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 1,664 codes. The source has the full list.
| Code | Code system | Status in this policy |
|---|---|---|
| 92651 | HCPCS | Covered |
| 92652 | HCPCS | Covered |
| 92653 | HCPCS | Covered |
| 95925 | HCPCS | Covered |
| 95926 | HCPCS | Covered |
| 95927 | HCPCS | Covered |
| 95928 | HCPCS | Covered |
| 95929 | HCPCS | Covered |
| 95930 | HCPCS | Covered |
| 95938 | HCPCS | Covered |
| 95939 | HCPCS | Covered |
| A39.82 | ICD10CM | Covered |
| A52.11 | ICD10CM | Covered |
| A52.13 | ICD10CM | Covered |
| A52.14 | ICD10CM | Covered |
| A52.15 | ICD10CM | Covered |
| A52.17 | ICD10CM | Covered |
| A52.19 | ICD10CM | Covered |
| A69.21 | ICD10CM | Covered |
| A69.22 | ICD10CM | Covered |
| A69.23 | ICD10CM | Covered |
| A69.29 | ICD10CM | Covered |
| A83.0 | ICD10CM | Covered |
| A83.1 | ICD10CM | Covered |
| A83.2 | ICD10CM | Covered |
| A83.3 | ICD10CM | Covered |
| A83.4 | ICD10CM | Covered |
| A83.5 | ICD10CM | Covered |
| A83.6 | ICD10CM | Covered |
| A83.8 | ICD10CM | Covered |
| A84.0 | ICD10CM | Covered |
| A84.1 | ICD10CM | Covered |
| A84.81 | ICD10CM | Covered |
| A84.89 | ICD10CM | Covered |
| A85.2 | ICD10CM | Covered |
| B00.4 | ICD10CM | Covered |
| B00.82 | ICD10CM | Covered |
| B02.24 | ICD10CM | Covered |
| B05.0 | ICD10CM | Covered |
| B06.01 | ICD10CM | Covered |
| C41.2 | ICD10CM | Covered |
| C70.0 | ICD10CM | Covered |
| C70.1 | ICD10CM | Covered |
| C71.6 | ICD10CM | Covered |
| C72.0 | ICD10CM | Covered |
| C72.1 | ICD10CM | Covered |
| C72.21 | ICD10CM | Covered |
| C72.22 | ICD10CM | Covered |
| C72.31 | ICD10CM | Covered |
| C72.32 | ICD10CM | Covered |
| C72.41 | ICD10CM | Covered |
| C72.42 | ICD10CM | Covered |
| C72.59 | ICD10CM | Covered |
| C79.31 | ICD10CM | Covered |
| C79.32 | ICD10CM | Covered |
| C79.49 | ICD10CM | Covered |
| D32.0 | ICD10CM | Covered |
| D32.1 | ICD10CM | Covered |
| D33.0 | ICD10CM | Covered |
| D33.1 | ICD10CM | Covered |
| D33.3 | ICD10CM | Covered |
| D33.4 | ICD10CM | Covered |
| D33.7 | ICD10CM | Covered |
| D42.0 | ICD10CM | Covered |
| D42.1 | ICD10CM | Covered |
| D43.0 | ICD10CM | Covered |
| D43.1 | ICD10CM | Covered |
| D43.4 | ICD10CM | Covered |
| D44.3 | ICD10CM | Covered |
| D44.4 | ICD10CM | Covered |
| D44.5 | ICD10CM | Covered |
| E03.5 | ICD10CM | Covered |
| E08.42 | ICD10CM | Covered |
| E09.42 | ICD10CM | Covered |
| E10.42 | ICD10CM | Covered |
| E11.42 | ICD10CM | Covered |
| E13.42 | ICD10CM | Covered |
| E71.50 | ICD10CM | Covered |
| E71.510 | ICD10CM | Covered |
| E71.511 | ICD10CM | Covered |
| E71.518 | ICD10CM | Covered |
| E71.520 | ICD10CM | Covered |
| E71.521 | ICD10CM | Covered |
| E71.522 | ICD10CM | Covered |
| E71.528 | ICD10CM | Covered |
| E71.53 | ICD10CM | Covered |
| E71.540 | ICD10CM | Covered |
| E71.541 | ICD10CM | Covered |
| E71.542 | ICD10CM | Covered |
| E71.548 | ICD10CM | Covered |
| E75.23 | ICD10CM | Covered |
| E75.25 | ICD10CM | Covered |
| E75.27 | ICD10CM | Covered |
| E75.29 | ICD10CM | Covered |
| F44.4 | ICD10CM | Covered |
| F44.5 | ICD10CM | Covered |
| F44.6 | ICD10CM | Covered |
| F44.7 | ICD10CM | Covered |
| G05.4 | ICD10CM | Covered |
| G06.1 | ICD10CM | Covered |
| G10 | ICD10CM | Covered |
| G11.0 | ICD10CM | Covered |
| G11.11 | ICD10CM | Covered |
| G11.19 | ICD10CM | Covered |
| G11.2 | ICD10CM | Covered |
| G11.3 | ICD10CM | Covered |
| G11.4 | ICD10CM | Covered |
| G11.8 | ICD10CM | Covered |
| G13.0 | ICD10CM | Covered |
| G13.1 | ICD10CM | Covered |
| G21.0 | ICD10CM | Covered |
| G23.0 | ICD10CM | Covered |
| G23.1 | ICD10CM | Covered |
| G23.2 | ICD10CM | Covered |
| G23.8 | ICD10CM | Covered |
| G23.9 | ICD10CM | Covered |
| G24.01 | ICD10CM | Covered |
| G24.02 | ICD10CM | Covered |
| G24.09 | ICD10CM | Covered |
| G24.1 | ICD10CM | Covered |
| G24.2 | ICD10CM | Covered |
