About this policy
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) Cosmetic and Reconstructive Surgery L33428.
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 |
|---|---|---|
| 15730 | HCPCS | Covered |
| 15733 | HCPCS | Covered |
| 15780 | HCPCS | Covered |
| 15781 | HCPCS | Covered |
| 15782 | HCPCS | Covered |
| 15783 | HCPCS | Covered |
| 15830 | HCPCS | Covered |
| 15847 | HCPCS | Covered |
| 19316 | HCPCS | Covered |
| 19318 | HCPCS | Covered |
| 19325 | HCPCS | Covered |
| 19328 | HCPCS | Covered |
| 19330 | HCPCS | Covered |
| 19340 | HCPCS | Covered |
| 19342 | HCPCS | Covered |
| 19350 | HCPCS | Covered |
| 19355 | HCPCS | Covered |
| 19357 | HCPCS | Covered |
| 19361 | HCPCS | Covered |
| 19364 | HCPCS | Covered |
| 19367 | HCPCS | Covered |
| 19368 | HCPCS | Covered |
| 19369 | HCPCS | Covered |
| 19370 | HCPCS | Covered |
| 19371 | HCPCS | Covered |
| 19380 | HCPCS | Covered |
| 19396 | HCPCS | Covered |
| 20912 | HCPCS | Covered |
| 21076 | HCPCS | Covered |
| 21077 | HCPCS | Covered |
| 21079 | HCPCS | Covered |
| 21080 | HCPCS | Covered |
| 21081 | HCPCS | Covered |
| 21082 | HCPCS | Covered |
| 21083 | HCPCS | Covered |
| 21084 | HCPCS | Covered |
| 21086 | HCPCS | Covered |
| 21087 | HCPCS | Covered |
| 21088 | HCPCS | Covered |
| 21089 | HCPCS | Covered |
| 21120 | HCPCS | Covered |
| 21121 | HCPCS | Covered |
| 21122 | HCPCS | Covered |
| 21123 | HCPCS | Covered |
| 21125 | HCPCS | Covered |
| 21127 | HCPCS | Covered |
| 21137 | HCPCS | Covered |
| 21138 | HCPCS | Covered |
| 21139 | HCPCS | Covered |
| 21141 | HCPCS | Covered |
| 21142 | HCPCS | Covered |
| 21143 | HCPCS | Covered |
| 21145 | HCPCS | Covered |
| 21146 | HCPCS | Covered |
| 21147 | HCPCS | Covered |
| 21150 | HCPCS | Covered |
| 21151 | HCPCS | Covered |
| 21154 | HCPCS | Covered |
| 21155 | HCPCS | Covered |
| 21159 | HCPCS | Covered |
| 21160 | HCPCS | Covered |
| 21172 | HCPCS | Covered |
| 21175 | HCPCS | Covered |
| 21179 | HCPCS | Covered |
| 21180 | HCPCS | Covered |
| 21181 | HCPCS | Covered |
| 21182 | HCPCS | Covered |
| 21183 | HCPCS | Covered |
| 21184 | HCPCS | Covered |
| 21188 | HCPCS | Covered |
| 21193 | HCPCS | Covered |
| 21194 | HCPCS | Covered |
| 21195 | HCPCS | Covered |
| 21196 | HCPCS | Covered |
| 21198 | HCPCS | Covered |
| 21199 | HCPCS | Covered |
| 21206 | HCPCS | Covered |
| 21208 | HCPCS | Covered |
| 21209 | HCPCS | Covered |
| 21210 | HCPCS | Covered |
| 21215 | HCPCS | Covered |
| 21230 | HCPCS | Covered |
| 21235 | HCPCS | Covered |
| 21240 | HCPCS | Covered |
| 21242 | HCPCS | Covered |
| 21243 | HCPCS | Covered |
| 21244 | HCPCS | Covered |
| 21245 | HCPCS | Covered |
| 21246 | HCPCS | Covered |
| 21247 | HCPCS | Covered |
| 21248 | HCPCS | Covered |
| 21249 | HCPCS | Covered |
| 21255 | HCPCS | Covered |
| 21256 | HCPCS | Covered |
| 21260 | HCPCS | Covered |
| 21261 | HCPCS | Covered |
| 21263 | HCPCS | Covered |
| 21267 | HCPCS | Covered |
| 21268 | HCPCS | Covered |
| 21270 | HCPCS | Covered |
