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 |
|---|---|---|
| 31500 | HCPCS | Covered |
| 31502 | HCPCS | Covered |
| 31720 | HCPCS | Covered |
| 92950 | HCPCS | Covered |
| 94002 | HCPCS | Covered |
| 94003 | HCPCS | Covered |
| 94004 | HCPCS | Covered |
| 94010 | HCPCS | Covered |
| 94011 | HCPCS | Covered |
| 94012 | HCPCS | Covered |
| 94013 | HCPCS | Covered |
| 94060 | HCPCS | Covered |
| 94070 | HCPCS | Covered |
| 94150 | HCPCS | Covered |
| 94200 | HCPCS | Covered |
| 94375 | HCPCS | Covered |
| 94450 | HCPCS | Covered |
| 94621 | HCPCS | Covered |
| 94640 | HCPCS | Covered |
| 94642 | HCPCS | Covered |
| 94660 | HCPCS | Covered |
| 94664 | HCPCS | Covered |
| 94667 | HCPCS | Covered |
| 94668 | HCPCS | Covered |
| 94669 | HCPCS | Covered |
| 94726 | HCPCS | Covered |
| 94727 | HCPCS | Covered |
| 94728 | HCPCS | Covered |
| 94729 | HCPCS | Covered |
| 94772 | HCPCS | Covered |
| G0237 | HCPCS | Covered |
| G0238 | HCPCS | Covered |
| G0239 | HCPCS | Covered |
| A15.0 | ICD10CM | Covered |
| A15.5 | ICD10CM | Covered |
| A15.6 | ICD10CM | Covered |
| A15.7 | ICD10CM | Covered |
| A15.8 | ICD10CM | Covered |
| A20.2 | ICD10CM | Covered |
| A20.7 | ICD10CM | Covered |
| A22.1 | ICD10CM | Covered |
| A31.0 | ICD10CM | Covered |
| A36.2 | ICD10CM | Covered |
| A37.00 | ICD10CM | Covered |
| A37.01 | ICD10CM | Covered |
| A37.10 | ICD10CM | Covered |
| A37.11 | ICD10CM | Covered |
| A37.80 | ICD10CM | Covered |
| A37.81 | ICD10CM | Covered |
| A37.90 | ICD10CM | Covered |
| A37.91 | ICD10CM | Covered |
| A42.0 | ICD10CM | Covered |
| A43.0 | ICD10CM | Covered |
| A52.72 | ICD10CM | Covered |
| A75.3 | ICD10CM | Covered |
| A78 | ICD10CM | Covered |
| B01.2 | ICD10CM | Covered |
| B05.2 | ICD10CM | Covered |
| B25.0 | ICD10CM | Covered |
| B37.1 | ICD10CM | Covered |
| B38.0 | ICD10CM | Covered |
| B38.1 | ICD10CM | Covered |
| B38.2 | ICD10CM | Covered |
| B39.0 | ICD10CM | Covered |
| B39.1 | ICD10CM | Covered |
| B39.2 | ICD10CM | Covered |
| B44.0 | ICD10CM | Covered |
| B44.1 | ICD10CM | Covered |
| B44.2 | ICD10CM | Covered |
| B44.7 | ICD10CM | Covered |
| B44.81 | ICD10CM | Covered |
| B44.89 | ICD10CM | Covered |
| B44.9 | ICD10CM | Covered |
| B45.0 | ICD10CM | Covered |
| B45.7 | ICD10CM | Covered |
| B45.8 | ICD10CM | Covered |
| B48.4 | ICD10CM | Covered |
| B58.3 | ICD10CM | Covered |
| B59 | ICD10CM | Covered |
| B77.81 | ICD10CM | Covered |
| C33 | ICD10CM | Covered |
| C34.01 | ICD10CM | Covered |
| C34.02 | ICD10CM | Covered |
| C34.11 | ICD10CM | Covered |
| C34.12 | ICD10CM | Covered |
| C34.2 | ICD10CM | Covered |
| C34.31 | ICD10CM | Covered |
| C34.32 | ICD10CM | Covered |
| C34.81 | ICD10CM | Covered |
| C34.82 | ICD10CM | Covered |
| C38.4 | ICD10CM | Covered |
| C39.9 | ICD10CM | Covered |
| C45.0 | ICD10CM | Covered |
| C45.7 | ICD10CM | Covered |
| C46.51 | ICD10CM | Covered |
| C46.52 | ICD10CM | Covered |
| C76.8 | ICD10CM | Covered |
| C78.01 | ICD10CM | Covered |
| C78.02 | ICD10CM | Covered |
| C78.1 | ICD10CM | Covered |
| C78.2 | ICD10CM | Covered |
| C78.39 | ICD10CM | Covered |
| D02.0 | ICD10CM | Covered |
| D02.1 | ICD10CM | Covered |
| D02.21 | ICD10CM | Covered |
| D02.22 | ICD10CM | Covered |
| D02.3 | ICD10CM | Covered |
| D14.1 | ICD10CM | Covered |
| D14.2 | ICD10CM | Covered |