| G24.3 | ICD10CM | Covered |
| G24.4 | ICD10CM | Covered |
| G24.5 | ICD10CM | Covered |
| G24.8 | ICD10CM | Covered |
| G24.9 | ICD10CM | Covered |
| G25.0 | ICD10CM | Covered |
| G25.1 | ICD10CM | Covered |
| G25.2 | ICD10CM | Covered |
| G25.3 | ICD10CM | Covered |
| G25.4 | ICD10CM | Covered |
| G25.5 | ICD10CM | Covered |
| G25.61 | ICD10CM | Covered |
| G25.69 | ICD10CM | Covered |
| G25.70 | ICD10CM | Covered |
| G25.71 | ICD10CM | Covered |
| G25.79 | ICD10CM | Covered |
| G25.81 | ICD10CM | Covered |
| G25.82 | ICD10CM | Covered |
| G25.83 | ICD10CM | Covered |
| G25.89 | ICD10CM | Covered |
| G26 | ICD10CM | Covered |
| G32.0 | ICD10CM | Covered |
| G32.81 | ICD10CM | Covered |
| G35.A | ICD10CM | Covered |
| G35.B0 | ICD10CM | Covered |
| G35.B1 | ICD10CM | Covered |
| G35.B2 | ICD10CM | Covered |
| G35.C0 | ICD10CM | Covered |
| G35.C1 | ICD10CM | Covered |
| G35.C2 | ICD10CM | Covered |
| G35.D | ICD10CM | Covered |
| G36.0 | ICD10CM | Covered |
| G36.1 | ICD10CM | Covered |
| G36.8 | ICD10CM | Covered |
| G37.0 | ICD10CM | Covered |
| G37.1 | ICD10CM | Covered |
| G37.2 | ICD10CM | Covered |
| G37.3 | ICD10CM | Covered |
| G37.4 | ICD10CM | Covered |
| G37.5 | ICD10CM | Covered |
| G37.81 | ICD10CM | Covered |
| G37.89 | ICD10CM | Covered |
| G37.9 | ICD10CM | Covered |
| G45.0 | ICD10CM | Covered |
| G45.1 | ICD10CM | Covered |
| G45.2 | ICD10CM | Covered |
| G45.8 | ICD10CM | Covered |
| G46.0 | ICD10CM | Covered |
| G46.1 | ICD10CM | Covered |
| G46.2 | ICD10CM | Covered |
| G51.0 | ICD10CM | Covered |
| G51.1 | ICD10CM | Covered |
| G51.2 | ICD10CM | Covered |
| G51.31 | ICD10CM | Covered |
| G51.32 | ICD10CM | Covered |
| G51.33 | ICD10CM | Covered |
| G51.4 | ICD10CM | Covered |
| G51.8 | ICD10CM | Covered |
| G54.0 | ICD10CM | Covered |
| G54.1 | ICD10CM | Covered |
| G54.2 | ICD10CM | Covered |
| G54.3 | ICD10CM | Covered |
| G54.4 | ICD10CM | Covered |
| G54.5 | ICD10CM | Covered |
| G54.6 | ICD10CM | Covered |
| G54.7 | ICD10CM | Covered |
| G54.8 | ICD10CM | Covered |
| G55 | ICD10CM | Covered |
| G56.41 | ICD10CM | Covered |
| G56.42 | ICD10CM | Covered |
| G56.43 | ICD10CM | Covered |
| G57.01 | ICD10CM | Covered |
| G57.02 | ICD10CM | Covered |
| G57.03 | ICD10CM | Covered |
| G57.11 | ICD10CM | Covered |
| G57.12 | ICD10CM | Covered |
| G57.13 | ICD10CM | Covered |
| G57.21 | ICD10CM | Covered |
| G57.22 | ICD10CM | Covered |
| G57.23 | ICD10CM | Covered |
| G57.31 | ICD10CM | Covered |
| G57.32 | ICD10CM | Covered |
| G57.33 | ICD10CM | Covered |
| G57.41 | ICD10CM | Covered |
| G57.42 | ICD10CM | Covered |
| G57.43 | ICD10CM | Covered |
| G57.51 | ICD10CM | Covered |
| G57.52 | ICD10CM | Covered |
| G57.53 | ICD10CM | Covered |
| G57.61 | ICD10CM | Covered |
| G57.62 | ICD10CM | Covered |
| G57.63 | ICD10CM | Covered |
| G57.71 | ICD10CM | Covered |
| G57.72 | ICD10CM | Covered |
| G57.73 | ICD10CM | Covered |
| G57.81 | ICD10CM | Covered |
| G57.82 | ICD10CM | Covered |
| G57.83 | ICD10CM | Covered |
| G58.7 | ICD10CM | Covered |
| G60.0 | ICD10CM | Covered |
| G60.1 | ICD10CM | Covered |
| G60.2 | ICD10CM | Covered |
| G60.3 | ICD10CM | Covered |
| G60.8 | ICD10CM | Covered |
| G61.0 | ICD10CM | Covered |
| G61.1 | ICD10CM | Covered |
| G61.81 | ICD10CM | Covered |
| G61.89 | ICD10CM | Covered |
| G62.0 | ICD10CM | Covered |
| G62.1 | ICD10CM | Covered |
| G62.2 | ICD10CM | Covered |
| G62.81 | ICD10CM | Covered |
| G62.82 | ICD10CM | Covered |
| G62.89 | ICD10CM | Covered |
| G63 | ICD10CM | Covered |
| G64 | ICD10CM | Covered |
| G65.0 | ICD10CM | Covered |
| G65.1 | ICD10CM | Covered |
| G65.2 | ICD10CM | Covered |
| G70.00 | ICD10CM | Covered |
| G70.01 | ICD10CM | Covered |
| G70.1 | ICD10CM | Covered |
| G70.2 | ICD10CM | Covered |
| G70.81 | ICD10CM | Covered |
| G70.89 | ICD10CM | Covered |
