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 |
|---|---|---|
| 31579 | HCPCS | Covered |
| 92507 | HCPCS | Covered |
| 92508 | HCPCS | Covered |
| 92511 | HCPCS | Covered |
| 92512 | HCPCS | Covered |
| 92517 | HCPCS | Covered |
| 92518 | HCPCS | Covered |
| 92519 | HCPCS | Covered |
| 92520 | HCPCS | Covered |
| 92521 | HCPCS | Covered |
| 92522 | HCPCS | Covered |
| 92523 | HCPCS | Covered |
| 92524 | HCPCS | Covered |
| 92526 | HCPCS | Covered |
| 92597 | HCPCS | Covered |
| 92605 | HCPCS | Covered |
| 92606 | HCPCS | Covered |
| 92607 | HCPCS | Covered |
| 92608 | HCPCS | Covered |
| 92609 | HCPCS | Covered |
| 92610 | HCPCS | Covered |
| 92611 | HCPCS | Covered |
| 92612 | HCPCS | Covered |
| 92613 | HCPCS | Covered |
| 92614 | HCPCS | Covered |
| 92615 | HCPCS | Covered |
| 92616 | HCPCS | Covered |
| 92617 | HCPCS | Covered |
| 92618 | HCPCS | Covered |
| 92626 | HCPCS | Covered |
| 92627 | HCPCS | Covered |
| 92630 | HCPCS | Covered |
| 92633 | HCPCS | Covered |
| 92650 | HCPCS | Covered |
| 92651 | HCPCS | Covered |
| 92652 | HCPCS | Covered |
| 92653 | HCPCS | Covered |
| 95857 | HCPCS | Covered |
| 96105 | HCPCS | Covered |
| 96112 | HCPCS | Covered |
| 96113 | HCPCS | Covered |
| 96116 | HCPCS | Covered |
| 96121 | HCPCS | Covered |
| 96125 | HCPCS | Covered |
| 97129 | HCPCS | Covered |
| 97130 | HCPCS | Covered |
| 97150 | HCPCS | Covered |
| 97533 | HCPCS | Covered |
| 97535 | HCPCS | Covered |
| 97550 | HCPCS | Covered |
| 97551 | HCPCS | Covered |
| 97552 | HCPCS | Covered |
| A52.17 | ICD10CM | Covered |
| A81.00 | ICD10CM | Covered |
| A81.01 | ICD10CM | Covered |
| A81.09 | ICD10CM | Covered |
| E75.00 | ICD10CM | Covered |
| E75.01 | ICD10CM | Covered |
| E75.02 | ICD10CM | Covered |
| E75.09 | ICD10CM | Covered |
| E75.11 | ICD10CM | Covered |
| E75.19 | ICD10CM | Covered |
| E75.27 | ICD10CM | Covered |
| E75.28 | ICD10CM | Covered |
| E75.4 | ICD10CM | Covered |
| E83.01 | ICD10CM | Covered |
| E83.09 | ICD10CM | Covered |
| F01.518 | ICD10CM | Covered |
| F01.A18 | ICD10CM | Covered |
| F01.B18 | ICD10CM | Covered |
| F01.C18 | ICD10CM | Covered |
| F02.818 | ICD10CM | Covered |
| F02.A18 | ICD10CM | Covered |
| F02.B18 | ICD10CM | Covered |
| F02.C18 | ICD10CM | Covered |
| F07.81 | ICD10CM | Covered |
| F80.0 | ICD10CM | Covered |
| F80.1 | ICD10CM | Covered |
| F80.2 | ICD10CM | Covered |
| F80.4 | ICD10CM | Covered |
| F80.81 | ICD10CM | Covered |
| F80.82 | ICD10CM | Covered |
| F80.89 | ICD10CM | Covered |
| F80.9 | ICD10CM | Covered |
| F81.0 | ICD10CM | Covered |
| F81.81 | ICD10CM | Covered |
| F82 | ICD10CM | Covered |
| F88 | ICD10CM | Covered |
