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 |
|---|---|---|
| 10060 | HCPCS | Covered |
| 10061 | HCPCS | Covered |
| 10080 | HCPCS | Covered |
| 10081 | HCPCS | Covered |
| 10140 | HCPCS | Covered |
| 10160 | HCPCS | Covered |
| 10180 | HCPCS | Covered |
| J34.0 | ICD10CM | Covered |
| K11.3 | ICD10CM | Covered |
| K12.2 | ICD10CM | Covered |
| K13.0 | ICD10CM | Covered |
| K61.31 | ICD10CM | Covered |
| K61.39 | ICD10CM | Covered |
| K61.5 | ICD10CM | Covered |
| K68.11 | ICD10CM | Covered |
| K68.12 | ICD10CM | Covered |
| K68.19 | ICD10CM | Covered |
| K68.3 | ICD10CM | Covered |
| K75.0 | ICD10CM | Covered |
| L02.01 | ICD10CM | Covered |
| L02.02 | ICD10CM | Covered |
| L02.03 | ICD10CM | Covered |
| L02.11 | ICD10CM | Covered |
| L02.12 | ICD10CM | Covered |
| L02.13 | ICD10CM | Covered |
| L02.211 | ICD10CM | Covered |
| L02.212 | ICD10CM | Covered |
| L02.213 | ICD10CM | Covered |
| L02.214 | ICD10CM | Covered |
| L02.215 | ICD10CM | Covered |
| L02.216 | ICD10CM | Covered |
| L02.217 | ICD10CM | Covered |
| L02.221 | ICD10CM | Covered |
| L02.222 | ICD10CM | Covered |
| L02.223 | ICD10CM | Covered |
| L02.224 | ICD10CM | Covered |
| L02.225 | ICD10CM | Covered |
| L02.226 | ICD10CM | Covered |
| L02.227 | ICD10CM | Covered |
| L02.231 | ICD10CM | Covered |
| L02.232 | ICD10CM | Covered |
| L02.233 | ICD10CM | Covered |
| L02.234 | ICD10CM | Covered |
| L02.235 | ICD10CM | Covered |
| L02.236 | ICD10CM | Covered |
| L02.237 | ICD10CM | Covered |
| L02.31 | ICD10CM | Covered |
| L02.32 | ICD10CM | Covered |
| L02.33 | ICD10CM | Covered |
| L02.411 | ICD10CM | Covered |
| L02.412 | ICD10CM | Covered |
| L02.413 | ICD10CM | Covered |
| L02.414 | ICD10CM | Covered |
| L02.415 | ICD10CM | Covered |
| L02.416 | ICD10CM | Covered |
| L02.421 | ICD10CM | Covered |
| L02.422 | ICD10CM | Covered |
| L02.423 | ICD10CM | Covered |
| L02.424 | ICD10CM | Covered |
| L02.425 | ICD10CM | Covered |
| L02.426 | ICD10CM | Covered |
| L02.431 | ICD10CM | Covered |
| L02.432 | ICD10CM | Covered |
| L02.433 | ICD10CM | Covered |
| L02.434 | ICD10CM | Covered |
| L02.435 | ICD10CM | Covered |
| L02.436 | ICD10CM | Covered |
| L02.511 | ICD10CM | Covered |
| L02.512 | ICD10CM | Covered |
| L02.521 | ICD10CM | Covered |
| L02.522 | ICD10CM | Covered |
| L02.531 | ICD10CM | Covered |
| L02.532 | ICD10CM | Covered |
| L02.611 | ICD10CM | Covered |
| L02.612 | ICD10CM | Covered |
| L02.621 | ICD10CM | Covered |
| L02.622 | ICD10CM | Covered |
| L02.631 | ICD10CM | Covered |
| L02.632 | ICD10CM | Covered |
| L02.811 | ICD10CM | Covered |
| L02.818 | ICD10CM | Covered |
| L02.821 | ICD10CM | Covered |
| L02.828 | ICD10CM | Covered |
| L02.831 | ICD10CM | Covered |
| L02.838 | ICD10CM | Covered |
| L03.011 | ICD10CM | Covered |
