
| F45.21 | ICD10CM | Covered |
| F45.22 | ICD10CM | Covered |
| F45.29 | ICD10CM | Covered |
| F45.41 | ICD10CM | Covered |
| F45.42 | ICD10CM | Covered |
| F45.8 | ICD10CM | Covered |
| F45.9 | ICD10CM | Covered |
| F55.0 | ICD10CM | Covered |
| F55.1 | ICD10CM | Covered |
| F55.2 | ICD10CM | Covered |
| F55.3 | ICD10CM | Covered |
| F55.4 | ICD10CM | Covered |
| F55.8 | ICD10CM | Covered |
| F60.0 | ICD10CM | Covered |
| F60.1 | ICD10CM | Covered |
| F60.2 | ICD10CM | Covered |
| F60.3 | ICD10CM | Covered |
| F60.4 | ICD10CM | Covered |
| F60.5 | ICD10CM | Covered |
| F60.6 | ICD10CM | Covered |
| F60.7 | ICD10CM | Covered |
| F60.81 | ICD10CM | Covered |
| F60.89 | ICD10CM | Covered |
| F60.9 | ICD10CM | Covered |
| G40.001 | ICD10CM | Covered |
| G40.009 | ICD10CM | Covered |
| G40.011 | ICD10CM | Covered |
| G40.019 | ICD10CM | Covered |
| G40.101 | ICD10CM | Covered |
| G40.109 | ICD10CM | Covered |
| G40.111 | ICD10CM | Covered |
| G40.119 | ICD10CM | Covered |
| G40.201 | ICD10CM | Covered |
| G40.209 | ICD10CM | Covered |
| G40.211 | ICD10CM | Covered |
| G40.219 | ICD10CM | Covered |
| G40.301 | ICD10CM | Covered |
| G40.309 | ICD10CM | Covered |
| G40.311 | ICD10CM | Covered |
| G40.319 | ICD10CM | Covered |
| G40.401 | ICD10CM | Covered |
| G40.409 | ICD10CM | Covered |
| G40.411 | ICD10CM | Covered |
| G40.419 | ICD10CM | Covered |
| G40.501 | ICD10CM | Covered |
| G40.509 | ICD10CM | Covered |
| G40.801 | ICD10CM | Covered |
| G40.802 | ICD10CM | Covered |
| G40.803 | ICD10CM | Covered |
| G40.804 | ICD10CM | Covered |
| G40.811 | ICD10CM | Covered |
| G40.812 | ICD10CM | Covered |
| G40.813 | ICD10CM | Covered |
| G40.814 | ICD10CM | Covered |
| G40.821 | ICD10CM | Covered |
| G40.822 | ICD10CM | Covered |
| G40.823 | ICD10CM | Covered |
| G40.824 | ICD10CM | Covered |
| G40.89 | ICD10CM | Covered |
| G40.901 | ICD10CM | Covered |
| G40.909 | ICD10CM | Covered |
| G40.911 | ICD10CM | Covered |
| G40.919 | ICD10CM | Covered |
| G40.A01 | ICD10CM | Covered |
| G40.A09 | ICD10CM | Covered |
| G40.A11 | ICD10CM | Covered |
| G40.A19 | ICD10CM | Covered |
| G40.B01 | ICD10CM | Covered |
| G40.B09 | ICD10CM | Covered |
| G40.B11 | ICD10CM | Covered |
| G40.B19 | ICD10CM | Covered |
| I44.0 | ICD10CM | Covered |
| I44.1 | ICD10CM | Covered |
| I44.2 | ICD10CM | Covered |
| I44.30 | ICD10CM | Covered |
| I45.81 | ICD10CM | Covered |
| I47.0 | ICD10CM | Covered |
| I47.11 | ICD10CM | Covered |
| I47.19 | ICD10CM | Covered |
| I47.21 | ICD10CM | Covered |
| I47.29 | ICD10CM | Covered |
| I49.2 | ICD10CM | Covered |