| G73.1 | ICD10CM | Covered |
| G73.3 | ICD10CM | Covered |
| G80.0 | ICD10CM | Covered |
| G80.1 | ICD10CM | Covered |
| G80.2 | ICD10CM | Covered |
| G80.3 | ICD10CM | Covered |
| G80.4 | ICD10CM | Covered |
| G80.8 | ICD10CM | Covered |
| G81.01 | ICD10CM | Covered |
| G81.02 | ICD10CM | Covered |
| G81.03 | ICD10CM | Covered |
| G81.04 | ICD10CM | Covered |
| G81.11 | ICD10CM | Covered |
| G81.12 | ICD10CM | Covered |
| G81.13 | ICD10CM | Covered |
| G81.14 | ICD10CM | Covered |
| G83.4 | ICD10CM | Covered |
| G90.3 | ICD10CM | Covered |
| G93.2 | ICD10CM | Covered |
| G95.0 | ICD10CM | Covered |
| G95.11 | ICD10CM | Covered |
| G95.19 | ICD10CM | Covered |
| G95.81 | ICD10CM | Covered |
| G95.89 | ICD10CM | Covered |
| G99.2 | ICD10CM | Covered |
| H35.54 | ICD10CM | Covered |
| H46.00 | ICD10CM | Covered |
| H46.01 | ICD10CM | Covered |
| H46.02 | ICD10CM | Covered |
| H46.03 | ICD10CM | Covered |
| H46.10 | ICD10CM | Covered |
| H46.11 | ICD10CM | Covered |
| H46.12 | ICD10CM | Covered |
| H46.13 | ICD10CM | Covered |
| H46.2 | ICD10CM | Covered |
| H46.3 | ICD10CM | Covered |
| H46.8 | ICD10CM | Covered |
| H46.9 | ICD10CM | Covered |
| H47.011 | ICD10CM | Covered |
| H47.012 | ICD10CM | Covered |
| H47.013 | ICD10CM | Covered |
| H47.021 | ICD10CM | Covered |
| H47.022 | ICD10CM | Covered |
| H47.023 | ICD10CM | Covered |
| H47.031 | ICD10CM | Covered |
| H47.032 | ICD10CM | Covered |
| H47.033 | ICD10CM | Covered |
| H47.091 | ICD10CM | Covered |
| H47.092 | ICD10CM | Covered |
| H47.093 | ICD10CM | Covered |
| H47.11 | ICD10CM | Covered |
| H47.12 | ICD10CM | Covered |
| H47.13 | ICD10CM | Covered |
| H47.141 | ICD10CM | Covered |
| H47.142 | ICD10CM | Covered |
| H47.143 | ICD10CM | Covered |
| H47.211 | ICD10CM | Covered |
| H47.212 | ICD10CM | Covered |
| H47.213 | ICD10CM | Covered |
| H47.231 | ICD10CM | Covered |
| H47.232 | ICD10CM | Covered |
| H47.233 | ICD10CM | Covered |
| H47.291 | ICD10CM | Covered |
| H47.292 | ICD10CM | Covered |
| H47.293 | ICD10CM | Covered |
| H47.311 | ICD10CM | Covered |
| H47.312 | ICD10CM | Covered |
| H47.313 | ICD10CM | Covered |
| H47.321 | ICD10CM | Covered |
| H47.322 | ICD10CM | Covered |
| H47.323 | ICD10CM | Covered |
| H47.331 | ICD10CM | Covered |
| H47.332 | ICD10CM | Covered |
| H47.333 | ICD10CM | Covered |
| H47.391 | ICD10CM | Covered |
| H47.392 | ICD10CM | Covered |
| H47.393 | ICD10CM | Covered |
| H47.41 | ICD10CM | Covered |
| H47.42 | ICD10CM | Covered |
| H47.43 | ICD10CM | Covered |
| H47.49 | ICD10CM | Covered |
| H47.511 | ICD10CM | Covered |
| H47.512 | ICD10CM | Covered |
| H47.521 | ICD10CM | Covered |
| H47.522 | ICD10CM | Covered |
| H47.531 | ICD10CM | Covered |
| H47.532 | ICD10CM | Covered |
| H47.611 | ICD10CM | Covered |
| H47.612 | ICD10CM | Covered |
| H47.621 | ICD10CM | Covered |
| H47.622 | ICD10CM | Covered |
| H47.631 | ICD10CM | Covered |
| H47.632 | ICD10CM | Covered |
| H47.641 | ICD10CM | Covered |
| H47.642 | ICD10CM | Covered |
| H53.011 | ICD10CM | Covered |
| H53.012 | ICD10CM | Covered |
| H53.013 | ICD10CM | Covered |
| H53.021 | ICD10CM | Covered |
| H53.022 | ICD10CM | Covered |
| H53.023 | ICD10CM | Covered |
| H53.031 | ICD10CM | Covered |
| H53.032 | ICD10CM | Covered |
| H53.033 | ICD10CM | Covered |
| H53.11 | ICD10CM | Covered |
| H53.121 | ICD10CM | Covered |
| H53.122 | ICD10CM | Covered |
| H53.123 | ICD10CM | Covered |
| H53.131 | ICD10CM | Covered |
| H53.132 | ICD10CM | Covered |
| H53.133 | ICD10CM | Covered |
| H53.141 | ICD10CM | Covered |
| H53.142 | ICD10CM | Covered |
| H53.143 | ICD10CM | Covered |
| H53.15 | ICD10CM | Covered |
| H53.16 | ICD10CM | Covered |
| H53.19 | ICD10CM | Covered |
| H53.2 | ICD10CM | Covered |
| H53.31 | ICD10CM | Covered |
| H53.32 | ICD10CM | Covered |
| H53.33 | ICD10CM | Covered |