| F95.2 | ICD10CM | Covered |
| F98.29 | ICD10CM | Covered |
| F98.5 | ICD10CM | Covered |
| G10 | ICD10CM | Covered |
| G24.09 | ICD10CM | Covered |
| G24.2 | ICD10CM | Covered |
| G24.4 | ICD10CM | Covered |
| G24.8 | ICD10CM | Covered |
| G30.0 | ICD10CM | Covered |
| G30.1 | ICD10CM | Covered |
| G30.8 | ICD10CM | Covered |
| G31.01 | ICD10CM | Covered |
| G31.09 | ICD10CM | Covered |
| G31.80 | ICD10CM | Covered |
| G31.83 | ICD10CM | Covered |
| G31.85 | ICD10CM | Covered |
| G31.87 | 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 |
| G36.9 | 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 |
| G37.89 | ICD10CM | Covered |
| G37.9 | ICD10CM | Covered |
| G40.001 | ICD10CM | Covered |
| G40.009 | ICD10CM | Covered |
| G40.011 | ICD10CM | Covered |
| G40.019 | ICD10CM | Covered |
| G40.101 | ICD10CM | Covered |
| G40.109 | ICD10CM | Covered |
| G40.111 | ICD10CM | Covered |
| G40.119 | ICD10CM | Covered |
| G40.201 | ICD10CM | Covered |
| G40.209 | ICD10CM | Covered |
| G40.211 | ICD10CM | Covered |
| G40.219 | ICD10CM | Covered |
| G40.301 | ICD10CM | Covered |
| G40.309 | ICD10CM | Covered |
| G40.311 | ICD10CM | Covered |
| G40.319 | ICD10CM | Covered |
| G40.401 | ICD10CM | Covered |
| G40.409 | ICD10CM | Covered |
| G40.411 | ICD10CM | Covered |
| G40.419 | ICD10CM | Covered |
| G40.42 | ICD10CM | Covered |
| G40.501 | ICD10CM | Covered |
| G40.509 | ICD10CM | Covered |
| G40.801 | ICD10CM | Covered |
| G40.802 | ICD10CM | Covered |
| G40.803 | ICD10CM | Covered |
| G40.804 | ICD10CM | Covered |
| G40.811 | ICD10CM | Covered |
| G40.812 | ICD10CM | Covered |
| G40.813 | ICD10CM | Covered |
| G40.814 | ICD10CM | Covered |
| G40.821 | ICD10CM | Covered |
| G40.822 | ICD10CM | Covered |
| G40.823 | ICD10CM | Covered |
| G40.824 | ICD10CM | Covered |
| G40.833 | ICD10CM | Covered |
| G40.834 | ICD10CM | Covered |
| G40.841 | ICD10CM | Covered |
| G40.842 | ICD10CM | Covered |
| G40.843 | ICD10CM | Covered |
| G40.844 | ICD10CM | Covered |
| G40.89 | ICD10CM | Covered |
| G40.901 | ICD10CM | Covered |
| G40.909 | ICD10CM | Covered |
| G40.911 | ICD10CM | Covered |
| G40.919 | ICD10CM | Covered |
| G40.A01 | ICD10CM | Covered |
| G40.A09 | ICD10CM | Covered |
| G40.A11 | ICD10CM | Covered |
| G40.A19 | ICD10CM | Covered |
| G40.B01 | ICD10CM | Covered |
| G40.B09 | ICD10CM | Covered |
| G40.B11 | ICD10CM | Covered |
| G40.B19 | ICD10CM | Covered |
| G51.0 | ICD10CM | Covered |
| G51.1 | ICD10CM | Covered |
| G51.2 | ICD10CM | Covered |
| G51.4 | ICD10CM | Covered |
| G51.8 | ICD10CM | Covered |
| G51.9 | ICD10CM | Covered |
| G52.1 | ICD10CM | Covered |
| G70.00 | ICD10CM | Covered |