| M25.50 | ICD10CM | Covered |
| M25.59 | ICD10CM | Covered |
| M47.811 | ICD10CM | Covered |
| M47.812 | ICD10CM | Covered |
| M47.813 | ICD10CM | Covered |
| M47.816 | ICD10CM | Covered |
| M47.817 | ICD10CM | Covered |
| M47.818 | ICD10CM | Covered |
| M51.14 | ICD10CM | Covered |
| M51.15 | ICD10CM | Covered |
| M51.16 | ICD10CM | Covered |
| M51.17 | ICD10CM | Covered |
| M51.360 | ICD10CM | Covered |
| M51.361 | ICD10CM | Covered |
| M51.362 | ICD10CM | Covered |
| M51.369 | ICD10CM | Covered |
| M51.370 | ICD10CM | Covered |
| M51.371 | ICD10CM | Covered |
| M51.372 | ICD10CM | Covered |
| M51.379 | ICD10CM | Covered |
| M54.10 | ICD10CM | Covered |
| M54.14 | ICD10CM | Covered |
| M54.15 | ICD10CM | Covered |
| M54.16 | ICD10CM | Covered |
| M54.17 | ICD10CM | Covered |
| M54.18 | ICD10CM | Covered |
| M54.2 | ICD10CM | Covered |
| M54.50 | ICD10CM | Covered |
| M54.51 | ICD10CM | Covered |
| M54.59 | ICD10CM | Covered |
| M60.811 | ICD10CM | Covered |
| M60.812 | ICD10CM | Covered |
| M60.821 | ICD10CM | Covered |
| M60.822 | ICD10CM | Covered |
| M60.831 | ICD10CM | Covered |
| M60.832 | ICD10CM | Covered |
| M60.841 | ICD10CM | Covered |
| M60.842 | ICD10CM | Covered |
| M60.851 | ICD10CM | Covered |
| M60.852 | ICD10CM | Covered |
| M60.861 | ICD10CM | Covered |
| M60.862 | ICD10CM | Covered |
| M60.871 | ICD10CM | Covered |
| M60.872 | ICD10CM | Covered |
| M60.88 | ICD10CM | Covered |
| M60.89 | ICD10CM | Covered |
| M79.11 | ICD10CM | Covered |
| M79.12 | ICD10CM | Covered |
| M79.18 | ICD10CM | Covered |
| M79.2 | ICD10CM | Covered |
| M79.7 | ICD10CM | Covered |
| R40.0 | ICD10CM | Covered |
| R40.1 | ICD10CM | Covered |
| R40.2111 | ICD10CM | Covered |
| R40.2112 | ICD10CM | Covered |
| R40.2113 | ICD10CM | Covered |
| R40.2114 | ICD10CM | Covered |
| R40.2121 | ICD10CM | Covered |
| R40.2122 | ICD10CM | Covered |
| R40.2123 | ICD10CM | Covered |
| R40.2124 | ICD10CM | Covered |
| R40.2131 | ICD10CM | Covered |
| R40.2132 | ICD10CM | Covered |
| R40.2133 | ICD10CM | Covered |
| R40.2134 | ICD10CM | Covered |
| R40.2141 | ICD10CM | Covered |
| R40.2142 | ICD10CM | Covered |
| R40.2143 | ICD10CM | Covered |
| R40.2144 | ICD10CM | Covered |
| R40.2211 | ICD10CM | Covered |
| R40.2212 | ICD10CM | Covered |
| R40.2213 | ICD10CM | Covered |
| R40.2214 | ICD10CM | Covered |
| R40.2221 | ICD10CM | Covered |
| R40.2222 | ICD10CM | Covered |
| R40.2223 | ICD10CM | Covered |
| R40.2224 | ICD10CM | Covered |
| R40.2231 | ICD10CM | Covered |
| R40.2232 | ICD10CM | Covered |
| R40.2233 | ICD10CM | Covered |
| R40.2234 | ICD10CM | Covered |