| D14.31 | ICD10CM | Covered |
| D14.32 | ICD10CM | Covered |
| D15.2 | ICD10CM | Covered |
| D19.0 | ICD10CM | Covered |
| D38.1 | ICD10CM | Covered |
| D38.2 | ICD10CM | Covered |
| D38.3 | ICD10CM | Covered |
| D38.4 | ICD10CM | Covered |
| D57.01 | ICD10CM | Covered |
| D57.04 | ICD10CM | Covered |
| D57.211 | ICD10CM | Covered |
| D57.214 | ICD10CM | Covered |
| D57.411 | ICD10CM | Covered |
| D57.414 | ICD10CM | Covered |
| D57.431 | ICD10CM | Covered |
| D57.434 | ICD10CM | Covered |
| D57.451 | ICD10CM | Covered |
| D57.454 | ICD10CM | Covered |
| D57.811 | ICD10CM | Covered |
| D57.814 | ICD10CM | Covered |
| D86.0 | ICD10CM | Covered |
| D86.2 | ICD10CM | Covered |
| E66.2 | ICD10CM | Covered |
| E84.0 | ICD10CM | Covered |
| E84.9 | ICD10CM | Covered |
| E85.0 | ICD10CM | Covered |
| E85.1 | ICD10CM | Covered |
| E85.2 | ICD10CM | Covered |
| E85.3 | ICD10CM | Covered |
| E85.4 | ICD10CM | Covered |
| E85.81 | ICD10CM | Covered |
| E85.82 | ICD10CM | Covered |
| E85.89 | ICD10CM | Covered |
| E85.9 | ICD10CM | Covered |
| E88.01 | ICD10CM | Covered |
| E88.02 | ICD10CM | Covered |
| E88.3 | ICD10CM | Covered |
| G12.21 | ICD10CM | Covered |
| G12.23 | ICD10CM | Covered |
| G12.24 | ICD10CM | Covered |
| G12.25 | ICD10CM | Covered |
| G47.30 | ICD10CM | Covered |
| G47.31 | ICD10CM | Covered |
| G47.33 | ICD10CM | Covered |
| G47.34 | ICD10CM | Covered |
| G47.35 | ICD10CM | Covered |
| G47.36 | ICD10CM | Covered |
| G47.37 | ICD10CM | Covered |
| G47.39 | ICD10CM | Covered |
| G70.80 | ICD10CM | Covered |
| G70.81 | ICD10CM | Covered |
| G71.00 | ICD10CM | Covered |
| G71.01 | ICD10CM | Covered |
| G71.02 | ICD10CM | Covered |
| G71.031 | ICD10CM | Covered |
| G71.032 | ICD10CM | Covered |
| G71.033 | ICD10CM | Covered |
| G71.0340 | ICD10CM | Covered |
| G71.0341 | ICD10CM | Covered |
| G71.0342 | ICD10CM | Covered |
| G71.0349 | ICD10CM | Covered |
| G71.035 | ICD10CM | Covered |
| G71.036 | ICD10CM | Covered |
| G71.038 | ICD10CM | Covered |
| G71.09 | ICD10CM | Covered |
| G72.41 | ICD10CM | Covered |
| G72.49 | ICD10CM | Covered |
| G73.1 | ICD10CM | Covered |
| I26.01 | ICD10CM | Covered |
| I26.02 | ICD10CM | Covered |
| I26.03 | ICD10CM | Covered |
| I26.04 | ICD10CM | Covered |
| I26.09 | ICD10CM | Covered |
| I26.90 | ICD10CM | Covered |
| I26.92 | ICD10CM | Covered |
| I26.93 | ICD10CM | Covered |
| I26.94 | ICD10CM | Covered |
| I26.95 | ICD10CM | Covered |
| I26.96 | ICD10CM | Covered |
| I26.99 | ICD10CM | Covered |
| I27.0 | ICD10CM | Covered |
| I27.1 | ICD10CM | Covered |
| I27.20 | ICD10CM | Covered |
| I27.21 | ICD10CM | Covered |
| I27.22 | ICD10CM | Covered |
| I27.23 | ICD10CM | Covered |
| I27.24 | ICD10CM | Covered |
| I27.29 | ICD10CM | Covered |
| I27.82 | ICD10CM | Covered |
| I27.83 | ICD10CM | Covered |
| I27.840 | ICD10CM | Covered |
| I27.841 | ICD10CM | Covered |
| I27.848 | ICD10CM | Covered |
| I27.849 | ICD10CM | Covered |
| I27.89 | ICD10CM | Covered |
| I28.0 | ICD10CM | Covered |
| I28.8 | ICD10CM | Covered |
| I37.0 | ICD10CM | Covered |
| I37.1 | ICD10CM | Covered |
| I37.2 | ICD10CM | Covered |
| I37.8 | ICD10CM | Covered |
| I37.9 | ICD10CM | Covered |
| I46.2 | ICD10CM | Covered |
| I46.8 | ICD10CM | Covered |
| I46.9 | ICD10CM | Covered |
| I50.1 | ICD10CM | Covered |