| H53.34 | ICD10CM | Covered |
| H53.411 | ICD10CM | Covered |
| H53.412 | ICD10CM | Covered |
| H53.413 | ICD10CM | Covered |
| H53.421 | ICD10CM | Covered |
| H53.422 | ICD10CM | Covered |
| H53.423 | ICD10CM | Covered |
| H53.431 | ICD10CM | Covered |
| H53.432 | ICD10CM | Covered |
| H53.433 | ICD10CM | Covered |
| H53.451 | ICD10CM | Covered |
| H53.452 | ICD10CM | Covered |
| H53.453 | ICD10CM | Covered |
| H53.461 | ICD10CM | Covered |
| H53.462 | ICD10CM | Covered |
| H53.47 | ICD10CM | Covered |
| H53.481 | ICD10CM | Covered |
| H53.482 | ICD10CM | Covered |
| H53.483 | ICD10CM | Covered |
| H53.51 | ICD10CM | Covered |
| H53.52 | ICD10CM | Covered |
| H53.53 | ICD10CM | Covered |
| H53.54 | ICD10CM | Covered |
| H53.55 | ICD10CM | Covered |
| H53.59 | ICD10CM | Covered |
| H53.61 | ICD10CM | Covered |
| H53.62 | ICD10CM | Covered |
| H53.63 | ICD10CM | Covered |
| H53.69 | ICD10CM | Covered |
| H53.71 | ICD10CM | Covered |
| H53.72 | ICD10CM | Covered |
| H53.8 | ICD10CM | Covered |
| H81.01 | ICD10CM | Covered |
| H81.02 | ICD10CM | Covered |
| H81.03 | ICD10CM | Covered |
| H81.09 | ICD10CM | Covered |
| H81.4 | ICD10CM | Covered |
| H83.3X1 | ICD10CM | Covered |
| H83.3X2 | ICD10CM | Covered |
| H83.3X3 | ICD10CM | Covered |
| H83.3X9 | ICD10CM | Covered |
| H90.0 | ICD10CM | Covered |
| H90.11 | ICD10CM | Covered |
| H90.12 | ICD10CM | Covered |
| H90.2 | ICD10CM | Covered |
| H90.3 | ICD10CM | Covered |
| H90.41 | ICD10CM | Covered |
| H90.42 | ICD10CM | Covered |
| H90.5 | ICD10CM | Covered |
| H90.6 | ICD10CM | Covered |
| H90.71 | ICD10CM | Covered |
| H90.72 | ICD10CM | Covered |
| H90.8 | ICD10CM | Covered |
| H90.A11 | ICD10CM | Covered |
| H90.A12 | ICD10CM | Covered |
| H90.A21 | ICD10CM | Covered |
| H90.A22 | ICD10CM | Covered |
| H90.A31 | ICD10CM | Covered |
| H90.A32 | ICD10CM | Covered |
| H91.01 | ICD10CM | Covered |
| H91.02 | ICD10CM | Covered |
| H91.03 | ICD10CM | Covered |
| H91.09 | ICD10CM | Covered |
| H91.10 | ICD10CM | Covered |
| H91.11 | ICD10CM | Covered |
| H91.12 | ICD10CM | Covered |
| H91.13 | ICD10CM | Covered |
| H91.20 | ICD10CM | Covered |
| H91.21 | ICD10CM | Covered |
| H91.22 | ICD10CM | Covered |
| H91.23 | ICD10CM | Covered |
| H91.3 | ICD10CM | Covered |
| H91.8X1 | ICD10CM | Covered |
| H91.8X2 | ICD10CM | Covered |
| H91.8X3 | ICD10CM | Covered |
| H91.8X9 | ICD10CM | Covered |
| H91.90 | ICD10CM | Covered |
| H91.91 | ICD10CM | Covered |
| H91.92 | ICD10CM | Covered |
| H91.93 | ICD10CM | Covered |
| H93.011 | ICD10CM | Covered |
| H93.012 | ICD10CM | Covered |
| H93.013 | ICD10CM | Covered |
| H93.019 | ICD10CM | Covered |
| H93.091 | ICD10CM | Covered |
| H93.092 | ICD10CM | Covered |
| H93.093 | ICD10CM | Covered |
| H93.099 | ICD10CM | Covered |
| H93.11 | ICD10CM | Covered |
| H93.12 | ICD10CM | Covered |
| H93.13 | ICD10CM | Covered |
| H93.19 | ICD10CM | Covered |
| H93.211 | ICD10CM | Covered |
| H93.212 | ICD10CM | Covered |
| H93.213 | ICD10CM | Covered |
| H93.219 | ICD10CM | Covered |
| H93.221 | ICD10CM | Covered |
| H93.222 | ICD10CM | Covered |
| H93.223 | ICD10CM | Covered |
| H93.229 | ICD10CM | Covered |
| H93.231 | ICD10CM | Covered |
| H93.232 | ICD10CM | Covered |
| H93.233 | ICD10CM | Covered |
| H93.239 | ICD10CM | Covered |
| H93.241 | ICD10CM | Covered |
| H93.242 | ICD10CM | Covered |
| H93.243 | ICD10CM | Covered |
| H93.249 | ICD10CM | Covered |
| H93.25 | ICD10CM | Covered |
| H93.291 | ICD10CM | Covered |
| H93.292 | ICD10CM | Covered |
| H93.293 | ICD10CM | Covered |
| H93.299 | ICD10CM | Covered |
| H93.3X1 | ICD10CM | Covered |
| H93.3X2 | ICD10CM | Covered |
| H93.3X3 | ICD10CM | Covered |
| H93.3X9 | ICD10CM | Covered |
| H94.00 | ICD10CM | Covered |
| H94.01 | ICD10CM | Covered |
| H94.02 | ICD10CM | Covered |
| H94.03 | ICD10CM | Covered |
| I60.01 | ICD10CM | Covered |