| R40.2241 | ICD10CM | Covered |
| R40.2242 | ICD10CM | Covered |
| R40.2243 | ICD10CM | Covered |
| R40.2244 | ICD10CM | Covered |
| R40.2251 | ICD10CM | Covered |
| R40.2252 | ICD10CM | Covered |
| R40.2253 | ICD10CM | Covered |
| R40.2254 | ICD10CM | Covered |
| R40.2311 | ICD10CM | Covered |
| R40.2312 | ICD10CM | Covered |
| R40.2313 | ICD10CM | Covered |
| R40.2314 | ICD10CM | Covered |
| R40.2321 | ICD10CM | Covered |
| R40.2322 | ICD10CM | Covered |
| R40.2323 | ICD10CM | Covered |
| R40.2324 | ICD10CM | Covered |
| R40.2331 | ICD10CM | Covered |
| R40.2332 | ICD10CM | Covered |
| R40.2333 | ICD10CM | Covered |
| R40.2334 | ICD10CM | Covered |
| R40.2341 | ICD10CM | Covered |
| R40.2342 | ICD10CM | Covered |
| R40.2343 | ICD10CM | Covered |
| R40.2344 | ICD10CM | Covered |
| R40.2351 | ICD10CM | Covered |
| R40.2352 | ICD10CM | Covered |
| R40.2353 | ICD10CM | Covered |
| R40.2354 | ICD10CM | Covered |
| R40.2361 | ICD10CM | Covered |
| R40.2362 | ICD10CM | Covered |
| R40.2363 | ICD10CM | Covered |
| R40.2364 | ICD10CM | Covered |
| R40.2410 | ICD10CM | Covered |
| R40.2411 | ICD10CM | Covered |
| R40.2412 | ICD10CM | Covered |
| R40.2413 | ICD10CM | Covered |
| R40.2414 | ICD10CM | Covered |
| R40.2420 | ICD10CM | Covered |
| R40.2421 | ICD10CM | Covered |
| R40.2422 | ICD10CM | Covered |
| R40.2423 | ICD10CM | Covered |
| R40.2424 | ICD10CM | Covered |
| R40.2430 | ICD10CM | Covered |
| R40.2431 | ICD10CM | Covered |
| R40.2432 | ICD10CM | Covered |
| R40.2433 | ICD10CM | Covered |
| R40.2434 | ICD10CM | Covered |
| R40.2440 | ICD10CM | Covered |
| R40.2441 | ICD10CM | Covered |
| R40.2442 | ICD10CM | Covered |
| R40.2443 | ICD10CM | Covered |
| R40.2444 | ICD10CM | Covered |
| R40.2A | ICD10CM | Covered |
| R41.0 | ICD10CM | Covered |
| R41.82 | ICD10CM | Covered |
| R41.85 | ICD10CM | Covered |
| R44.0 | ICD10CM | Covered |
| R44.3 | ICD10CM | Covered |
| R56.00 | ICD10CM | Covered |
| R56.01 | ICD10CM | Covered |
| R56.1 | ICD10CM | Covered |
| R56.9 | ICD10CM | Covered |
| T39.011A | ICD10CM | Covered |
| T39.011D | ICD10CM | Covered |
| T39.012A | ICD10CM | Covered |
| T39.012D | ICD10CM | Covered |
| T39.013A | ICD10CM | Covered |
| T39.013D | ICD10CM | Covered |
| T39.014A | ICD10CM | Covered |
| T39.014D | ICD10CM | Covered |
| T39.015A | ICD10CM | Covered |
| T39.015D | ICD10CM | Covered |
| T39.016A | ICD10CM | Covered |
| T39.016D | ICD10CM | Covered |
| T39.091A | ICD10CM | Covered |
| T39.091D | ICD10CM | Covered |
| T39.092A | ICD10CM | Covered |
| T39.092D | ICD10CM | Covered |
| T39.093A | ICD10CM | Covered |