| I50.20 | ICD10CM | Covered |
| I50.21 | ICD10CM | Covered |
| I50.22 | ICD10CM | Covered |
| I50.23 | ICD10CM | Covered |
| I50.30 | ICD10CM | Covered |
| I50.31 | ICD10CM | Covered |
| I50.32 | ICD10CM | Covered |
| I50.33 | ICD10CM | Covered |
| I50.40 | ICD10CM | Covered |
| I50.41 | ICD10CM | Covered |
| I50.42 | ICD10CM | Covered |
| I50.43 | ICD10CM | Covered |
| I50.810 | ICD10CM | Covered |
| I50.811 | ICD10CM | Covered |
| I50.812 | ICD10CM | Covered |
| I50.813 | ICD10CM | Covered |
| I50.814 | ICD10CM | Covered |
| I50.82 | ICD10CM | Covered |
| I50.83 | ICD10CM | Covered |
| I50.84 | ICD10CM | Covered |
| I50.89 | ICD10CM | Covered |
| I50.9 | ICD10CM | Covered |
| J04.10 | ICD10CM | Covered |
| J04.11 | ICD10CM | Covered |
| J04.2 | ICD10CM | Covered |
| J05.0 | ICD10CM | Covered |
| J05.10 | ICD10CM | Covered |
| J05.11 | ICD10CM | Covered |
| J06.0 | ICD10CM | Covered |
| J09.X1 | ICD10CM | Covered |
| J09.X2 | ICD10CM | Covered |
| J10.00 | ICD10CM | Covered |
| J10.01 | ICD10CM | Covered |
| J10.08 | ICD10CM | Covered |
| J10.1 | ICD10CM | Covered |
| J11.00 | ICD10CM | Covered |
| J11.08 | ICD10CM | Covered |
| J11.1 | ICD10CM | Covered |
| J12.0 | ICD10CM | Covered |
| J12.1 | ICD10CM | Covered |
| J12.82 | ICD10CM | Covered |
| J12.9 | ICD10CM | Covered |
| J13 | ICD10CM | Covered |
| J15.20 | ICD10CM | Covered |
| J15.211 | ICD10CM | Covered |
| J15.212 | ICD10CM | Covered |
| J15.29 | ICD10CM | Covered |
| J15.3 | ICD10CM | Covered |
| J15.4 | ICD10CM | Covered |
| J15.7 | ICD10CM | Covered |
| J16.0 | ICD10CM | Covered |
| J17 | ICD10CM | Covered |
| J18.0 | ICD10CM | Covered |
| J18.1 | ICD10CM | Covered |
| J18.2 | ICD10CM | Covered |
| J18.8 | ICD10CM | Covered |
| J18.9 | ICD10CM | Covered |
| J20.0 | ICD10CM | Covered |
| J20.1 | ICD10CM | Covered |
| J20.2 | ICD10CM | Covered |
| J20.3 | ICD10CM | Covered |
| J20.4 | ICD10CM | Covered |
| J20.5 | ICD10CM | Covered |
| J20.6 | ICD10CM | Covered |
| J20.7 | ICD10CM | Covered |
| J20.8 | ICD10CM | Covered |
| J20.9 | ICD10CM | Covered |
| J21.0 | ICD10CM | Covered |
| J21.1 | ICD10CM | Covered |
| J21.8 | ICD10CM | Covered |
| J21.9 | ICD10CM | Covered |
| J22 | ICD10CM | Covered |
| J37.1 | ICD10CM | Covered |
| J38.01 | ICD10CM | Covered |
| J38.02 | ICD10CM | Covered |
| J38.4 | ICD10CM | Covered |
| J38.5 | ICD10CM | Covered |
| J38.6 | ICD10CM | Covered |
| J39.3 | ICD10CM | Covered |
| J39.8 | ICD10CM | Covered |
| J40 | ICD10CM | Covered |
| J41.0 | ICD10CM | Covered |
| J41.1 | ICD10CM | Covered |
| J41.8 | ICD10CM | Covered |
| J43.0 | ICD10CM | Covered |
| J43.1 | ICD10CM | Covered |
| J43.2 | ICD10CM | Covered |
| J43.8 | ICD10CM | Covered |
| J43.9 | ICD10CM | Covered |
| J44.0 | ICD10CM | Covered |
| J44.1 | ICD10CM | Covered |
| J44.81 | ICD10CM | Covered |
| J44.89 | ICD10CM | Covered |
| J44.9 | 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 |
| J45.990 | ICD10CM | Covered |
| J45.991 | ICD10CM | Covered |
| J45.998 | ICD10CM | Covered |
| J47.0 | ICD10CM | Covered |
| J47.1 | ICD10CM | Covered |
| J47.9 | ICD10CM | Covered |
| J60 | ICD10CM | Covered |
| J61 | ICD10CM | Covered |
| J62.0 | ICD10CM | Covered |
| J62.8 | ICD10CM | Covered |
| J63.0 | ICD10CM | Covered |
| J63.1 | ICD10CM | Covered |
| J63.2 | ICD10CM | Covered |