| G70.01 | ICD10CM | Covered |
| G70.1 | ICD10CM | Covered |
| G70.2 | ICD10CM | Covered |
| G70.80 | ICD10CM | Covered |
| G70.81 | ICD10CM | Covered |
| G70.89 | ICD10CM | Covered |
| G70.9 | ICD10CM | Covered |
| G71.11 | ICD10CM | Covered |
| G71.12 | ICD10CM | Covered |
| G71.13 | ICD10CM | Covered |
| G71.14 | ICD10CM | Covered |
| G71.19 | ICD10CM | Covered |
| G71.20 | ICD10CM | Covered |
| G71.21 | ICD10CM | Covered |
| G71.220 | ICD10CM | Covered |
| G71.228 | ICD10CM | Covered |
| G71.29 | ICD10CM | Covered |
| G72.0 | ICD10CM | Covered |
| G72.1 | ICD10CM | Covered |
| G72.2 | ICD10CM | Covered |
| G72.3 | ICD10CM | Covered |
| G73.1 | 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 |
| G80.9 | 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 |
| G81.91 | ICD10CM | Covered |
| G81.92 | ICD10CM | Covered |
| G81.93 | ICD10CM | Covered |
| G81.94 | ICD10CM | Covered |
| G83.5 | ICD10CM | Covered |
| G83.81 | ICD10CM | Covered |
| G83.82 | ICD10CM | Covered |
| G83.83 | ICD10CM | Covered |
| G83.84 | ICD10CM | Covered |
| G83.89 | ICD10CM | Covered |
| G83.9 | ICD10CM | Covered |
| H90.0 | ICD10CM | Covered |
| H90.11 | ICD10CM | Covered |
| H90.12 | ICD10CM | Covered |
| H90.3 | ICD10CM | Covered |
| H90.41 | ICD10CM | Covered |
| H90.42 | ICD10CM | Covered |
| H90.6 | ICD10CM | Covered |
| H90.71 | ICD10CM | Covered |
| H90.72 | 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 |
| H91.3 | ICD10CM | Covered |
| H93.221 | ICD10CM | Covered |
| H93.222 | ICD10CM | Covered |
| H93.223 | ICD10CM | Covered |
| H93.241 | ICD10CM | Covered |
| H93.242 | ICD10CM | Covered |
| H93.243 | ICD10CM | Covered |
| H93.25 | ICD10CM | Covered |
| H93.291 | ICD10CM | Covered |
| H93.292 | ICD10CM | Covered |
| H93.293 | ICD10CM | Covered |
| I69.010 | ICD10CM | Covered |
| I69.012 | ICD10CM | Covered |
| I69.013 | ICD10CM | Covered |
| I69.014 | ICD10CM | Covered |
| I69.015 | ICD10CM | Covered |
| I69.018 | ICD10CM | Covered |
| I69.019 | ICD10CM | Covered |
| I69.020 | ICD10CM | Covered |
| I69.021 | ICD10CM | Covered |
| I69.022 | ICD10CM | Covered |
| I69.023 | ICD10CM | Covered |
| I69.028 | ICD10CM | Covered |
| I69.090 | ICD10CM | Covered |
| I69.091 | ICD10CM | Covered |
| I69.092 | ICD10CM | Covered |
| I69.110 | ICD10CM | Covered |
| I69.112 | ICD10CM | Covered |
| I69.114 | ICD10CM | Covered |
| I69.115 | ICD10CM | Covered |
| I69.118 | ICD10CM | Covered |
| I69.120 | ICD10CM | Covered |
| I69.121 | ICD10CM | Covered |
| I69.122 | ICD10CM | Covered |
| I69.123 | ICD10CM | Covered |
| I69.128 | ICD10CM | Covered |
| I69.190 | ICD10CM | Covered |