| T39.093D | ICD10CM | Covered |
| T39.094A | ICD10CM | Covered |
| T39.094D | ICD10CM | Covered |
| T39.095A | ICD10CM | Covered |
| T39.095D | ICD10CM | Covered |
| T39.096A | ICD10CM | Covered |
| T39.096D | ICD10CM | Covered |
| T39.1X1A | ICD10CM | Covered |
| T39.1X1D | ICD10CM | Covered |
| T39.1X2A | ICD10CM | Covered |
| T39.1X2D | ICD10CM | Covered |
| T39.1X3A | ICD10CM | Covered |
| T39.1X3D | ICD10CM | Covered |
| T39.1X4A | ICD10CM | Covered |
| T39.1X4D | ICD10CM | Covered |
| T39.1X5A | ICD10CM | Covered |
| T39.1X5D | ICD10CM | Covered |
| T39.1X6A | ICD10CM | Covered |
| T39.1X6D | ICD10CM | Covered |
| T39.2X1A | ICD10CM | Covered |
| T39.2X1D | ICD10CM | Covered |
| T39.2X2A | ICD10CM | Covered |
| T39.2X2D | ICD10CM | Covered |
| T39.2X3A | ICD10CM | Covered |
| T39.2X3D | ICD10CM | Covered |
| T39.2X4A | ICD10CM | Covered |
| T39.2X4D | ICD10CM | Covered |
| T39.2X5A | ICD10CM | Covered |
| T39.2X5D | ICD10CM | Covered |
| T39.311A | ICD10CM | Covered |
| T39.311D | ICD10CM | Covered |
| T39.312A | ICD10CM | Covered |
| T39.312D | ICD10CM | Covered |
| T39.313A | ICD10CM | Covered |
| T39.313D | ICD10CM | Covered |
| T39.314A | ICD10CM | Covered |
| T39.314D | ICD10CM | Covered |
| T39.315A | ICD10CM | Covered |
| T39.315D | ICD10CM | Covered |
| T39.316A | ICD10CM | Covered |
| T39.316D | ICD10CM | Covered |
| T39.391A | ICD10CM | Covered |
| T39.391D | ICD10CM | Covered |
| T39.392A | ICD10CM | Covered |
| T39.392D | ICD10CM | Covered |
| T39.393A | ICD10CM | Covered |
| T39.393D | ICD10CM | Covered |
| T39.394A | ICD10CM | Covered |
| T39.394D | ICD10CM | Covered |
| T39.395A | ICD10CM | Covered |
| T39.395D | ICD10CM | Covered |
| T39.396A | ICD10CM | Covered |
| T39.396D | ICD10CM | Covered |
| T40.0X1A | ICD10CM | Covered |
| T40.0X1D | ICD10CM | Covered |
| T40.0X2A | ICD10CM | Covered |
| T40.0X2D | ICD10CM | Covered |
| T40.0X3A | ICD10CM | Covered |
| T40.0X3D | ICD10CM | Covered |
| T40.0X4A | ICD10CM | Covered |
| T40.0X4D | ICD10CM | Covered |
| T40.0X5A | ICD10CM | Covered |
| T40.0X5D | ICD10CM | Covered |
| T40.0X6A | ICD10CM | Covered |
| T40.0X6D | ICD10CM | Covered |
| T40.1X1A | ICD10CM | Covered |
| T40.1X1D | ICD10CM | Covered |
| T40.1X2A | ICD10CM | Covered |
| T40.1X2D | ICD10CM | Covered |
| T40.1X3A | ICD10CM | Covered |
| T40.1X3D | ICD10CM | Covered |
| T40.1X4A | ICD10CM | Covered |
| T40.1X4D | ICD10CM | Covered |
| T40.2X1A | ICD10CM | Covered |
| T40.2X1D | ICD10CM | Covered |
| T40.2X2A | ICD10CM | Covered |
| T40.2X2D | ICD10CM | Covered |
| T40.2X3A | ICD10CM | Covered |