| J63.3 | ICD10CM | Covered |
| J63.4 | ICD10CM | Covered |
| J63.5 | ICD10CM | Covered |
| J63.6 | ICD10CM | Covered |
| J64 | ICD10CM | Covered |
| J65 | ICD10CM | Covered |
| J66.0 | ICD10CM | Covered |
| J66.1 | ICD10CM | Covered |
| J66.2 | ICD10CM | Covered |
| J66.8 | ICD10CM | Covered |
| J68.0 | ICD10CM | Covered |
| J68.1 | ICD10CM | Covered |
| J68.2 | ICD10CM | Covered |
| J68.3 | ICD10CM | Covered |
| J68.4 | ICD10CM | Covered |
| J69.0 | ICD10CM | Covered |
| J69.1 | ICD10CM | Covered |
| J69.8 | ICD10CM | Covered |
| J70.0 | ICD10CM | Covered |
| J70.1 | ICD10CM | Covered |
| J70.2 | ICD10CM | Covered |
| J70.3 | ICD10CM | Covered |
| J70.4 | ICD10CM | Covered |
| J70.5 | ICD10CM | Covered |
| J70.8 | ICD10CM | Covered |
| J70.9 | ICD10CM | Covered |
| J80 | ICD10CM | Covered |
| J81.0 | ICD10CM | Covered |
| J81.1 | ICD10CM | Covered |
| J82.81 | ICD10CM | Covered |
| J82.82 | ICD10CM | Covered |
| J82.83 | ICD10CM | Covered |
| J84.01 | ICD10CM | Covered |
| J84.02 | ICD10CM | Covered |
| J84.03 | ICD10CM | Covered |
| J84.09 | ICD10CM | Covered |
| J84.10 | ICD10CM | Covered |
| J84.111 | ICD10CM | Covered |
| J84.112 | ICD10CM | Covered |
| J84.113 | ICD10CM | Covered |
| J84.114 | ICD10CM | Covered |
| J84.115 | ICD10CM | Covered |
| J84.116 | ICD10CM | Covered |
| J84.117 | ICD10CM | Covered |
| J84.170 | ICD10CM | Covered |
| J84.178 | ICD10CM | Covered |
| J84.2 | ICD10CM | Covered |
| J84.81 | ICD10CM | Covered |
| J84.82 | ICD10CM | Covered |
| J84.83 | ICD10CM | Covered |
| J84.841 | ICD10CM | Covered |
| J84.842 | ICD10CM | Covered |
| J84.843 | ICD10CM | Covered |
| J84.848 | ICD10CM | Covered |
| J84.89 | ICD10CM | Covered |
| J84.9 | ICD10CM | Covered |
| J85.0 | ICD10CM | Covered |
| J85.1 | ICD10CM | Covered |
| J85.2 | ICD10CM | Covered |
| J85.3 | ICD10CM | Covered |
| J86.0 | ICD10CM | Covered |
| J86.9 | ICD10CM | Covered |
| J90 | ICD10CM | Covered |
| J91.0 | ICD10CM | Covered |
| J92.0 | ICD10CM | Covered |
| J92.9 | ICD10CM | Covered |
| J93.0 | ICD10CM | Covered |
| J93.11 | ICD10CM | Covered |
| J93.12 | ICD10CM | Covered |
| J93.81 | ICD10CM | Covered |
| J93.82 | ICD10CM | Covered |
| J93.83 | ICD10CM | Covered |
| J93.9 | ICD10CM | Covered |
| J94.0 | ICD10CM | Covered |
| J94.1 | ICD10CM | Covered |
| J94.2 | ICD10CM | Covered |
| J94.8 | ICD10CM | Covered |
| J94.9 | ICD10CM | Covered |
| J95.00 | ICD10CM | Covered |
| J95.01 | ICD10CM | Covered |
| J95.02 | ICD10CM | Covered |
| J95.03 | ICD10CM | Covered |
| J95.04 | ICD10CM | Covered |
| J95.09 | ICD10CM | Covered |
| J95.1 | ICD10CM | Covered |
| J95.2 | ICD10CM | Covered |
| J95.3 | ICD10CM | Covered |
| J95.811 | ICD10CM | Covered |
| J95.812 | ICD10CM | Covered |
| J95.821 | ICD10CM | Covered |
| J95.822 | ICD10CM | Covered |
| J95.84 | ICD10CM | Covered |
| J95.850 | ICD10CM | Covered |
| J95.860 | ICD10CM | Covered |
| J95.861 | ICD10CM | Covered |
| J95.862 | ICD10CM | Covered |
| J95.863 | ICD10CM | Covered |
| J95.89 | ICD10CM | Covered |
| J96.00 | ICD10CM | Covered |
| J96.01 | ICD10CM | Covered |
| J96.02 | ICD10CM | Covered |
| J96.10 | ICD10CM | Covered |
| J96.11 | ICD10CM | Covered |
| J96.12 | ICD10CM | Covered |
| J96.20 | ICD10CM | Covered |
| J96.21 | ICD10CM | Covered |
| J96.22 | ICD10CM | Covered |