| I60.02 | ICD10CM | Covered |
| I60.11 | ICD10CM | Covered |
| I60.12 | ICD10CM | Covered |
| I60.2 | ICD10CM | Covered |
| I60.31 | ICD10CM | Covered |
| I60.32 | ICD10CM | Covered |
| I60.4 | ICD10CM | Covered |
| I60.51 | ICD10CM | Covered |
| I60.52 | ICD10CM | Covered |
| I60.6 | ICD10CM | Covered |
| I60.8 | ICD10CM | Covered |
| I61.0 | ICD10CM | Covered |
| I61.1 | ICD10CM | Covered |
| I61.3 | ICD10CM | Covered |
| I61.4 | ICD10CM | Covered |
| I61.5 | ICD10CM | Covered |
| I61.6 | ICD10CM | Covered |
| I61.8 | ICD10CM | Covered |
| I62.01 | ICD10CM | Covered |
| I62.02 | ICD10CM | Covered |
| I62.03 | ICD10CM | Covered |
| I62.1 | ICD10CM | Covered |
| I63.011 | ICD10CM | Covered |
| I63.012 | ICD10CM | Covered |
| I63.013 | ICD10CM | Covered |
| I63.02 | ICD10CM | Covered |
| I63.031 | ICD10CM | Covered |
| I63.032 | ICD10CM | Covered |
| I63.033 | ICD10CM | Covered |
| I63.09 | ICD10CM | Covered |
| I63.111 | ICD10CM | Covered |
| I63.112 | ICD10CM | Covered |
| I63.113 | ICD10CM | Covered |
| I63.12 | ICD10CM | Covered |
| I63.131 | ICD10CM | Covered |
| I63.132 | ICD10CM | Covered |
| I63.133 | ICD10CM | Covered |
| I63.19 | ICD10CM | Covered |
| I63.311 | ICD10CM | Covered |
| I63.312 | ICD10CM | Covered |
| I63.313 | ICD10CM | Covered |
| I63.321 | ICD10CM | Covered |
| I63.322 | ICD10CM | Covered |
| I63.323 | ICD10CM | Covered |
| I63.331 | ICD10CM | Covered |
| I63.332 | ICD10CM | Covered |
| I63.333 | ICD10CM | Covered |
| I63.341 | ICD10CM | Covered |
| I63.342 | ICD10CM | Covered |
| I63.343 | ICD10CM | Covered |
| I63.39 | ICD10CM | Covered |
| I63.411 | ICD10CM | Covered |
| I63.412 | ICD10CM | Covered |
| I63.413 | ICD10CM | Covered |
| I63.421 | ICD10CM | Covered |
| I63.422 | ICD10CM | Covered |
| I63.423 | ICD10CM | Covered |
| I63.431 | ICD10CM | Covered |
| I63.432 | ICD10CM | Covered |
| I63.433 | ICD10CM | Covered |
| I63.441 | ICD10CM | Covered |
| I63.442 | ICD10CM | Covered |
| I63.443 | ICD10CM | Covered |
| I63.49 | ICD10CM | Covered |
| I63.6 | ICD10CM | Covered |
| I65.01 | ICD10CM | Covered |
| I65.02 | ICD10CM | Covered |
| I65.03 | ICD10CM | Covered |
| I65.1 | ICD10CM | Covered |
| I65.21 | ICD10CM | Covered |
| I65.22 | ICD10CM | Covered |
| I65.23 | ICD10CM | Covered |
| I65.8 | ICD10CM | Covered |
| I66.01 | ICD10CM | Covered |
| I66.02 | ICD10CM | Covered |
| I66.03 | ICD10CM | Covered |
| I66.11 | ICD10CM | Covered |
| I66.12 | ICD10CM | Covered |
| I66.13 | ICD10CM | Covered |
| I66.21 | ICD10CM | Covered |
| I66.22 | ICD10CM | Covered |
| I66.23 | ICD10CM | Covered |
| I66.3 | ICD10CM | Covered |
| I67.1 | ICD10CM | Covered |
| M40.03 | ICD10CM | Covered |
| M40.04 | ICD10CM | Covered |
| M40.05 | ICD10CM | Covered |
| M40.12 | ICD10CM | Covered |
| M40.13 | ICD10CM | Covered |
| M40.14 | ICD10CM | Covered |
| M40.15 | ICD10CM | Covered |
| M40.292 | ICD10CM | Covered |
| M40.293 | ICD10CM | Covered |
| M40.294 | ICD10CM | Covered |
| M40.295 | ICD10CM | Covered |
| M40.35 | ICD10CM | Covered |
| M40.36 | ICD10CM | Covered |
| M40.37 | ICD10CM | Covered |
| M40.45 | ICD10CM | Covered |
| M40.46 | ICD10CM | Covered |
| M40.47 | ICD10CM | Covered |
| M41.02 | ICD10CM | Covered |
| M41.03 | ICD10CM | Covered |
| M41.04 | ICD10CM | Covered |
| M41.05 | ICD10CM | Covered |
| M41.06 | ICD10CM | Covered |
| M41.07 | ICD10CM | Covered |
| M41.08 | ICD10CM | Covered |
| M41.112 | ICD10CM | Covered |
| M41.113 | ICD10CM | Covered |
| M41.114 | ICD10CM | Covered |
| M41.115 | ICD10CM | Covered |
| M41.116 | ICD10CM | Covered |
| M41.117 | ICD10CM | Covered |
| M41.122 | ICD10CM | Covered |
| M41.123 | ICD10CM | Covered |
| M41.124 | ICD10CM | Covered |
| M41.125 | ICD10CM | Covered |
| M41.126 | ICD10CM | Covered |
| M41.127 | ICD10CM | Covered |
| M41.22 | ICD10CM | Covered |
| M41.23 | ICD10CM | Covered |