| T40.2X3D | ICD10CM | Covered |
| T40.2X4A | ICD10CM | Covered |
| T40.2X4D | ICD10CM | Covered |
| T40.2X5A | ICD10CM | Covered |
| T40.2X5D | ICD10CM | Covered |
| T40.2X6A | ICD10CM | Covered |
| T40.2X6D | ICD10CM | Covered |
| T40.3X1A | ICD10CM | Covered |
| T40.3X1D | ICD10CM | Covered |
| T40.3X2A | ICD10CM | Covered |
| T40.3X2D | ICD10CM | Covered |
| T40.3X3A | ICD10CM | Covered |
| T40.3X3D | ICD10CM | Covered |
| T40.3X4A | ICD10CM | Covered |
| T40.3X4D | ICD10CM | Covered |
| T40.3X5A | ICD10CM | Covered |
| T40.3X5D | ICD10CM | Covered |
| T40.3X6A | ICD10CM | Covered |
| T40.3X6D | ICD10CM | Covered |
| T40.491A | ICD10CM | Covered |
| T40.491D | ICD10CM | Covered |
| T40.492A | ICD10CM | Covered |
| T40.492D | ICD10CM | Covered |
| T40.493A | ICD10CM | Covered |
| T40.493D | ICD10CM | Covered |
| T40.494A | ICD10CM | Covered |
| T40.494D | ICD10CM | Covered |
| T40.495A | ICD10CM | Covered |
| T40.495D | ICD10CM | Covered |
| T40.496A | ICD10CM | Covered |
| T40.496D | ICD10CM | Covered |
| T40.5X1A | ICD10CM | Covered |
| T40.5X1D | ICD10CM | Covered |
| T40.5X2A | ICD10CM | Covered |
| T40.5X2D | ICD10CM | Covered |
| T40.5X3A | ICD10CM | Covered |
| T40.5X3D | ICD10CM | Covered |
| T40.5X4A | ICD10CM | Covered |
| T40.5X4D | ICD10CM | Covered |
| T40.5X5A | ICD10CM | Covered |
| T40.5X5D | ICD10CM | Covered |
| T40.5X6A | ICD10CM | Covered |
| T40.5X6D | ICD10CM | Covered |
| T40.601A | ICD10CM | Covered |
| T40.601D | ICD10CM | Covered |
| T40.602A | ICD10CM | Covered |
| T40.602D | ICD10CM | Covered |
| T40.603A | ICD10CM | Covered |
| T40.603D | ICD10CM | Covered |
| T40.604A | ICD10CM | Covered |
| T40.604D | ICD10CM | Covered |
| T40.605A | ICD10CM | Covered |
| T40.605D | ICD10CM | Covered |
| T40.606A | ICD10CM | Covered |
| T40.606D | ICD10CM | Covered |
| T40.691A | ICD10CM | Covered |
| T40.691D | ICD10CM | Covered |
| T40.692A | ICD10CM | Covered |
| T40.692D | ICD10CM | Covered |
| T40.693A | ICD10CM | Covered |
| T40.693D | ICD10CM | Covered |
| T40.694A | ICD10CM | Covered |
| T40.694D | ICD10CM | Covered |
| T40.695A | ICD10CM | Covered |
| T40.695D | ICD10CM | Covered |
| T40.696A | ICD10CM | Covered |
| T40.696D | ICD10CM | Covered |
| T40.711A | ICD10CM | Covered |
| T40.711D | ICD10CM | Covered |
| T40.712A | ICD10CM | Covered |
| T40.712D | ICD10CM | Covered |
| T40.713A | ICD10CM | Covered |
| T40.713D | ICD10CM | Covered |
| T40.714A | ICD10CM | Covered |
| T40.714D | ICD10CM | Covered |
| T40.715A | ICD10CM | Covered |
| T40.715D | ICD10CM | Covered |
| T40.716A | ICD10CM | Covered |