| J96.90 | ICD10CM | Covered |
| J96.91 | ICD10CM | Covered |
| J96.92 | ICD10CM | Covered |
| J98.01 | ICD10CM | Covered |
| J98.09 | ICD10CM | Covered |
| J98.11 | ICD10CM | Covered |
| J98.19 | ICD10CM | Covered |
| J98.2 | ICD10CM | Covered |
| J98.3 | ICD10CM | Covered |
| J98.4 | ICD10CM | Covered |
| J98.51 | ICD10CM | Covered |
| J98.59 | ICD10CM | Covered |
| J98.6 | ICD10CM | Covered |
| J98.8 | ICD10CM | Covered |
| J99 | ICD10CM | Covered |
| K76.81 | ICD10CM | Covered |
| M32.13 | ICD10CM | Covered |
| M33.01 | ICD10CM | Covered |
| M33.11 | ICD10CM | Covered |
| M33.21 | ICD10CM | Covered |
| M33.91 | ICD10CM | Covered |
| M34.81 | ICD10CM | Covered |
| M35.02 | ICD10CM | Covered |
| O08.2 | ICD10CM | Covered |
| O74.0 | ICD10CM | Covered |
| O74.1 | ICD10CM | Covered |
| O89.01 | ICD10CM | Covered |
| O89.09 | ICD10CM | Covered |
| P24.00 | ICD10CM | Covered |
| P24.01 | ICD10CM | Covered |
| P24.10 | ICD10CM | Covered |
| P24.11 | ICD10CM | Covered |
| P24.20 | ICD10CM | Covered |
| P24.21 | ICD10CM | Covered |
| P24.80 | ICD10CM | Covered |
| P24.81 | ICD10CM | Covered |
| P24.9 | ICD10CM | Covered |
| P28.81 | ICD10CM | Covered |
| P36.0 | ICD10CM | Covered |
| P36.10 | ICD10CM | Covered |
| P36.19 | ICD10CM | Covered |
| P36.2 | ICD10CM | Covered |
| P36.30 | ICD10CM | Covered |
| P36.39 | ICD10CM | Covered |
| P36.4 | ICD10CM | Covered |
| P36.5 | ICD10CM | Covered |
| P36.8 | ICD10CM | Covered |
| P36.9 | ICD10CM | Covered |
| P39.2 | ICD10CM | Covered |
| P39.8 | ICD10CM | Covered |
| R04.2 | ICD10CM | Covered |
| R04.81 | ICD10CM | Covered |
| R04.89 | ICD10CM | Covered |
| R04.9 | ICD10CM | Covered |
| R05.1 | ICD10CM | Covered |
| R05.2 | ICD10CM | Covered |
| R05.3 | ICD10CM | Covered |
| R06.00 | ICD10CM | Covered |
| R06.01 | ICD10CM | Covered |
| R06.02 | ICD10CM | Covered |
| R06.03 | ICD10CM | Covered |
| R06.09 | ICD10CM | Covered |
| R06.1 | ICD10CM | Covered |
| R06.2 | ICD10CM | Covered |
| R06.3 | ICD10CM | Covered |
| R06.4 | ICD10CM | Covered |
| R06.81 | ICD10CM | Covered |
| R06.82 | ICD10CM | Covered |
| R06.89 | ICD10CM | Covered |
| R07.1 | ICD10CM | Covered |
| R07.81 | ICD10CM | Covered |
| R09.01 | ICD10CM | Covered |
| R09.02 | ICD10CM | Covered |
| R09.1 | ICD10CM | Covered |
| R09.2 | ICD10CM | Covered |
| R09.89 | ICD10CM | Covered |
| R68.13 | ICD10CM | Covered |
| R79.81 | ICD10CM | Covered |
| R91.8 | ICD10CM | Covered |
| R94.2 | ICD10CM | Covered |
| S20.213A | ICD10CM | Covered |
| S20.214A | ICD10CM | Covered |
| S20.223A | ICD10CM | Covered |
| S20.224A | ICD10CM | Covered |
| S20.343A | ICD10CM | Covered |
| S20.344A | ICD10CM | Covered |
| S21.301A | ICD10CM | Covered |
| S21.301D | ICD10CM | Covered |
| S21.301S | ICD10CM | Covered |
| S21.302A | ICD10CM | Covered |
| S21.302D | ICD10CM | Covered |
| S21.302S | ICD10CM | Covered |
| S21.309A | ICD10CM | Covered |
| S21.309D | ICD10CM | Covered |
| S21.309S | ICD10CM | Covered |
| S21.311A | ICD10CM | Covered |
| S21.311D | ICD10CM | Covered |
| S21.311S | ICD10CM | Covered |
| S21.312A | ICD10CM | Covered |
| S21.312D | ICD10CM | Covered |
| S21.312S | ICD10CM | Covered |
| S21.319A | ICD10CM | Covered |
| S21.319D | ICD10CM | Covered |
| S21.319S | ICD10CM | Covered |
| S21.321A | ICD10CM | Covered |