| L03.012 | ICD10CM | Covered |
| L03.021 | ICD10CM | Covered |
| L03.022 | ICD10CM | Covered |
| L03.031 | ICD10CM | Covered |
| L03.032 | ICD10CM | Covered |
| L03.041 | ICD10CM | Covered |
| L03.042 | ICD10CM | Covered |
| L03.111 | ICD10CM | Covered |
| L03.112 | ICD10CM | Covered |
| L03.113 | ICD10CM | Covered |
| L03.114 | ICD10CM | Covered |
| L03.115 | ICD10CM | Covered |
| L03.116 | ICD10CM | Covered |
| L03.121 | ICD10CM | Covered |
| L03.122 | ICD10CM | Covered |
| L03.123 | ICD10CM | Covered |
| L03.124 | ICD10CM | Covered |
| L03.125 | ICD10CM | Covered |
| L03.126 | ICD10CM | Covered |
| L03.211 | ICD10CM | Covered |
| L03.212 | ICD10CM | Covered |
| L03.213 | ICD10CM | Covered |
| L03.221 | ICD10CM | Covered |
| L03.222 | ICD10CM | Covered |
| L03.311 | ICD10CM | Covered |
| L03.312 | ICD10CM | Covered |
| L03.313 | ICD10CM | Covered |
| L03.314 | ICD10CM | Covered |
| L03.315 | ICD10CM | Covered |
| L03.316 | ICD10CM | Covered |
| L03.317 | ICD10CM | Covered |
| L03.31A | ICD10CM | Covered |
| L03.321 | ICD10CM | Covered |
| L03.322 | ICD10CM | Covered |
| L03.323 | ICD10CM | Covered |
| L03.324 | ICD10CM | Covered |
| L03.325 | ICD10CM | Covered |
| L03.326 | ICD10CM | Covered |
| L03.327 | ICD10CM | Covered |
| L03.32A | ICD10CM | Covered |
| L03.811 | ICD10CM | Covered |
| L03.818 | ICD10CM | Covered |
| L03.891 | ICD10CM | Covered |
| L03.898 | ICD10CM | Covered |
| L05.01 | ICD10CM | Covered |
| L05.02 | ICD10CM | Covered |
| L05.91 | ICD10CM | Covered |
| L05.92 | ICD10CM | Covered |
| L44.8 | ICD10CM | Covered |
| L45 | ICD10CM | Covered |
| L72.0 | ICD10CM | Covered |
| L72.2 | ICD10CM | Covered |
| L72.3 | ICD10CM | Covered |
| L72.8 | ICD10CM | Covered |
| L73.2 | ICD10CM | Covered |
| L76.01 | ICD10CM | Covered |
| L76.02 | ICD10CM | Covered |
| L76.21 | ICD10CM | Covered |
| L76.22 | ICD10CM | Covered |
| L76.31 | ICD10CM | Covered |
| L76.32 | ICD10CM | Covered |
| L76.33 | ICD10CM | Covered |
| L76.34 | ICD10CM | Covered |
| L94.2 | ICD10CM | Covered |
| L94.4 | ICD10CM | Covered |
| L98.3 | ICD10CM | Covered |
| L98.8 | ICD10CM | Covered |
| L99 | ICD10CM | Covered |
| M23.000 | ICD10CM | Covered |
| M23.001 | ICD10CM | Covered |
| M23.003 | ICD10CM | Covered |
| M23.004 | ICD10CM | Covered |
| M23.006 | ICD10CM | Covered |
| M23.007 | ICD10CM | Covered |
| M23.011 | ICD10CM | Covered |
| M23.012 | ICD10CM | Covered |
| M23.021 | ICD10CM | Covered |
| M23.022 | ICD10CM | Covered |
| M23.031 | ICD10CM | Covered |
| M23.032 | ICD10CM | Covered |
| M23.041 | ICD10CM | Covered |
| M23.042 | ICD10CM | Covered |
| M23.051 | ICD10CM | Covered |
| M23.052 | ICD10CM | Covered |
| M23.061 | ICD10CM | Covered |
| M23.062 | ICD10CM | Covered |
| M66.0 | ICD10CM | Covered |
| M71.21 | ICD10CM | Covered |
| M71.22 | ICD10CM | Covered |