| 21275 | HCPCS | Covered |
| 21280 | HCPCS | Covered |
| 21282 | HCPCS | Covered |
| 21295 | HCPCS | Covered |
| 21296 | HCPCS | Covered |
| 21299 | HCPCS | Covered |
| 30400 | HCPCS | Covered |
| 30410 | HCPCS | Covered |
| 30420 | HCPCS | Covered |
| 30430 | HCPCS | Covered |
| 30435 | HCPCS | Covered |
| 30450 | HCPCS | Covered |
| 30460 | HCPCS | Covered |
| 30462 | HCPCS | Covered |
| 30465 | HCPCS | Covered |
| 30468 | HCPCS | Covered |
| C00.0 | ICD10CM | Covered |
| C00.1 | ICD10CM | Covered |
| C00.3 | ICD10CM | Covered |
| C00.4 | ICD10CM | Covered |
| C00.5 | ICD10CM | Covered |
| C00.6 | ICD10CM | Covered |
| C00.8 | ICD10CM | Covered |
| C01 | ICD10CM | Covered |
| C02.0 | ICD10CM | Covered |
| C02.1 | ICD10CM | Covered |
| C02.2 | ICD10CM | Covered |
| C02.8 | ICD10CM | Covered |
| C03.0 | ICD10CM | Covered |
| C03.1 | ICD10CM | Covered |
| C04.0 | ICD10CM | Covered |
| C04.1 | ICD10CM | Covered |
| C04.8 | ICD10CM | Covered |
| C05.0 | ICD10CM | Covered |
| C05.1 | ICD10CM | Covered |
| C05.2 | ICD10CM | Covered |
| C05.8 | ICD10CM | Covered |
| C06.0 | ICD10CM | Covered |
| C06.1 | ICD10CM | Covered |
| C06.2 | ICD10CM | Covered |
| C06.80 | ICD10CM | Covered |
| C06.89 | ICD10CM | Covered |
| C07 | ICD10CM | Covered |
| C08.0 | ICD10CM | Covered |
| C08.1 | ICD10CM | Covered |
| C08.9 | ICD10CM | Covered |
| C09.0 | ICD10CM | Covered |
| C09.1 | ICD10CM | Covered |
| C09.8 | ICD10CM | Covered |
| C10.0 | ICD10CM | Covered |
| C10.1 | ICD10CM | Covered |
| C10.2 | ICD10CM | Covered |
| C10.3 | ICD10CM | Covered |
| C10.4 | ICD10CM | Covered |
| C10.8 | ICD10CM | Covered |
| C11.0 | ICD10CM | Covered |
| C11.1 | ICD10CM | Covered |
| C11.2 | ICD10CM | Covered |
| C11.3 | ICD10CM | Covered |
| C11.8 | ICD10CM | Covered |
| C12 | ICD10CM | Covered |
| C13.0 | ICD10CM | Covered |
| C13.1 | ICD10CM | Covered |
| C13.2 | ICD10CM | Covered |
| C13.8 | ICD10CM | Covered |
| C14.0 | ICD10CM | Covered |
| C14.2 | ICD10CM | Covered |
| C14.8 | ICD10CM | Covered |
| C30.0 | ICD10CM | Covered |
| C30.1 | ICD10CM | Covered |
| C31.0 | ICD10CM | Covered |
| C31.1 | ICD10CM | Covered |
| C31.2 | ICD10CM | Covered |
| C31.3 | ICD10CM | Covered |
| C31.8 | ICD10CM | Covered |
| C31.9 | ICD10CM | Covered |
| C32.0 | ICD10CM | Covered |
| C32.1 | ICD10CM | Covered |
| C32.2 | ICD10CM | Covered |
| C32.3 | ICD10CM | Covered |
| C32.8 | ICD10CM | Covered |
| C32.9 | ICD10CM | Covered |
| C41.0 | ICD10CM | Covered |
| C41.1 | ICD10CM | Covered |
| C43.0 | ICD10CM | Covered |
| C43.111 | ICD10CM | Covered |
| C43.112 | ICD10CM | Covered |
| C43.121 | ICD10CM | Covered |
| C43.122 | ICD10CM | Covered |
| C43.21 | ICD10CM | Covered |
| C43.22 | ICD10CM | Covered |
| C43.30 | ICD10CM | Covered |
| C43.31 | ICD10CM | Covered |
| C43.39 | ICD10CM | Covered |
| C43.4 | ICD10CM | Covered |
| C43.8 | ICD10CM | Covered |
| C44.1021 | ICD10CM | Covered |
| C44.1022 | ICD10CM | Covered |
| C44.1091 | ICD10CM | Covered |
| C44.1092 | ICD10CM | Covered |