| S21.321D | ICD10CM | Covered |
| S21.321S | ICD10CM | Covered |
| S21.322A | ICD10CM | Covered |
| S21.322D | ICD10CM | Covered |
| S21.322S | ICD10CM | Covered |
| S21.329A | ICD10CM | Covered |
| S21.329D | ICD10CM | Covered |
| S21.329S | ICD10CM | Covered |
| S21.331A | ICD10CM | Covered |
| S21.331D | ICD10CM | Covered |
| S21.331S | ICD10CM | Covered |
| S21.332A | ICD10CM | Covered |
| S21.332D | ICD10CM | Covered |
| S21.332S | ICD10CM | Covered |
| S21.339A | ICD10CM | Covered |
| S21.339D | ICD10CM | Covered |
| S21.339S | ICD10CM | Covered |
| S21.341A | ICD10CM | Covered |
| S21.341D | ICD10CM | Covered |
| S21.341S | ICD10CM | Covered |
| S21.342A | ICD10CM | Covered |
| S21.342D | ICD10CM | Covered |
| S21.342S | ICD10CM | Covered |
| S21.349A | ICD10CM | Covered |
| S21.349D | ICD10CM | Covered |
| S21.349S | ICD10CM | Covered |
| S21.351A | ICD10CM | Covered |
| S21.351D | ICD10CM | Covered |
| S21.351S | ICD10CM | Covered |
| S21.352A | ICD10CM | Covered |
| S21.352D | ICD10CM | Covered |
| S21.352S | ICD10CM | Covered |
| S21.359A | ICD10CM | Covered |
| S21.359D | ICD10CM | Covered |
| S21.359S | ICD10CM | Covered |
| S21.401A | ICD10CM | Covered |
| S21.401D | ICD10CM | Covered |
| S21.401S | ICD10CM | Covered |
| S21.402A | ICD10CM | Covered |
| S21.402D | ICD10CM | Covered |
| S21.402S | ICD10CM | Covered |
| S21.409A | ICD10CM | Covered |
| S21.409D | ICD10CM | Covered |
| S21.409S | ICD10CM | Covered |
| S21.411A | ICD10CM | Covered |
| S21.411D | ICD10CM | Covered |
| S21.411S | ICD10CM | Covered |
| S21.412A | ICD10CM | Covered |
| S21.412D | ICD10CM | Covered |
| S21.412S | ICD10CM | Covered |
| S21.419A | ICD10CM | Covered |
| S21.419D | ICD10CM | Covered |
| S21.419S | ICD10CM | Covered |
| S21.421A | ICD10CM | Covered |
| S21.421D | ICD10CM | Covered |
| S21.421S | ICD10CM | Covered |
| S21.422A | ICD10CM | Covered |
| S21.422D | ICD10CM | Covered |
| S21.422S | ICD10CM | Covered |
| S21.429A | ICD10CM | Covered |
| S21.429D | ICD10CM | Covered |
| S21.429S | ICD10CM | Covered |
| S21.431A | ICD10CM | Covered |
| S21.431D | ICD10CM | Covered |
| S21.431S | ICD10CM | Covered |
| S21.432A | ICD10CM | Covered |
| S21.432D | ICD10CM | Covered |
| S21.432S | ICD10CM | Covered |
| S21.439A | ICD10CM | Covered |
| S21.439D | ICD10CM | Covered |
| S21.439S | ICD10CM | Covered |
| S21.441A | ICD10CM | Covered |
| S21.441D | ICD10CM | Covered |
| S21.441S | ICD10CM | Covered |
| S21.442A | ICD10CM | Covered |
| S21.442D | ICD10CM | Covered |
| S21.442S | ICD10CM | Covered |
| S21.449A | ICD10CM | Covered |
| S21.449D | ICD10CM | Covered |
| S21.449S | ICD10CM | Covered |
| S21.451A | ICD10CM | Covered |
| S21.451D | ICD10CM | Covered |
| S21.451S | ICD10CM | Covered |
| S21.452A | ICD10CM | Covered |
| S21.452D | ICD10CM | Covered |
| S21.452S | ICD10CM | Covered |
| S21.459A | ICD10CM | Covered |
| S21.459D | ICD10CM | Covered |
| S21.459S | ICD10CM | Covered |
| S27.0XXA | ICD10CM | Covered |
| S27.0XXD | ICD10CM | Covered |
| S27.0XXS | ICD10CM | Covered |
| S27.1XXA | ICD10CM | Covered |
| S27.1XXD | ICD10CM | Covered |
| S27.1XXS | ICD10CM | Covered |
| S27.2XXA | ICD10CM | Covered |
| S27.2XXD | ICD10CM | Covered |
| S27.2XXS | ICD10CM | Covered |
| S27.301A | ICD10CM | Covered |
| S27.301D | ICD10CM | Covered |