| N60.01 | ICD10CM | Covered |
| N60.02 | ICD10CM | Covered |
| N61.1 | ICD10CM | Covered |
| N83.201 | ICD10CM | Covered |
| N83.202 | ICD10CM | Covered |
| N83.291 | ICD10CM | Covered |
| N83.292 | ICD10CM | Covered |
| N88.8 | ICD10CM | Covered |
| N89.8 | ICD10CM | Covered |
| N90.7 | ICD10CM | Covered |
| O91.011 | ICD10CM | Covered |
| O91.012 | ICD10CM | Covered |
| O91.013 | ICD10CM | Covered |
| O91.02 | ICD10CM | Covered |
| O91.03 | ICD10CM | Covered |
| O91.111 | ICD10CM | Covered |
| O91.112 | ICD10CM | Covered |
| O91.113 | ICD10CM | Covered |
| O91.12 | ICD10CM | Covered |
| O91.13 | ICD10CM | Covered |
| S00.03XA | ICD10CM | Covered |
| S00.03XD | ICD10CM | Covered |
| S00.03XS | ICD10CM | Covered |
| S00.33XA | ICD10CM | Covered |
| S00.33XD | ICD10CM | Covered |
| S00.33XS | ICD10CM | Covered |
| S00.431A | ICD10CM | Covered |
| S00.431D | ICD10CM | Covered |
| S00.431S | ICD10CM | Covered |
| S00.432A | ICD10CM | Covered |
| S00.432D | ICD10CM | Covered |
| S00.432S | ICD10CM | Covered |
| S00.531A | ICD10CM | Covered |
| S00.531D | ICD10CM | Covered |
| S00.531S | ICD10CM | Covered |
| S00.532A | ICD10CM | Covered |
| S00.532D | ICD10CM | Covered |
| S00.532S | ICD10CM | Covered |
| S00.83XA | ICD10CM | Covered |
| S00.83XD | ICD10CM | Covered |
| S00.83XS | ICD10CM | Covered |
| S07.0XXA | ICD10CM | Covered |
| S07.0XXD | ICD10CM | Covered |
| S07.0XXS | ICD10CM | Covered |
| S07.1XXA | ICD10CM | Covered |
| S07.1XXD | ICD10CM | Covered |
| S07.1XXS | ICD10CM | Covered |
| S07.8XXA | ICD10CM | Covered |
| S07.8XXD | ICD10CM | Covered |
| S07.8XXS | ICD10CM | Covered |
| S10.0XXA | ICD10CM | Covered |
| S10.0XXD | ICD10CM | Covered |
| S10.0XXS | ICD10CM | Covered |
| S10.83XA | ICD10CM | Covered |
| S10.83XD | ICD10CM | Covered |
| S10.83XS | ICD10CM | Covered |
| S17.0XXA | ICD10CM | Covered |
| S17.0XXD | ICD10CM | Covered |
| S17.0XXS | ICD10CM | Covered |
| S17.8XXA | ICD10CM | Covered |
| S17.8XXD | ICD10CM | Covered |
| S17.8XXS | ICD10CM | Covered |
| S20.01XA | ICD10CM | Covered |
| S20.01XD | ICD10CM | Covered |
| S20.01XS | ICD10CM | Covered |
| S20.02XA | ICD10CM | Covered |
| S20.02XD | ICD10CM | Covered |
| S20.02XS | ICD10CM | Covered |
| S20.211A | ICD10CM | Covered |
| S20.211D | ICD10CM | Covered |
| S20.211S | ICD10CM | Covered |
| S20.212A | ICD10CM | Covered |
| S20.212D | ICD10CM | Covered |
| S20.212S | ICD10CM | Covered |
| S20.221A | ICD10CM | Covered |
| S20.221D | ICD10CM | Covered |
| S20.221S | ICD10CM | Covered |
| S20.222A | ICD10CM | Covered |
| S20.222D | ICD10CM | Covered |
| S20.222S | ICD10CM | Covered |
| S28.0XXA | ICD10CM | Covered |
| S28.0XXD | ICD10CM | Covered |
| S28.0XXS | ICD10CM | Covered |
| S30.0XXA | ICD10CM | Covered |
| S30.0XXD | ICD10CM | Covered |