| C44.1121 | ICD10CM | Covered |
| C44.1122 | ICD10CM | Covered |
| C44.1191 | ICD10CM | Covered |
| C44.1192 | ICD10CM | Covered |
| C44.1221 | ICD10CM | Covered |
| C44.1222 | ICD10CM | Covered |
| C44.1291 | ICD10CM | Covered |
| C44.1292 | ICD10CM | Covered |
| C44.1321 | ICD10CM | Covered |
| C44.1322 | ICD10CM | Covered |
| C44.1391 | ICD10CM | Covered |
| C44.1392 | ICD10CM | Covered |
| C44.1921 | ICD10CM | Covered |
| C44.1922 | ICD10CM | Covered |
| C44.1991 | ICD10CM | Covered |
| C44.1992 | ICD10CM | Covered |
| C44.212 | ICD10CM | Covered |
| C44.219 | ICD10CM | Covered |
| C44.222 | ICD10CM | Covered |
| C44.229 | ICD10CM | Covered |
| C44.300 | ICD10CM | Covered |
| C44.301 | ICD10CM | Covered |
| C44.309 | ICD10CM | Covered |
| C44.310 | ICD10CM | Covered |
| C44.311 | ICD10CM | Covered |
| C44.319 | ICD10CM | Covered |
| C44.320 | ICD10CM | Covered |
| C44.321 | ICD10CM | Covered |
| C44.329 | ICD10CM | Covered |
| C44.390 | ICD10CM | Covered |
| C44.391 | ICD10CM | Covered |
| C44.399 | ICD10CM | Covered |
| C44.42 | ICD10CM | Covered |
| C44.511 | ICD10CM | Covered |
| C44.521 | ICD10CM | Covered |
| C44.591 | ICD10CM | Covered |
| C47.0 | ICD10CM | Covered |
| C49.0 | ICD10CM | Covered |
| C4A.111 | ICD10CM | Covered |
| C4A.112 | ICD10CM | Covered |
| C4A.121 | ICD10CM | Covered |
| C4A.122 | ICD10CM | Covered |
| C4A.21 | ICD10CM | Covered |
| C4A.22 | ICD10CM | Covered |
| C50.011 | ICD10CM | Covered |
| C50.012 | ICD10CM | Covered |
| C50.021 | ICD10CM | Covered |
| C50.022 | ICD10CM | Covered |
| C50.111 | ICD10CM | Covered |
| C50.112 | ICD10CM | Covered |
| C50.121 | ICD10CM | Covered |
| C50.122 | ICD10CM | Covered |
| C50.211 | ICD10CM | Covered |
| C50.212 | ICD10CM | Covered |
| C50.221 | ICD10CM | Covered |
| C50.222 | ICD10CM | Covered |
| C50.311 | ICD10CM | Covered |
| C50.312 | ICD10CM | Covered |
| C50.321 | ICD10CM | Covered |
| C50.322 | ICD10CM | Covered |
| C50.411 | ICD10CM | Covered |
| C50.412 | ICD10CM | Covered |
| C50.421 | ICD10CM | Covered |
| C50.422 | ICD10CM | Covered |
| C50.511 | ICD10CM | Covered |
| C50.512 | ICD10CM | Covered |
| C50.521 | ICD10CM | Covered |
| C50.522 | ICD10CM | Covered |
| C50.611 | ICD10CM | Covered |
| C50.612 | ICD10CM | Covered |
| C50.621 | ICD10CM | Covered |
| C50.622 | ICD10CM | Covered |
| C50.811 | ICD10CM | Covered |
| C50.812 | ICD10CM | Covered |
| C50.821 | ICD10CM | Covered |
| C50.822 | ICD10CM | Covered |
| C50.911 | ICD10CM | Covered |
| C50.912 | ICD10CM | Covered |
| C50.921 | ICD10CM | Covered |
| C50.922 | ICD10CM | Covered |
| C69.51 | ICD10CM | Covered |
| C69.52 | ICD10CM | Covered |
| C69.61 | ICD10CM | Covered |
| C69.62 | ICD10CM | Covered |
| C76.0 | ICD10CM | Covered |
| C79.2 | ICD10CM | Covered |
| C79.81 | ICD10CM | Covered |
| C83.11 | ICD10CM | Covered |
| C83.31 | ICD10CM | Covered |
| C83.398 | ICD10CM | Covered |
| C83.81 | ICD10CM | Covered |
| C84.41 | ICD10CM | Covered |
| C84.4A | ICD10CM | Covered |
| C84.61 | ICD10CM | Covered |