| M41.24 | ICD10CM | Covered |
| M41.25 | ICD10CM | Covered |
| M41.26 | ICD10CM | Covered |
| M41.27 | ICD10CM | Covered |
| M41.34 | ICD10CM | Covered |
| M41.35 | ICD10CM | Covered |
| M41.41 | ICD10CM | Covered |
| M41.42 | ICD10CM | Covered |
| M41.43 | ICD10CM | Covered |
| M41.44 | ICD10CM | Covered |
| M41.45 | ICD10CM | Covered |
| M41.46 | ICD10CM | Covered |
| M41.47 | ICD10CM | Covered |
| M41.52 | ICD10CM | Covered |
| M41.53 | ICD10CM | Covered |
| M41.54 | ICD10CM | Covered |
| M41.55 | ICD10CM | Covered |
| M41.56 | ICD10CM | Covered |
| M41.57 | ICD10CM | Covered |
| M41.82 | ICD10CM | Covered |
| M41.83 | ICD10CM | Covered |
| M41.84 | ICD10CM | Covered |
| M41.85 | ICD10CM | Covered |
| M41.86 | ICD10CM | Covered |
| M41.87 | ICD10CM | Covered |
| M43.01 | ICD10CM | Covered |
| M43.02 | ICD10CM | Covered |
| M43.03 | ICD10CM | Covered |
| M43.04 | ICD10CM | Covered |
| M43.05 | ICD10CM | Covered |
| M43.06 | ICD10CM | Covered |
| M43.07 | ICD10CM | Covered |
| M43.08 | ICD10CM | Covered |
| M43.09 | ICD10CM | Covered |
| M43.11 | ICD10CM | Covered |
| M43.12 | ICD10CM | Covered |
| M43.13 | ICD10CM | Covered |
| M43.14 | ICD10CM | Covered |
| M43.15 | ICD10CM | Covered |
| M43.16 | ICD10CM | Covered |
| M43.17 | ICD10CM | Covered |
| M43.18 | ICD10CM | Covered |
| M43.19 | ICD10CM | Covered |
| M43.8X1 | ICD10CM | Covered |
| M43.8X2 | ICD10CM | Covered |
| M43.8X3 | ICD10CM | Covered |
| M43.8X4 | ICD10CM | Covered |
| M43.8X5 | ICD10CM | Covered |
| M43.8X6 | ICD10CM | Covered |
| M43.8X7 | ICD10CM | Covered |
| M43.8X8 | ICD10CM | Covered |
| M47.011 | ICD10CM | Covered |
| M47.012 | ICD10CM | Covered |
| M47.013 | ICD10CM | Covered |
| M47.014 | ICD10CM | Covered |
| M47.015 | ICD10CM | Covered |
| M47.016 | ICD10CM | Covered |
| M47.021 | ICD10CM | Covered |
| M47.022 | ICD10CM | Covered |
| M47.11 | ICD10CM | Covered |
| M47.12 | ICD10CM | Covered |
| M47.13 | ICD10CM | Covered |
| M47.14 | ICD10CM | Covered |
| M47.15 | ICD10CM | Covered |
| M47.16 | ICD10CM | Covered |
| M47.21 | ICD10CM | Covered |
| M47.22 | ICD10CM | Covered |
| M47.23 | ICD10CM | Covered |
| M47.24 | ICD10CM | Covered |
| M47.25 | ICD10CM | Covered |
| M47.26 | ICD10CM | Covered |
| M47.27 | ICD10CM | Covered |
| M47.28 | 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 |
| M47.891 | ICD10CM | Covered |
| M47.892 | ICD10CM | Covered |
| M47.893 | ICD10CM | Covered |
| M47.896 | ICD10CM | Covered |
| M47.897 | ICD10CM | Covered |
| M47.898 | ICD10CM | Covered |
| M48.01 | ICD10CM | Covered |
| M48.02 | ICD10CM | Covered |
| M48.03 | ICD10CM | Covered |
| M48.062 | ICD10CM | Covered |
| M48.07 | ICD10CM | Covered |
| M50.01 | ICD10CM | Covered |
| M50.021 | ICD10CM | Covered |
| M50.022 | ICD10CM | Covered |
| M50.023 | ICD10CM | Covered |
| M50.03 | ICD10CM | Covered |
| M50.11 | ICD10CM | Covered |
| M50.121 | ICD10CM | Covered |
| M50.122 | ICD10CM | Covered |
| M50.123 | ICD10CM | Covered |
| M50.21 | ICD10CM | Covered |
| M50.221 | ICD10CM | Covered |
| M50.222 | ICD10CM | Covered |
| M50.223 | ICD10CM | Covered |
| M50.23 | ICD10CM | Covered |
| M50.31 | ICD10CM | Covered |
| M50.321 | ICD10CM | Covered |
| M50.322 | ICD10CM | Covered |
| M50.323 | ICD10CM | Covered |
| M50.33 | ICD10CM | Covered |
| M51.04 | ICD10CM | Covered |
| M51.05 | ICD10CM | Covered |
| M51.06 | ICD10CM | Covered |
| M51.14 | ICD10CM | Covered |
| M51.15 | ICD10CM | Covered |
| M51.16 | ICD10CM | Covered |
| M51.17 | ICD10CM | Covered |
| M51.24 | ICD10CM | Covered |
| M51.25 | ICD10CM | Covered |
| M51.26 | ICD10CM | Covered |
| M51.27 | ICD10CM | Covered |
| M51.34 | ICD10CM | Covered |
| M51.35 | 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 |
| M53.0 | ICD10CM | Covered |
| M53.1 | ICD10CM | Covered |
| M54.11 | ICD10CM | Covered |