| S30.0XXS | ICD10CM | Covered |
| S30.11XA | ICD10CM | Covered |
| S30.11XD | ICD10CM | Covered |
| S30.11XS | ICD10CM | Covered |
| S30.12XA | ICD10CM | Covered |
| S30.12XD | ICD10CM | Covered |
| S30.12XS | ICD10CM | Covered |
| S30.13XA | ICD10CM | Covered |
| S30.13XD | ICD10CM | Covered |
| S30.13XS | ICD10CM | Covered |
| S30.21XA | ICD10CM | Covered |
| S30.21XD | ICD10CM | Covered |
| S30.21XS | ICD10CM | Covered |
| S30.22XA | ICD10CM | Covered |
| S30.22XD | ICD10CM | Covered |
| S30.22XS | ICD10CM | Covered |
| S30.23XA | ICD10CM | Covered |
| S30.23XD | ICD10CM | Covered |
| S30.23XS | ICD10CM | Covered |
| S30.3XXA | ICD10CM | Covered |
| S30.3XXD | ICD10CM | Covered |
| S30.3XXS | ICD10CM | Covered |
| S38.01XA | ICD10CM | Covered |
| S38.01XD | ICD10CM | Covered |
| S38.01XS | ICD10CM | Covered |
| S38.02XA | ICD10CM | Covered |
| S38.02XD | ICD10CM | Covered |
| S38.02XS | ICD10CM | Covered |
| S38.03XA | ICD10CM | Covered |
| S38.03XD | ICD10CM | Covered |
| S38.03XS | ICD10CM | Covered |
| S38.1XXA | ICD10CM | Covered |
| S38.1XXD | ICD10CM | Covered |
| S38.1XXS | ICD10CM | Covered |
| S40.011A | ICD10CM | Covered |
| S40.011D | ICD10CM | Covered |
| S40.011S | ICD10CM | Covered |
| S40.012A | ICD10CM | Covered |
| S40.012D | ICD10CM | Covered |
| S40.012S | ICD10CM | Covered |
| S40.021A | ICD10CM | Covered |
| S40.021D | ICD10CM | Covered |
| S40.021S | ICD10CM | Covered |
| S40.022A | ICD10CM | Covered |
| S40.022D | ICD10CM | Covered |
| S40.022S | ICD10CM | Covered |
| S47.1XXA | ICD10CM | Covered |
| S47.1XXD | ICD10CM | Covered |
| S47.1XXS | ICD10CM | Covered |
| S47.2XXA | ICD10CM | Covered |
| S47.2XXD | ICD10CM | Covered |
| S47.2XXS | ICD10CM | Covered |
| S50.01XA | ICD10CM | Covered |
| S50.01XD | ICD10CM | Covered |
| S50.01XS | ICD10CM | Covered |
| S50.02XA | ICD10CM | Covered |
| S50.02XD | ICD10CM | Covered |
| S50.02XS | ICD10CM | Covered |
| S50.11XA | ICD10CM | Covered |
| S50.11XD | ICD10CM | Covered |
| S50.11XS | ICD10CM | Covered |
| S50.12XA | ICD10CM | Covered |
| S50.12XD | ICD10CM | Covered |
| S50.12XS | ICD10CM | Covered |
| S57.01XA | ICD10CM | Covered |
| S57.01XD | ICD10CM | Covered |
| S57.01XS | ICD10CM | Covered |
| S57.02XA | ICD10CM | Covered |
| S57.02XD | ICD10CM | Covered |
| S57.02XS | ICD10CM | Covered |
| S57.81XA | ICD10CM | Covered |
| S57.81XD | ICD10CM | Covered |
| S57.81XS | ICD10CM | Covered |
| S57.82XA | ICD10CM | Covered |
| S57.82XD | ICD10CM | Covered |
| S57.82XS | ICD10CM | Covered |
| S60.011A | ICD10CM | Covered |
| S60.011D | ICD10CM | Covered |
| S60.011S | ICD10CM | Covered |
| S60.012A | ICD10CM | Covered |
| S60.012D | ICD10CM | Covered |
| S60.012S | ICD10CM | Covered |
| S60.021A | ICD10CM | Covered |
| S60.021D | ICD10CM | Covered |