| C84.6A | ICD10CM | Covered |
| C84.71 | ICD10CM | Covered |
| C84.7A | ICD10CM | Covered |
| C84.7B | ICD10CM | Covered |
| C85.21 | ICD10CM | Covered |
| C85.2A | ICD10CM | Covered |
| D03.0 | ICD10CM | Covered |
| D03.111 | ICD10CM | Covered |
| D03.112 | ICD10CM | Covered |
| D03.121 | ICD10CM | Covered |
| D03.122 | ICD10CM | Covered |
| D03.21 | ICD10CM | Covered |
| D03.22 | ICD10CM | Covered |
| D03.30 | ICD10CM | Covered |
| D03.39 | ICD10CM | Covered |
| D03.4 | ICD10CM | Covered |
| D03.8 | ICD10CM | Covered |
| D04.111 | ICD10CM | Covered |
| D04.112 | ICD10CM | Covered |
| D04.121 | ICD10CM | Covered |
| D04.122 | ICD10CM | Covered |
| D04.21 | ICD10CM | Covered |
| D04.22 | ICD10CM | Covered |
| D04.30 | ICD10CM | Covered |
| D04.39 | ICD10CM | Covered |
| D04.5 | ICD10CM | Covered |
| D05.01 | ICD10CM | Covered |
| D05.02 | ICD10CM | Covered |
| D05.11 | ICD10CM | Covered |
| D05.12 | ICD10CM | Covered |
| D05.81 | ICD10CM | Covered |
| D05.82 | ICD10CM | Covered |
| D05.91 | ICD10CM | Covered |
| D05.92 | ICD10CM | Covered |
| D09.21 | ICD10CM | Covered |
| D09.22 | ICD10CM | Covered |
| D10.1 | ICD10CM | Covered |
| D10.2 | ICD10CM | Covered |
| D10.39 | ICD10CM | Covered |
| D10.4 | ICD10CM | Covered |
| D10.5 | ICD10CM | Covered |
| D10.6 | ICD10CM | Covered |
| D10.7 | ICD10CM | Covered |
| D11.0 | ICD10CM | Covered |
| D11.7 | ICD10CM | Covered |
| D11.9 | ICD10CM | Covered |
| D14.0 | ICD10CM | Covered |
| D16.4 | ICD10CM | Covered |
| D22.0 | ICD10CM | Covered |
| D22.30 | ICD10CM | Covered |
| D22.39 | ICD10CM | Covered |
| D22.5 | ICD10CM | Covered |
| D23.0 | ICD10CM | Covered |
| D23.111 | ICD10CM | Covered |
| D23.112 | ICD10CM | Covered |
| D23.121 | ICD10CM | Covered |
| D23.122 | ICD10CM | Covered |
| D23.30 | ICD10CM | Covered |
| D23.39 | ICD10CM | Covered |
| D23.5 | ICD10CM | Covered |
| D24.1 | ICD10CM | Covered |
| D24.2 | ICD10CM | Covered |
| D31.61 | ICD10CM | Covered |
| D31.62 | ICD10CM | Covered |
| D43.3 | ICD10CM | Covered |
| D43.8 | ICD10CM | Covered |
| D48.61 | ICD10CM | Covered |
| D48.62 | ICD10CM | Covered |
| H05.021 | ICD10CM | Covered |
| H05.022 | ICD10CM | Covered |
| H05.023 | ICD10CM | Covered |
| H05.30 | ICD10CM | Covered |
| H05.51 | ICD10CM | Covered |
| H05.52 | ICD10CM | Covered |
| H05.53 | ICD10CM | Covered |
| H05.831 | ICD10CM | Covered |
| H05.832 | ICD10CM | Covered |
| H05.833 | ICD10CM | Covered |
| H05.89 | ICD10CM | Covered |
| H44.89 | ICD10CM | Covered |
| H72.01 | ICD10CM | Covered |
| H72.02 | ICD10CM | Covered |
| H72.03 | ICD10CM | Covered |
| H72.2X1 | ICD10CM | Covered |
| H72.2X2 | ICD10CM | Covered |
| H72.2X3 | ICD10CM | Covered |
| J32.0 | ICD10CM | Covered |
| J32.1 | ICD10CM | Covered |
| J32.2 | ICD10CM | Covered |
| J32.3 | ICD10CM | Covered |
| J32.4 | ICD10CM | Covered |
| J32.8 | ICD10CM | Covered |
| J32.9 | ICD10CM | Covered |
| J34.0 | ICD10CM | Covered |
| J34.1 | ICD10CM | Covered |
| J34.2 | ICD10CM | Covered |