| M54.12 | ICD10CM | Covered |
| M54.13 | ICD10CM | Covered |
| M54.14 | ICD10CM | Covered |
| M54.15 | ICD10CM | Covered |
| M54.16 | ICD10CM | Covered |
| M54.17 | ICD10CM | Covered |
| M54.18 | ICD10CM | Covered |
| M96.1 | ICD10CM | Covered |
| M96.2 | ICD10CM | Covered |
| M96.3 | ICD10CM | Covered |
| M96.4 | ICD10CM | Covered |
| M96.5 | ICD10CM | Covered |
| M99.20 | ICD10CM | Covered |
| M99.21 | ICD10CM | Covered |
| M99.22 | ICD10CM | Covered |
| M99.23 | ICD10CM | Covered |
| M99.24 | ICD10CM | Covered |
| M99.30 | ICD10CM | Covered |
| M99.31 | ICD10CM | Covered |
| M99.32 | ICD10CM | Covered |
| M99.33 | ICD10CM | Covered |
| M99.34 | ICD10CM | Covered |
| M99.40 | ICD10CM | Covered |
| M99.41 | ICD10CM | Covered |
| M99.42 | ICD10CM | Covered |
| M99.43 | ICD10CM | Covered |
| M99.44 | ICD10CM | Covered |
| M99.50 | ICD10CM | Covered |
| M99.51 | ICD10CM | Covered |
| M99.52 | ICD10CM | Covered |
| M99.53 | ICD10CM | Covered |
| M99.54 | ICD10CM | Covered |
| M99.60 | ICD10CM | Covered |
| M99.61 | ICD10CM | Covered |
| M99.62 | ICD10CM | Covered |
| M99.63 | ICD10CM | Covered |
| M99.64 | ICD10CM | Covered |
| M99.70 | ICD10CM | Covered |
| M99.71 | ICD10CM | Covered |
| M99.72 | ICD10CM | Covered |
| M99.73 | ICD10CM | Covered |
| M99.74 | ICD10CM | Covered |
| Q05.0 | ICD10CM | Covered |
| Q05.1 | ICD10CM | Covered |
| Q05.2 | ICD10CM | Covered |
| Q05.3 | ICD10CM | Covered |
| Q05.5 | ICD10CM | Covered |
| Q05.6 | ICD10CM | Covered |
| Q05.7 | ICD10CM | Covered |
| Q05.8 | ICD10CM | Covered |
| Q07.00 | ICD10CM | Covered |
| Q07.01 | ICD10CM | Covered |
| Q07.02 | ICD10CM | Covered |
| Q07.03 | ICD10CM | Covered |
| R20.0 | ICD10CM | Covered |
| R20.1 | ICD10CM | Covered |
| R20.2 | ICD10CM | Covered |
| R20.3 | ICD10CM | Covered |
| R20.8 | ICD10CM | Covered |
| R25.0 | ICD10CM | Covered |
| R25.1 | ICD10CM | Covered |
| R25.2 | ICD10CM | Covered |
| R25.3 | ICD10CM | Covered |
| R25.8 | ICD10CM | Covered |
| R25.9 | ICD10CM | Covered |
| R26.0 | ICD10CM | Covered |
| R26.1 | ICD10CM | Covered |
| R26.81 | ICD10CM | Covered |
| R26.89 | ICD10CM | Covered |
| R27.8 | ICD10CM | Covered |
| R29.5 | 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 |
| R40.2211 | 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 |
| R40.2311 | 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 |
| R40.2341 | ICD10CM | Covered |
| R40.2342 | ICD10CM | Covered |
| R40.2343 | ICD10CM | Covered |
| R40.2344 | ICD10CM | Covered |
| R40.3 | ICD10CM | Covered |
| R42 | ICD10CM | Covered |
| R44.1 | ICD10CM | Covered |
| R48.3 | ICD10CM | Covered |
| R94.110 | ICD10CM | Covered |
| R94.111 | ICD10CM | Covered |
| R94.112 | ICD10CM | Covered |
| R94.113 | ICD10CM | Covered |
| R94.118 | ICD10CM | Covered |
| R94.120 | ICD10CM | Covered |
| R94.121 | ICD10CM | Covered |
| R94.128 | ICD10CM | Covered |
| R94.131 | ICD10CM | Covered |
| R94.138 | ICD10CM | Covered |
| S04.011A | ICD10CM | Covered |
| S04.011D | ICD10CM | Covered |
| S04.011S | ICD10CM | Covered |
| S04.012A | ICD10CM | Covered |
| S04.012D | ICD10CM | Covered |
| S04.012S | ICD10CM | Covered |
| S04.02XA | ICD10CM | Covered |
| S04.02XD | ICD10CM | Covered |
| S04.02XS | ICD10CM | Covered |
| S04.031A | ICD10CM | Covered |
| S04.031D | ICD10CM | Covered |
| S04.031S | ICD10CM | Covered |
| S04.032A | ICD10CM | Covered |
| S04.032D | ICD10CM | Covered |
| S04.032S | ICD10CM | Covered |
| S04.041A | ICD10CM | Covered |
| S04.041D | ICD10CM | Covered |
| S04.041S | ICD10CM | Covered |
| S04.042A | ICD10CM | Covered |
| S04.042D | ICD10CM | Covered |
| S04.042S | ICD10CM | Covered |
| S04.11XA | ICD10CM | Covered |
| S04.11XD | ICD10CM | Covered |
| S04.11XS | ICD10CM | Covered |
| S04.12XA | ICD10CM | Covered |
| S04.12XD | ICD10CM | Covered |
| S04.12XS | ICD10CM | Covered |