| S27.301S | ICD10CM | Covered |
| S27.302A | ICD10CM | Covered |
| S27.302D | ICD10CM | Covered |
| S27.302S | ICD10CM | Covered |
| S27.309A | ICD10CM | Covered |
| S27.309D | ICD10CM | Covered |
| S27.309S | ICD10CM | Covered |
| S27.311A | ICD10CM | Covered |
| S27.311D | ICD10CM | Covered |
| S27.311S | ICD10CM | Covered |
| S27.312A | ICD10CM | Covered |
| S27.312D | ICD10CM | Covered |
| S27.312S | ICD10CM | Covered |
| S27.319A | ICD10CM | Covered |
| S27.319D | ICD10CM | Covered |
| S27.319S | ICD10CM | Covered |
| S27.321A | ICD10CM | Covered |
| S27.321D | ICD10CM | Covered |
| S27.321S | ICD10CM | Covered |
| S27.322A | ICD10CM | Covered |
| S27.322D | ICD10CM | Covered |
| S27.322S | ICD10CM | Covered |
| S27.329A | ICD10CM | Covered |
| S27.329D | ICD10CM | Covered |
| S27.329S | ICD10CM | Covered |
| S27.331A | ICD10CM | Covered |
| S27.331D | ICD10CM | Covered |
| S27.331S | ICD10CM | Covered |
| S27.332A | ICD10CM | Covered |
| S27.332D | ICD10CM | Covered |
| S27.332S | ICD10CM | Covered |
| S27.339A | ICD10CM | Covered |
| S27.339D | ICD10CM | Covered |
| S27.339S | ICD10CM | Covered |
| S27.391A | ICD10CM | Covered |
| S27.391D | ICD10CM | Covered |
| S27.391S | ICD10CM | Covered |
| S27.392A | ICD10CM | Covered |
| S27.392D | ICD10CM | Covered |
| S27.392S | ICD10CM | Covered |
| S27.399A | ICD10CM | Covered |
| S27.399D | ICD10CM | Covered |
| S27.399S | ICD10CM | Covered |
| S27.401A | ICD10CM | Covered |
| S27.401D | ICD10CM | Covered |
| S27.401S | ICD10CM | Covered |
| S27.402A | ICD10CM | Covered |
| S27.402D | ICD10CM | Covered |
| S27.402S | ICD10CM | Covered |
| S27.409A | ICD10CM | Covered |
| S27.409D | ICD10CM | Covered |
| S27.409S | ICD10CM | Covered |
| S27.411A | ICD10CM | Covered |
| S27.411D | ICD10CM | Covered |
| S27.411S | ICD10CM | Covered |
| S27.412A | ICD10CM | Covered |
| S27.412D | ICD10CM | Covered |
| S27.412S | ICD10CM | Covered |
| S27.419A | ICD10CM | Covered |
| S27.419D | ICD10CM | Covered |
| S27.419S | ICD10CM | Covered |
| S27.421A | ICD10CM | Covered |
| S27.421D | ICD10CM | Covered |
| S27.421S | ICD10CM | Covered |
| S27.422A | ICD10CM | Covered |
| S27.422D | ICD10CM | Covered |
| S27.422S | ICD10CM | Covered |
| S27.429A | ICD10CM | Covered |
| S27.429D | ICD10CM | Covered |
| S27.429S | ICD10CM | Covered |
| S27.431A | ICD10CM | Covered |
| S27.431D | ICD10CM | Covered |
| S27.431S | ICD10CM | Covered |
| S27.432A | ICD10CM | Covered |
| S27.432D | ICD10CM | Covered |
| S27.432S | ICD10CM | Covered |
| S27.439A | ICD10CM | Covered |
| S27.439D | ICD10CM | Covered |
| S27.439S | ICD10CM | Covered |
| S27.491A | ICD10CM | Covered |
| S27.491D | ICD10CM | Covered |
| S27.491S | ICD10CM | Covered |
| S27.492A | ICD10CM | Covered |
| S27.492D | ICD10CM | Covered |
| S27.492S | ICD10CM | Covered |
| S27.499A | ICD10CM | Covered |
| S27.499D | ICD10CM | Covered |
| S27.499S | ICD10CM | Covered |
| S27.50XA | ICD10CM | Covered |
| S27.50XD | ICD10CM | Covered |
| S27.50XS | ICD10CM | Covered |
| S27.51XA | ICD10CM | Covered |
| S27.51XD | ICD10CM | Covered |
| S27.51XS | ICD10CM | Covered |
| S27.52XD | ICD10CM | Covered |
| S27.52XS | ICD10CM | Covered |
| S27.53XA | ICD10CM | Covered |
| S27.53XD | ICD10CM | Covered |
| S27.53XS | ICD10CM | Covered |
| S27.59XA | ICD10CM | Covered |