| J34.8201 | ICD10CM | Covered |
| J34.8202 | ICD10CM | Covered |
| J34.8211 | ICD10CM | Covered |
| J34.8212 | ICD10CM | Covered |
| J34.89 | ICD10CM | Covered |
| J34.9 | ICD10CM | Covered |
| J95.01 | ICD10CM | Covered |
| J95.03 | ICD10CM | Covered |
| J95.04 | ICD10CM | Covered |
| J95.09 | ICD10CM | Covered |
| K09.0 | ICD10CM | Covered |
| K09.1 | ICD10CM | Covered |
| K43.0 | ICD10CM | Covered |
| K43.1 | ICD10CM | Covered |
| K43.2 | ICD10CM | Covered |
| K43.3 | ICD10CM | Covered |
| K43.4 | ICD10CM | Covered |
| K43.5 | ICD10CM | Covered |
| K43.6 | ICD10CM | Covered |
| K43.7 | ICD10CM | Covered |
| K43.9 | ICD10CM | Covered |
| K46.9 | ICD10CM | Covered |
| L26 | ICD10CM | Covered |
| L30.4 | ICD10CM | Covered |
| L53.8 | ICD10CM | Covered |
| L54 | ICD10CM | Covered |
| L57.4 | ICD10CM | Covered |
| L71.0 | ICD10CM | Covered |
| L71.1 | ICD10CM | Covered |
| L71.8 | ICD10CM | Covered |
| L81.8 | ICD10CM | Covered |
| L87.9 | ICD10CM | Covered |
| L90.9 | ICD10CM | Covered |
| L91.9 | ICD10CM | Covered |
| L92.0 | ICD10CM | Covered |
| L95.1 | ICD10CM | Covered |
| L98.2 | ICD10CM | Covered |
| L98.411 | ICD10CM | Covered |
| L98.412 | ICD10CM | Covered |
| L98.413 | ICD10CM | Covered |
| L98.414 | ICD10CM | Covered |
| L98.419 | ICD10CM | Covered |
| L98.421 | ICD10CM | Covered |
| L98.422 | ICD10CM | Covered |
| L98.423 | ICD10CM | Covered |
| L98.424 | ICD10CM | Covered |
| L98.429 | 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 |
| M25.511 | ICD10CM | Covered |
| M25.512 | ICD10CM | Covered |
| M27.0 | ICD10CM | Covered |
| M27.1 | ICD10CM | Covered |
| M27.2 | ICD10CM | Covered |
| M27.40 | ICD10CM | Covered |
| M27.49 | ICD10CM | Covered |
| M27.8 | ICD10CM | Covered |
| M30.1 | ICD10CM | Covered |
| M31.2 | ICD10CM | Covered |
| M31.30 | ICD10CM | Covered |
| M31.31 | ICD10CM | Covered |
| M35.6 | ICD10CM | Covered |
| M54.2 | ICD10CM | Covered |
| M54.6 | ICD10CM | Covered |
| M54.89 | ICD10CM | Covered |
| M54.9 | ICD10CM | Covered |
| M79.3 | ICD10CM | Covered |
| M87.180 | ICD10CM | Covered |
| N60.01 | ICD10CM | Covered |
| N60.02 | ICD10CM | Covered |
| N60.11 | ICD10CM | Covered |
| N60.12 | ICD10CM | Covered |
| N60.21 | ICD10CM | Covered |
| N60.22 | ICD10CM | Covered |
| N60.31 | ICD10CM | Covered |
| N60.32 | ICD10CM | Covered |
| N60.41 | ICD10CM | Covered |
| N60.42 | ICD10CM | Covered |
| N60.81 | ICD10CM | Covered |
| N60.82 | ICD10CM | Covered |
| N61.1 | ICD10CM | Covered |
| N62 | ICD10CM | Covered |
| N64.1 | ICD10CM | Covered |
| N64.89 | ICD10CM | Covered |
| N65.0 | ICD10CM | Covered |
| N65.1 | ICD10CM | Covered |
| Q17.3 | ICD10CM | Covered |
| Q17.4 | ICD10CM | Covered |
| Q35.1 | ICD10CM | Covered |
| Q35.3 | ICD10CM | Covered |
| Q35.5 | ICD10CM | Covered |
| Q35.7 | ICD10CM | Covered |
| Q35.9 | ICD10CM | Covered |
| Q36.0 | ICD10CM | Covered |
| Q36.1 | ICD10CM | Covered |
| Q36.9 | ICD10CM | Covered |
| Q37.0 | ICD10CM | Covered |
| Q37.1 | ICD10CM | Covered |
| Q37.2 | ICD10CM | Covered |