| S04.21XA | ICD10CM | Covered |
| S04.21XD | ICD10CM | Covered |
| S04.21XS | ICD10CM | Covered |
| S04.22XA | ICD10CM | Covered |
| S04.22XD | ICD10CM | Covered |
| S04.22XS | ICD10CM | Covered |
| S04.31XA | ICD10CM | Covered |
| S04.31XD | ICD10CM | Covered |
| S04.31XS | ICD10CM | Covered |
| S04.32XA | ICD10CM | Covered |
| S04.32XD | ICD10CM | Covered |
| S04.32XS | ICD10CM | Covered |
| S04.41XA | ICD10CM | Covered |
| S04.41XD | ICD10CM | Covered |
| S04.41XS | ICD10CM | Covered |
| S04.42XA | ICD10CM | Covered |
| S04.42XD | ICD10CM | Covered |
| S04.42XS | ICD10CM | Covered |
| S04.51XA | ICD10CM | Covered |
| S04.51XD | ICD10CM | Covered |
| S04.51XS | ICD10CM | Covered |
| S04.52XA | ICD10CM | Covered |
| S04.52XD | ICD10CM | Covered |
| S04.52XS | ICD10CM | Covered |
| S04.61XA | ICD10CM | Covered |
| S04.61XD | ICD10CM | Covered |
| S04.61XS | ICD10CM | Covered |
| S04.62XA | ICD10CM | Covered |
| S04.62XD | ICD10CM | Covered |
| S04.62XS | ICD10CM | Covered |
| S04.71XA | ICD10CM | Covered |
| S04.71XD | ICD10CM | Covered |
| S04.71XS | ICD10CM | Covered |
| S04.72XA | ICD10CM | Covered |
| S04.72XD | ICD10CM | Covered |
| S04.72XS | ICD10CM | Covered |
| S04.811A | ICD10CM | Covered |
| S04.811D | ICD10CM | Covered |
| S04.811S | ICD10CM | Covered |
| S04.812A | ICD10CM | Covered |
| S04.812D | ICD10CM | Covered |
| S04.812S | ICD10CM | Covered |
| S04.891A | ICD10CM | Covered |
| S04.891D | ICD10CM | Covered |
| S04.891S | ICD10CM | Covered |
| S04.892A | ICD10CM | Covered |
| S04.892D | ICD10CM | Covered |
| S04.892S | ICD10CM | Covered |
| S06.310A | ICD10CM | Covered |
| S06.310D | ICD10CM | Covered |
| S06.310S | ICD10CM | Covered |
| S06.311A | ICD10CM | Covered |
| S06.311D | ICD10CM | Covered |
| S06.311S | ICD10CM | Covered |
| S06.312A | ICD10CM | Covered |
| S06.312D | ICD10CM | Covered |
| S06.312S | ICD10CM | Covered |
| S06.313A | ICD10CM | Covered |
| S06.313D | ICD10CM | Covered |
| S06.313S | ICD10CM | Covered |
| S06.314A | ICD10CM | Covered |
| S06.314D | ICD10CM | Covered |
| S06.314S | ICD10CM | Covered |
| S06.315A | ICD10CM | Covered |
| S06.315D | ICD10CM | Covered |
| S06.315S | ICD10CM | Covered |
| S06.316A | ICD10CM | Covered |
| S06.316D | ICD10CM | Covered |
| S06.316S | ICD10CM | Covered |
| S06.317A | ICD10CM | Covered |
| S06.318A | ICD10CM | Covered |
| S06.320A | ICD10CM | Covered |
| S06.320D | ICD10CM | Covered |
| S06.320S | ICD10CM | Covered |
| S06.321A | ICD10CM | Covered |
| S06.321D | ICD10CM | Covered |
| S06.321S | ICD10CM | Covered |
| S06.322A | ICD10CM | Covered |
| S06.322D | ICD10CM | Covered |
| S06.322S | ICD10CM | Covered |
| S06.323A | ICD10CM | Covered |
| S06.323D | ICD10CM | Covered |
| S06.323S | ICD10CM | Covered |
| S06.324A | ICD10CM | Covered |
| S06.324D | ICD10CM | Covered |
| S06.324S | ICD10CM | Covered |
| S06.325A | ICD10CM | Covered |
| S06.325D | ICD10CM | Covered |
| S06.325S | ICD10CM | Covered |
| S06.326A | ICD10CM | Covered |
| S06.326D | ICD10CM | Covered |
| S06.326S | ICD10CM | Covered |
| S06.327A | ICD10CM | Covered |
| S06.328A | ICD10CM | Covered |
| S06.340A | ICD10CM | Covered |
| S06.340D | ICD10CM | Covered |
| S06.340S | ICD10CM | Covered |
| S06.341A | ICD10CM | Covered |
| S06.341D | ICD10CM | Covered |
| S06.341S | ICD10CM | Covered |
| S06.342A | ICD10CM | Covered |
| S06.342D | ICD10CM | Covered |
| S06.342S | ICD10CM | Covered |
| S06.343A | ICD10CM | Covered |
| S06.343D | ICD10CM | Covered |
| S06.343S | ICD10CM | Covered |
| S06.344A | ICD10CM | Covered |
| S06.344D | ICD10CM | Covered |
| S06.344S | ICD10CM | Covered |
| S06.345A | ICD10CM | Covered |
| S06.345D | ICD10CM | Covered |
| S06.345S | ICD10CM | Covered |
| S06.346A | ICD10CM | Covered |
| S06.346D | ICD10CM | Covered |
| S06.346S | ICD10CM | Covered |
| S06.347A | ICD10CM | Covered |