| S60.021S | ICD10CM | Covered |
| S60.022A | ICD10CM | Covered |
| S60.022D | ICD10CM | Covered |
| S60.022S | ICD10CM | Covered |
| S60.031A | ICD10CM | Covered |
| S60.031D | ICD10CM | Covered |
| S60.031S | ICD10CM | Covered |
| S60.032A | ICD10CM | Covered |
| S60.032D | ICD10CM | Covered |
| S60.032S | ICD10CM | Covered |
| S60.041A | ICD10CM | Covered |
| S60.041D | ICD10CM | Covered |
| S60.041S | ICD10CM | Covered |
| S60.042A | ICD10CM | Covered |
| S60.042D | ICD10CM | Covered |
| S60.042S | ICD10CM | Covered |
| S60.051A | ICD10CM | Covered |
| S60.051D | ICD10CM | Covered |
| S60.051S | ICD10CM | Covered |
| S60.052A | ICD10CM | Covered |
| S60.052D | ICD10CM | Covered |
| S60.052S | ICD10CM | Covered |
| S60.111A | ICD10CM | Covered |
| S60.111D | ICD10CM | Covered |
| S60.111S | ICD10CM | Covered |
| S60.112A | ICD10CM | Covered |
| S60.112D | ICD10CM | Covered |
| S60.112S | ICD10CM | Covered |
| S60.121A | ICD10CM | Covered |
| S60.121D | ICD10CM | Covered |
| S60.121S | ICD10CM | Covered |
| S60.122A | ICD10CM | Covered |
| S60.122D | ICD10CM | Covered |
| S60.122S | ICD10CM | Covered |
| S60.131A | ICD10CM | Covered |
| S60.131D | ICD10CM | Covered |
| S60.131S | ICD10CM | Covered |
| S60.132A | ICD10CM | Covered |
| S60.132D | ICD10CM | Covered |
| S60.132S | ICD10CM | Covered |
| S60.141A | ICD10CM | Covered |
| S60.141D | ICD10CM | Covered |
| S60.141S | ICD10CM | Covered |
| S60.142A | ICD10CM | Covered |
| S60.142D | ICD10CM | Covered |
| S60.142S | ICD10CM | Covered |
| S60.151A | ICD10CM | Covered |
| S60.151D | ICD10CM | Covered |
| S60.151S | ICD10CM | Covered |
| S60.152A | ICD10CM | Covered |
| S60.152D | ICD10CM | Covered |
| S60.152S | ICD10CM | Covered |
| S60.211A | ICD10CM | Covered |
| S60.211D | ICD10CM | Covered |
| S60.211S | ICD10CM | Covered |
| S60.212A | ICD10CM | Covered |
| S60.212D | ICD10CM | Covered |
| S60.212S | ICD10CM | Covered |
| S60.221A | ICD10CM | Covered |
| S60.221D | ICD10CM | Covered |
| S60.221S | ICD10CM | Covered |
| S60.222A | ICD10CM | Covered |
| S60.222D | ICD10CM | Covered |
| S60.222S | ICD10CM | Covered |
| S67.01XA | ICD10CM | Covered |
| S67.01XD | ICD10CM | Covered |
| S67.01XS | ICD10CM | Covered |
| S67.02XA | ICD10CM | Covered |
| S67.02XD | ICD10CM | Covered |
| S67.02XS | ICD10CM | Covered |
| S67.190A | ICD10CM | Covered |
| S67.190D | ICD10CM | Covered |
| S67.190S | ICD10CM | Covered |
| S67.191A | ICD10CM | Covered |
| S67.191D | ICD10CM | Covered |
| S67.191S | ICD10CM | Covered |
| S67.192A | ICD10CM | Covered |
| S67.192D | ICD10CM | Covered |
| S67.192S | ICD10CM | Covered |
| S67.193A | ICD10CM | Covered |
| S67.193D | ICD10CM | Covered |
| S67.193S | ICD10CM | Covered |
| S67.194A | ICD10CM | Covered |
| S67.194D | ICD10CM | Covered |