| Q37.3 | ICD10CM | Covered |
| Q37.4 | ICD10CM | Covered |
| Q37.5 | ICD10CM | Covered |
| Q67.0 | ICD10CM | Covered |
| Q67.1 | ICD10CM | Covered |
| Q67.2 | ICD10CM | Covered |
| Q67.3 | ICD10CM | Covered |
| Q67.4 | ICD10CM | Covered |
| Q85.00 | ICD10CM | Covered |
| Q85.01 | ICD10CM | Covered |
| Q85.02 | ICD10CM | Covered |
| Q85.03 | ICD10CM | Covered |
| Q85.09 | ICD10CM | Covered |
| R09.81 | ICD10CM | Covered |
| R13.0 | ICD10CM | Covered |
| R13.10 | ICD10CM | Covered |
| R13.11 | ICD10CM | Covered |
| R13.12 | ICD10CM | Covered |
| R21 | ICD10CM | Covered |
| S01.01XA | ICD10CM | Covered |
| S01.01XD | ICD10CM | Covered |
| S01.01XS | ICD10CM | Covered |
| S01.02XA | ICD10CM | Covered |
| S01.02XD | ICD10CM | Covered |
| S01.02XS | ICD10CM | Covered |
| S01.03XA | ICD10CM | Covered |
| S01.03XD | ICD10CM | Covered |
| S01.03XS | ICD10CM | Covered |
| S01.04XA | ICD10CM | Covered |
| S01.04XD | ICD10CM | Covered |
| S01.04XS | ICD10CM | Covered |
| S01.05XA | ICD10CM | Covered |
| S01.05XD | ICD10CM | Covered |
| S01.05XS | ICD10CM | Covered |
| S01.111D | ICD10CM | Covered |
| S01.111S | ICD10CM | Covered |
| S01.112D | ICD10CM | Covered |
| S01.112S | ICD10CM | Covered |
| S01.121D | ICD10CM | Covered |
| S01.121S | ICD10CM | Covered |
| S01.122D | ICD10CM | Covered |
| S01.122S | ICD10CM | Covered |
| S01.131D | ICD10CM | Covered |
| S01.131S | ICD10CM | Covered |
| S01.132D | ICD10CM | Covered |
| S01.132S | ICD10CM | Covered |
| S01.141D | ICD10CM | Covered |
| S01.141S | ICD10CM | Covered |
| S01.142D | ICD10CM | Covered |
| S01.142S | ICD10CM | Covered |
| S01.151D | ICD10CM | Covered |
| S01.151S | ICD10CM | Covered |
| S01.152D | ICD10CM | Covered |
| S01.152S | ICD10CM | Covered |
| S01.20XD | ICD10CM | Covered |
| S01.20XS | ICD10CM | Covered |
| S01.21XD | ICD10CM | Covered |
| S01.21XS | ICD10CM | Covered |
| S01.22XD | ICD10CM | Covered |
| S01.22XS | ICD10CM | Covered |
| S01.23XD | ICD10CM | Covered |
| S01.23XS | ICD10CM | Covered |
| S01.24XD | ICD10CM | Covered |
| S01.24XS | ICD10CM | Covered |
| S01.25XD | ICD10CM | Covered |
| S01.25XS | ICD10CM | Covered |
| S01.301D | ICD10CM | Covered |
| S01.301S | ICD10CM | Covered |
| S01.302D | ICD10CM | Covered |
| S01.302S | ICD10CM | Covered |
| S01.311D | ICD10CM | Covered |
| S01.311S | ICD10CM | Covered |
| S01.312D | ICD10CM | Covered |
| S01.312S | ICD10CM | Covered |
| S01.319D | ICD10CM | Covered |
| S01.319S | ICD10CM | Covered |
| S01.321D | ICD10CM | Covered |
| S01.321S | ICD10CM | Covered |
| S01.322D | ICD10CM | Covered |
| S01.322S | ICD10CM | Covered |
| S01.329D | ICD10CM | Covered |
| S01.329S | ICD10CM | Covered |
| S01.331D | ICD10CM | Covered |
| S01.331S | ICD10CM | Covered |
| S01.332D | ICD10CM | Covered |
| S01.332S | ICD10CM | Covered |
| S01.341D | ICD10CM | Covered |
| S01.341S | ICD10CM | Covered |
| S01.342D | ICD10CM | Covered |
| S01.342S | ICD10CM | Covered |
| S01.349D | ICD10CM | Covered |
| S01.349S | ICD10CM | Covered |