| S27.59XD | ICD10CM | Covered |
| S27.59XS | ICD10CM | Covered |
| S27.60XA | ICD10CM | Covered |
| S27.60XD | ICD10CM | Covered |
| S27.60XS | ICD10CM | Covered |
| S27.63XA | ICD10CM | Covered |
| S27.63XD | ICD10CM | Covered |
| S27.63XS | ICD10CM | Covered |
| S27.69XA | ICD10CM | Covered |
| S27.69XD | ICD10CM | Covered |
| S27.69XS | ICD10CM | Covered |
| S27.802A | ICD10CM | Covered |
| S27.802D | ICD10CM | Covered |
| S27.802S | ICD10CM | Covered |
| S27.803A | ICD10CM | Covered |
| S27.803D | ICD10CM | Covered |
| S27.803S | ICD10CM | Covered |
| S27.808A | ICD10CM | Covered |
| S27.808D | ICD10CM | Covered |
| S27.808S | ICD10CM | Covered |
| S27.809A | ICD10CM | Covered |
| S27.809D | ICD10CM | Covered |
| S27.809S | ICD10CM | Covered |
| S27.9XXA | ICD10CM | Covered |
| S27.9XXD | ICD10CM | Covered |
| S27.9XXS | ICD10CM | Covered |
| T17.508A | ICD10CM | Covered |
| T17.508D | ICD10CM | Covered |
| T17.508S | ICD10CM | Covered |
| T17.518A | ICD10CM | Covered |
| T17.518D | ICD10CM | Covered |
| T17.518S | ICD10CM | Covered |
| T17.528A | ICD10CM | Covered |
| T17.528D | ICD10CM | Covered |
| T17.528S | ICD10CM | Covered |
| T17.598A | ICD10CM | Covered |
| T17.598D | ICD10CM | Covered |
| T17.598S | ICD10CM | Covered |
| T53.5X1A | ICD10CM | Covered |
| T53.5X2A | ICD10CM | Covered |
| T53.5X3A | ICD10CM | Covered |
| T53.5X4A | ICD10CM | Covered |
| T57.3X1A | ICD10CM | Covered |
| T57.3X2A | ICD10CM | Covered |
| T57.3X3A | ICD10CM | Covered |
| T57.3X4A | ICD10CM | Covered |
| T59.0X1A | ICD10CM | Covered |
| T59.0X2A | ICD10CM | Covered |
| T59.0X3A | ICD10CM | Covered |
| T59.0X4A | ICD10CM | Covered |
| T59.1X1A | ICD10CM | Covered |
| T59.1X2A | ICD10CM | Covered |
| T59.1X3A | ICD10CM | Covered |
| T59.1X4A | ICD10CM | Covered |
| T59.2X1A | ICD10CM | Covered |
| T59.2X2A | ICD10CM | Covered |
| T59.2X3A | ICD10CM | Covered |
| T59.2X4A | ICD10CM | Covered |
| T59.3X1A | ICD10CM | Covered |
| T59.3X2A | ICD10CM | Covered |
| T59.3X3A | ICD10CM | Covered |
| T59.3X4A | ICD10CM | Covered |
| T59.4X1A | ICD10CM | Covered |
| T59.4X2A | ICD10CM | Covered |
| T59.4X3A | ICD10CM | Covered |
| T59.4X4A | ICD10CM | Covered |
| T59.5X1A | ICD10CM | Covered |
| T59.5X2A | ICD10CM | Covered |
| T59.5X3A | ICD10CM | Covered |
| T59.5X4A | ICD10CM | Covered |
| T59.6X1A | ICD10CM | Covered |
| T59.6X2A | ICD10CM | Covered |
| T59.6X3A | ICD10CM | Covered |
| T59.6X4A | ICD10CM | Covered |
| T59.7X1A | ICD10CM | Covered |
| T59.7X2A | ICD10CM | Covered |
| T59.7X3A | ICD10CM | Covered |
| T59.7X4A | ICD10CM | Covered |
| T59.811A | ICD10CM | Covered |
| T59.812A | ICD10CM | Covered |
| T59.813A | ICD10CM | Covered |
| T59.814A | ICD10CM | Covered |
| T59.891A | ICD10CM | Covered |
| T59.892A | ICD10CM | Covered |
| T59.893A | ICD10CM | Covered |
| T59.894A | ICD10CM | Covered |
| T59.91XA | ICD10CM | Covered |
| T59.92XA | ICD10CM | Covered |
| T59.93XA | ICD10CM | Covered |
| T59.94XA | ICD10CM | Covered |
| U09.9 | ICD10CM | Covered |
| Z43.0 | ICD10CM | Covered |
| Z48.24 | ICD10CM | Covered |
| Z48.280 | ICD10CM | Covered |
| Z53.32 | ICD10CM | Covered |
| Z79.899 | ICD10CM | Covered |
| Z93.0 | ICD10CM | Covered |
| Z94.2 | ICD10CM | Covered |
| Z94.3 | ICD10CM | Covered |
| Z99.11 | ICD10CM | Covered |