| S67.194S | ICD10CM | Covered |
| S67.195A | ICD10CM | Covered |
| S67.195D | ICD10CM | Covered |
| S67.195S | ICD10CM | Covered |
| S67.196A | ICD10CM | Covered |
| S67.196D | ICD10CM | Covered |
| S67.196S | ICD10CM | Covered |
| S67.197A | ICD10CM | Covered |
| S67.197D | ICD10CM | Covered |
| S67.197S | ICD10CM | Covered |
| S67.198A | ICD10CM | Covered |
| S67.198D | ICD10CM | Covered |
| S67.198S | ICD10CM | Covered |
| S67.21XA | ICD10CM | Covered |
| S67.21XD | ICD10CM | Covered |
| S67.21XS | ICD10CM | Covered |
| S67.22XA | ICD10CM | Covered |
| S67.22XD | ICD10CM | Covered |
| S67.22XS | ICD10CM | Covered |
| S67.31XA | ICD10CM | Covered |
| S67.31XD | ICD10CM | Covered |
| S67.31XS | ICD10CM | Covered |
| S67.32XA | ICD10CM | Covered |
| S67.32XD | ICD10CM | Covered |
| S67.32XS | ICD10CM | Covered |
| S67.41XA | ICD10CM | Covered |
| S67.41XD | ICD10CM | Covered |
| S67.41XS | ICD10CM | Covered |
| S67.42XA | ICD10CM | Covered |
| S67.42XD | ICD10CM | Covered |
| S67.42XS | ICD10CM | Covered |
| S70.01XA | ICD10CM | Covered |
| S70.01XD | ICD10CM | Covered |
| S70.01XS | ICD10CM | Covered |
| S70.02XA | ICD10CM | Covered |
| S70.02XD | ICD10CM | Covered |
| S70.02XS | ICD10CM | Covered |
| S70.11XA | ICD10CM | Covered |
| S70.11XD | ICD10CM | Covered |
| S70.11XS | ICD10CM | Covered |
| S70.12XA | ICD10CM | Covered |
| S70.12XD | ICD10CM | Covered |
| S70.12XS | ICD10CM | Covered |
| S77.01XA | ICD10CM | Covered |
| S77.01XD | ICD10CM | Covered |
| S77.01XS | ICD10CM | Covered |
| S77.02XA | ICD10CM | Covered |
| S77.02XD | ICD10CM | Covered |
| S77.02XS | ICD10CM | Covered |
| S77.11XA | ICD10CM | Covered |
| S77.11XD | ICD10CM | Covered |
| S77.11XS | ICD10CM | Covered |
| S77.12XA | ICD10CM | Covered |
| S77.12XD | ICD10CM | Covered |
| S77.12XS | ICD10CM | Covered |
| S77.21XA | ICD10CM | Covered |
| S77.21XD | ICD10CM | Covered |
| S77.21XS | ICD10CM | Covered |
| S77.22XA | ICD10CM | Covered |
| S77.22XD | ICD10CM | Covered |
| S77.22XS | ICD10CM | Covered |
| S80.01XA | ICD10CM | Covered |
| S80.01XD | ICD10CM | Covered |
| S80.01XS | ICD10CM | Covered |
| S80.02XA | ICD10CM | Covered |
| S80.02XD | ICD10CM | Covered |
| S80.02XS | ICD10CM | Covered |
| S80.11XA | ICD10CM | Covered |
| S80.11XD | ICD10CM | Covered |
| S80.11XS | ICD10CM | Covered |
| S80.12XA | ICD10CM | Covered |
| S80.12XD | ICD10CM | Covered |
| S80.12XS | ICD10CM | Covered |
| S87.01XA | ICD10CM | Covered |
| S87.01XD | ICD10CM | Covered |
| S87.01XS | ICD10CM | Covered |
| S87.02XA | ICD10CM | Covered |
| S87.02XD | ICD10CM | Covered |
| S87.02XS | ICD10CM | Covered |
| S87.81XA | ICD10CM | Covered |
| S87.81XD | ICD10CM | Covered |
| S87.81XS | ICD10CM | Covered |
| S87.82XA | ICD10CM | Covered |
| S87.82XD | ICD10CM | Covered |
| S87.82XS | ICD10CM | Covered |