| I69.191 | ICD10CM | Covered |
| I69.192 | ICD10CM | Covered |
| I69.210 | ICD10CM | Covered |
| I69.212 | ICD10CM | Covered |
| I69.214 | ICD10CM | Covered |
| I69.215 | ICD10CM | Covered |
| I69.220 | ICD10CM | Covered |
| I69.221 | ICD10CM | Covered |
| I69.222 | ICD10CM | Covered |
| I69.223 | ICD10CM | Covered |
| I69.228 | ICD10CM | Covered |
| I69.290 | ICD10CM | Covered |
| I69.291 | ICD10CM | Covered |
| I69.292 | ICD10CM | Covered |
| I69.310 | ICD10CM | Covered |
| I69.312 | ICD10CM | Covered |
| I69.313 | ICD10CM | Covered |
| I69.314 | ICD10CM | Covered |
| I69.315 | ICD10CM | Covered |
| I69.320 | ICD10CM | Covered |
| I69.321 | ICD10CM | Covered |
| I69.322 | ICD10CM | Covered |
| I69.323 | ICD10CM | Covered |
| I69.328 | ICD10CM | Covered |
| I69.390 | ICD10CM | Covered |
| I69.391 | ICD10CM | Covered |
| I69.392 | ICD10CM | Covered |
| I69.810 | ICD10CM | Covered |
| I69.812 | ICD10CM | Covered |
| I69.813 | ICD10CM | Covered |
| I69.814 | ICD10CM | Covered |
| I69.815 | ICD10CM | Covered |
| I69.820 | ICD10CM | Covered |
| I69.821 | ICD10CM | Covered |
| I69.822 | ICD10CM | Covered |
| I69.823 | ICD10CM | Covered |
| I69.828 | ICD10CM | Covered |
| I69.890 | ICD10CM | Covered |
| I69.891 | ICD10CM | Covered |
| I69.892 | ICD10CM | Covered |
| I69.910 | ICD10CM | Covered |
| I69.912 | ICD10CM | Covered |
| I69.913 | ICD10CM | Covered |
| I69.914 | ICD10CM | Covered |
| I69.915 | ICD10CM | Covered |
| I69.920 | ICD10CM | Covered |
| I69.921 | ICD10CM | Covered |
| I69.922 | ICD10CM | Covered |
| I69.923 | ICD10CM | Covered |
| I69.928 | ICD10CM | Covered |
| I69.990 | ICD10CM | Covered |
| I69.991 | ICD10CM | Covered |
| I69.992 | ICD10CM | Covered |
| J37.0 | ICD10CM | Covered |
| J37.1 | ICD10CM | Covered |
| J38.01 | ICD10CM | Covered |
| J38.02 | ICD10CM | Covered |
| J38.1 | ICD10CM | Covered |
| J38.2 | ICD10CM | Covered |
| J38.3 | ICD10CM | Covered |
| J38.4 | ICD10CM | Covered |
| J38.5 | ICD10CM | Covered |
| J38.6 | ICD10CM | Covered |
| J38.7 | ICD10CM | Covered |
| J39.0 | ICD10CM | Covered |
| J39.1 | ICD10CM | Covered |
| J39.2 | ICD10CM | Covered |
| K14.8 | ICD10CM | Covered |
| M26.20 | ICD10CM | Covered |
| M26.211 | ICD10CM | Covered |
| M26.212 | ICD10CM | Covered |
| M26.213 | ICD10CM | Covered |
| M26.220 | ICD10CM | Covered |
| M26.221 | ICD10CM | Covered |
| M26.23 | ICD10CM | Covered |
| M26.24 | ICD10CM | Covered |
| M26.25 | ICD10CM | Covered |
| M26.29 | ICD10CM | Covered |
| M26.50 | ICD10CM | Covered |
| M30.0 | ICD10CM | Covered |
| M30.2 | ICD10CM | Covered |
| M30.8 | ICD10CM | Covered |
| M31.7 | ICD10CM | Covered |
| Q31.1 | ICD10CM | Covered |