| S01.351D | ICD10CM | Covered |
| S01.351S | ICD10CM | Covered |
| S01.352D | ICD10CM | Covered |
| S01.352S | ICD10CM | Covered |
| S01.401D | ICD10CM | Covered |
| S01.401S | ICD10CM | Covered |
| S01.402D | ICD10CM | Covered |
| S01.402S | ICD10CM | Covered |
| S01.411D | ICD10CM | Covered |
| S01.411S | ICD10CM | Covered |
| S01.412D | ICD10CM | Covered |
| S01.412S | ICD10CM | Covered |
| S01.421D | ICD10CM | Covered |
| S01.421S | ICD10CM | Covered |
| S01.422D | ICD10CM | Covered |
| S01.422S | ICD10CM | Covered |
| S01.429D | ICD10CM | Covered |
| S01.429S | ICD10CM | Covered |
| S01.431D | ICD10CM | Covered |
| S01.431S | ICD10CM | Covered |
| S01.432D | ICD10CM | Covered |
| S01.432S | ICD10CM | Covered |
| S01.439D | ICD10CM | Covered |
| S01.439S | ICD10CM | Covered |
| S01.441D | ICD10CM | Covered |
| S01.441S | ICD10CM | Covered |
| S01.442D | ICD10CM | Covered |
| S01.442S | ICD10CM | Covered |
| S01.451D | ICD10CM | Covered |
| S01.451S | ICD10CM | Covered |
| S01.452D | ICD10CM | Covered |
| S01.452S | ICD10CM | Covered |
| S01.501D | ICD10CM | Covered |
| S01.501S | ICD10CM | Covered |
| S01.502D | ICD10CM | Covered |
| S01.502S | ICD10CM | Covered |
| S01.511D | ICD10CM | Covered |
| S01.511S | ICD10CM | Covered |
| S01.512D | ICD10CM | Covered |
| S01.512S | ICD10CM | Covered |
| S01.521D | ICD10CM | Covered |
| S01.521S | ICD10CM | Covered |
| S01.522D | ICD10CM | Covered |
| S01.522S | ICD10CM | Covered |
| S01.531D | ICD10CM | Covered |
| S01.531S | ICD10CM | Covered |
| S01.532D | ICD10CM | Covered |
| S01.532S | ICD10CM | Covered |
| S01.541D | ICD10CM | Covered |
| S01.541S | ICD10CM | Covered |
| S01.542D | ICD10CM | Covered |
| S01.542S | ICD10CM | Covered |
| S01.551D | ICD10CM | Covered |
| S01.551S | ICD10CM | Covered |
| S01.552D | ICD10CM | Covered |
| S01.552S | ICD10CM | Covered |
| S01.80XD | ICD10CM | Covered |
| S01.80XS | ICD10CM | Covered |
| S01.81XD | ICD10CM | Covered |
| S01.81XS | ICD10CM | Covered |
| S01.82XD | ICD10CM | Covered |
| S01.82XS | ICD10CM | Covered |
| S01.83XD | ICD10CM | Covered |
| S01.83XS | ICD10CM | Covered |
| S01.84XD | ICD10CM | Covered |
| S01.84XS | ICD10CM | Covered |
| S01.85XD | ICD10CM | Covered |
| S01.85XS | ICD10CM | Covered |
| S02.2XXA | ICD10CM | Covered |
| S02.2XXB | ICD10CM | Covered |
| S02.2XXD | ICD10CM | Covered |
| S02.2XXG | ICD10CM | Covered |
| S02.2XXK | ICD10CM | Covered |
| S02.2XXS | ICD10CM | Covered |
| S02.5XXD | ICD10CM | Covered |
| S02.5XXG | ICD10CM | Covered |
| S02.5XXK | ICD10CM | Covered |
| S02.5XXS | ICD10CM | Covered |
| S03.2XXD | ICD10CM | Covered |
| S03.2XXS | ICD10CM | Covered |
| S05.20XD | ICD10CM | Covered |
| S05.20XS | ICD10CM | Covered |
| S05.21XD | ICD10CM | Covered |
| S05.21XS | ICD10CM | Covered |
| S05.22XD | ICD10CM | Covered |
| S05.22XS | ICD10CM | Covered |
| S05.31XD | ICD10CM | Covered |
| S05.31XS | ICD10CM | Covered |
| S05.32XD | ICD10CM | Covered |
| S05.32XS | ICD10CM | Covered |
| S05.41XD | ICD10CM | Covered |