| S90.01XA | ICD10CM | Covered |
| S90.01XD | ICD10CM | Covered |
| S90.01XS | ICD10CM | Covered |
| S90.02XA | ICD10CM | Covered |
| S90.02XD | ICD10CM | Covered |
| S90.02XS | ICD10CM | Covered |
| S90.111A | ICD10CM | Covered |
| S90.111D | ICD10CM | Covered |
| S90.111S | ICD10CM | Covered |
| S90.112A | ICD10CM | Covered |
| S90.112D | ICD10CM | Covered |
| S90.112S | ICD10CM | Covered |
| S90.121A | ICD10CM | Covered |
| S90.121D | ICD10CM | Covered |
| S90.121S | ICD10CM | Covered |
| S90.122A | ICD10CM | Covered |
| S90.122D | ICD10CM | Covered |
| S90.122S | ICD10CM | Covered |
| S90.211A | ICD10CM | Covered |
| S90.211D | ICD10CM | Covered |
| S90.211S | ICD10CM | Covered |
| S90.212A | ICD10CM | Covered |
| S90.212D | ICD10CM | Covered |
| S90.212S | ICD10CM | Covered |
| S90.221A | ICD10CM | Covered |
| S90.221D | ICD10CM | Covered |
| S90.221S | ICD10CM | Covered |
| S90.222A | ICD10CM | Covered |
| S90.222D | ICD10CM | Covered |
| S90.222S | ICD10CM | Covered |
| S90.31XA | ICD10CM | Covered |
| S90.31XD | ICD10CM | Covered |
| S90.31XS | ICD10CM | Covered |
| S90.32XA | ICD10CM | Covered |
| S90.32XD | ICD10CM | Covered |
| S90.32XS | ICD10CM | Covered |
| S97.01XA | ICD10CM | Covered |
| S97.01XD | ICD10CM | Covered |
| S97.01XS | ICD10CM | Covered |
| S97.02XA | ICD10CM | Covered |
| S97.02XD | ICD10CM | Covered |
| S97.02XS | ICD10CM | Covered |
| S97.111A | ICD10CM | Covered |
| S97.111D | ICD10CM | Covered |
| S97.111S | ICD10CM | Covered |
| S97.112A | ICD10CM | Covered |
| S97.112D | ICD10CM | Covered |
| S97.112S | ICD10CM | Covered |
| S97.121A | ICD10CM | Covered |
| S97.121D | ICD10CM | Covered |
| S97.121S | ICD10CM | Covered |
| S97.122A | ICD10CM | Covered |
| S97.122D | ICD10CM | Covered |
| S97.122S | ICD10CM | Covered |
| S97.81XA | ICD10CM | Covered |
| S97.81XD | ICD10CM | Covered |
| S97.81XS | ICD10CM | Covered |
| S97.82XA | ICD10CM | Covered |
| S97.82XD | ICD10CM | Covered |
| S97.82XS | ICD10CM | Covered |
| T81.31XA | ICD10CM | Covered |
| T81.31XD | ICD10CM | Covered |
| T81.31XS | ICD10CM | Covered |
| T81.41XA | ICD10CM | Covered |
| T81.41XD | ICD10CM | Covered |
| T81.41XS | ICD10CM | Covered |
| T81.42XA | ICD10CM | Covered |
| T81.42XD | ICD10CM | Covered |
| T81.42XS | ICD10CM | Covered |
| T81.43XA | ICD10CM | Covered |
| T81.43XD | ICD10CM | Covered |
| T81.43XS | ICD10CM | Covered |
| T81.44XA | ICD10CM | Covered |
| T81.44XD | ICD10CM | Covered |
| T81.44XS | ICD10CM | Covered |
| T81.49XA | ICD10CM | Covered |
| T81.49XD | ICD10CM | Covered |
| T81.49XS | ICD10CM | Covered |
| T82.898A | ICD10CM | Covered |
| T82.898D | ICD10CM | Covered |
| T82.898S | ICD10CM | Covered |
| T88.8XXA | ICD10CM | Covered |
| T88.8XXD | ICD10CM | Covered |
| T88.8XXS | ICD10CM | Covered |