| T40.716D | ICD10CM | Covered |
| T40.721A | ICD10CM | Covered |
| T40.721D | ICD10CM | Covered |
| T40.722A | ICD10CM | Covered |
| T40.722D | ICD10CM | Covered |
| T40.723A | ICD10CM | Covered |
| T40.723D | ICD10CM | Covered |
| T40.724A | ICD10CM | Covered |
| T40.724D | ICD10CM | Covered |
| T40.725A | ICD10CM | Covered |
| T40.725D | ICD10CM | Covered |
| T40.726A | ICD10CM | Covered |
| T40.726D | ICD10CM | Covered |
| T40.8X1A | ICD10CM | Covered |
| T40.8X1D | ICD10CM | Covered |
| T40.8X2A | ICD10CM | Covered |
| T40.8X2D | ICD10CM | Covered |
| T40.8X3A | ICD10CM | Covered |
| T40.8X4A | ICD10CM | Covered |
| T40.8X4D | ICD10CM | Covered |
| T40.901A | ICD10CM | Covered |
| T40.901D | ICD10CM | Covered |
| T40.902A | ICD10CM | Covered |
| T40.902D | ICD10CM | Covered |
| T40.903A | ICD10CM | Covered |
| T40.903D | ICD10CM | Covered |
| T40.904A | ICD10CM | Covered |
| T40.904D | ICD10CM | Covered |
| T40.905A | ICD10CM | Covered |
| T40.905D | ICD10CM | Covered |
| T40.906A | ICD10CM | Covered |
| T40.906D | ICD10CM | Covered |
| T40.991A | ICD10CM | Covered |
| T40.991D | ICD10CM | Covered |
| T40.992A | ICD10CM | Covered |
| T40.992D | ICD10CM | Covered |
| T40.993A | ICD10CM | Covered |
| T40.993D | ICD10CM | Covered |
| T40.994A | ICD10CM | Covered |
| T40.994D | ICD10CM | Covered |
| T40.995A | ICD10CM | Covered |
| T40.995D | ICD10CM | Covered |
| T40.996A | ICD10CM | Covered |
| T40.996D | ICD10CM | Covered |
| T42.0X1A | ICD10CM | Covered |
| T42.0X1D | ICD10CM | Covered |
| T42.0X2A | ICD10CM | Covered |
| T42.0X2D | ICD10CM | Covered |
| T42.0X3A | ICD10CM | Covered |
| T42.0X3D | ICD10CM | Covered |
| T42.0X4A | ICD10CM | Covered |
| T42.0X4D | ICD10CM | Covered |
| T42.0X5A | ICD10CM | Covered |
| T42.0X5D | ICD10CM | Covered |
| T42.0X6A | ICD10CM | Covered |
| T42.0X6D | ICD10CM | Covered |
| T42.3X1A | ICD10CM | Covered |
| T42.3X1D | ICD10CM | Covered |
| T42.3X2A | ICD10CM | Covered |
| T42.3X2D | ICD10CM | Covered |
| T42.3X3A | ICD10CM | Covered |
| T42.3X3D | ICD10CM | Covered |
| T42.3X4A | ICD10CM | Covered |
| T42.3X4D | ICD10CM | Covered |
| T42.3X5A | ICD10CM | Covered |
| T42.3X5D | ICD10CM | Covered |
| T42.3X6A | ICD10CM | Covered |
| T42.3X6D | ICD10CM | Covered |
| T42.4X1A | ICD10CM | Covered |
| T42.4X1D | ICD10CM | Covered |
| T42.4X2A | ICD10CM | Covered |
| T42.4X2D | ICD10CM | Covered |
| T42.4X3A | ICD10CM | Covered |
| T42.4X3D | ICD10CM | Covered |
| T42.4X4A | ICD10CM | Covered |
| T42.4X4D | ICD10CM | Covered |
| T42.4X5A | ICD10CM | Covered |
| T42.4X5D | ICD10CM | Covered |