| S05.41XS | ICD10CM | Covered |
| S05.42XD | ICD10CM | Covered |
| S05.42XS | ICD10CM | Covered |
| S05.51XD | ICD10CM | Covered |
| S05.51XS | ICD10CM | Covered |
| S05.52XD | ICD10CM | Covered |
| S05.52XS | ICD10CM | Covered |
| S05.61XD | ICD10CM | Covered |
| S05.61XS | ICD10CM | Covered |
| S05.62XD | ICD10CM | Covered |
| S05.62XS | ICD10CM | Covered |
| S05.71XD | ICD10CM | Covered |
| S05.71XS | ICD10CM | Covered |
| S05.72XD | ICD10CM | Covered |
| S05.72XS | ICD10CM | Covered |
| S05.8X1D | ICD10CM | Covered |
| S05.8X1S | ICD10CM | Covered |
| S05.8X2D | ICD10CM | Covered |
| S05.8X2S | ICD10CM | Covered |
| S05.91XD | ICD10CM | Covered |
| S05.91XS | ICD10CM | Covered |
| S05.92XD | ICD10CM | Covered |
| S05.92XS | ICD10CM | Covered |
| S08.111D | ICD10CM | Covered |
| S08.111S | ICD10CM | Covered |
| S08.112D | ICD10CM | Covered |
| S08.112S | ICD10CM | Covered |
| S08.121D | ICD10CM | Covered |
| S08.121S | ICD10CM | Covered |
| S08.122D | ICD10CM | Covered |
| S08.122S | ICD10CM | Covered |
| S08.811D | ICD10CM | Covered |
| S08.811S | ICD10CM | Covered |
| S08.812D | ICD10CM | Covered |
| S08.812S | ICD10CM | Covered |
| S08.89XD | ICD10CM | Covered |
| S08.89XS | ICD10CM | Covered |
| S09.12XD | ICD10CM | Covered |
| S09.12XS | ICD10CM | Covered |
| S09.311D | ICD10CM | Covered |
| S09.311S | ICD10CM | Covered |
| S09.312D | ICD10CM | Covered |
| S09.312S | ICD10CM | Covered |
| S09.313D | ICD10CM | Covered |
| S09.313S | ICD10CM | Covered |
| S09.8XXD | ICD10CM | Covered |
| S09.8XXS | ICD10CM | Covered |
| T21.31XA | ICD10CM | Covered |
| T21.31XD | ICD10CM | Covered |
| T21.31XS | ICD10CM | Covered |
| T21.71XA | ICD10CM | Covered |
| T21.71XD | ICD10CM | Covered |
| T21.71XS | ICD10CM | Covered |
| T85.41XA | ICD10CM | Covered |
| T85.41XD | ICD10CM | Covered |
| T85.41XS | ICD10CM | Covered |
| T85.42XA | ICD10CM | Covered |
| T85.42XD | ICD10CM | Covered |
| T85.42XS | ICD10CM | Covered |
| T85.43XA | ICD10CM | Covered |
| T85.43XD | ICD10CM | Covered |
| T85.43XS | ICD10CM | Covered |
| T85.44XA | ICD10CM | Covered |
| T85.44XD | ICD10CM | Covered |
| T85.44XS | ICD10CM | Covered |
| T85.49XA | ICD10CM | Covered |
| T85.49XD | ICD10CM | Covered |
| T85.49XS | ICD10CM | Covered |
| T85.79XA | ICD10CM | Covered |
| T85.79XD | ICD10CM | Covered |
| T85.79XS | ICD10CM | Covered |
| Z40.89 | ICD10CM | Not covered |
| Z40.9 | ICD10CM | Not covered |
| Z41.1 | ICD10CM | Not covered |
| Z41.3 | ICD10CM | Not covered |
| Z41.8 | ICD10CM | Not covered |
| Z41.9 | ICD10CM | Not covered |
| Z42.1 | ICD10CM | Covered |
| Z44.30 | ICD10CM | Covered |
| Z44.31 | ICD10CM | Covered |
| Z44.32 | ICD10CM | Covered |
| Z45.811 | ICD10CM | Covered |
| Z45.812 | ICD10CM | Covered |
| Z45.819 | ICD10CM | Covered |
| Z48.1 | ICD10CM | Covered |
| Z48.3 | ICD10CM | Covered |
| Z85.3 | ICD10CM | Covered |
| Z90.11 | ICD10CM | Covered |
| Z90.12 | ICD10CM | Covered |
| Z90.13 | ICD10CM | Covered |
| Z98.82 | ICD10CM | Covered |