| Q31.2 | ICD10CM | Covered |
| Q31.3 | ICD10CM | Covered |
| Q31.5 | ICD10CM | Covered |
| Q31.8 | ICD10CM | Covered |
| Q31.9 | ICD10CM | Covered |
| Q32.0 | ICD10CM | Covered |
| Q32.1 | ICD10CM | Covered |
| Q32.2 | ICD10CM | Covered |
| Q32.3 | ICD10CM | Covered |
| Q32.4 | ICD10CM | Covered |
| Q35.1 | ICD10CM | Covered |
| Q35.3 | ICD10CM | Covered |
| Q35.5 | ICD10CM | Covered |
| Q35.7 | 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 |
| Q38.1 | ICD10CM | Covered |
| Q38.2 | ICD10CM | Covered |
| Q38.3 | ICD10CM | Covered |
| R05.8 | ICD10CM | Covered |
| R06.89 | ICD10CM | Covered |
| R13.0 | ICD10CM | Covered |
| R13.10 | ICD10CM | Covered |
| R13.11 | ICD10CM | Covered |
| R13.12 | ICD10CM | Covered |
| R13.13 | ICD10CM | Covered |
| R13.14 | ICD10CM | Covered |
| R13.19 | ICD10CM | Covered |
| R41.4 | ICD10CM | Covered |
| R41.841 | ICD10CM | Covered |
| R41.85 | ICD10CM | Covered |
| R47.01 | ICD10CM | Covered |
| R47.02 | ICD10CM | Covered |
| R47.1 | ICD10CM | Covered |
| R47.81 | ICD10CM | Covered |
| R47.82 | ICD10CM | Covered |
| R47.89 | ICD10CM | Covered |
| R48.0 | ICD10CM | Covered |
| R48.1 | ICD10CM | Covered |
| R48.2 | ICD10CM | Covered |
| R48.8 | ICD10CM | Covered |
| R49.0 | ICD10CM | Covered |
| R49.1 | ICD10CM | Covered |
| R49.8 | ICD10CM | Covered |
| R62.0 | ICD10CM | Covered |
| R63.39 | ICD10CM | Covered |
| S01.522S | ICD10CM | Covered |
| S01.531S | ICD10CM | Covered |
| S01.532S | ICD10CM | Covered |
| S01.541S | ICD10CM | Covered |
| S01.542S | ICD10CM | Covered |
| S06.0X0S | ICD10CM | Covered |
| S06.0X1S | ICD10CM | Covered |
| S06.0X9S | ICD10CM | Covered |
| S06.1X0S | ICD10CM | Covered |
| S06.1X1S | ICD10CM | Covered |
| S06.1X2S | ICD10CM | Covered |
| S06.1X3S | ICD10CM | Covered |
| S06.1X4S | ICD10CM | Covered |
| S06.1X5S | ICD10CM | Covered |
| S06.1X9S | ICD10CM | Covered |
| S06.1XAA | ICD10CM | Covered |
| S06.1XAD | ICD10CM | Covered |
| S06.1XAS | ICD10CM | Covered |
| S06.2X0S | ICD10CM | Covered |
| S06.2X1S | ICD10CM | Covered |
| S06.2X2S | ICD10CM | Covered |
| S06.2X3S | ICD10CM | Covered |
| S06.2X4S | ICD10CM | Covered |
| S06.2X5S | ICD10CM | Covered |
| S06.2X9S | ICD10CM | Covered |
| S06.2XAA | ICD10CM | Covered |
| S06.2XAD | ICD10CM | Covered |
| S06.2XAS | ICD10CM | Covered |
| S06.300S | ICD10CM | Covered |
| S06.301S | ICD10CM | Covered |
| S06.302S | ICD10CM | Covered |
| S06.303S | ICD10CM | Covered |
| S06.304S | ICD10CM | Covered |
| S06.305S | ICD10CM | Covered |
| S06.309S | ICD10CM | Covered |
| S06.310S | ICD10CM | Covered |
| S06.311S | ICD10CM | Covered |
| S06.312S | ICD10CM | Covered |
| S06.313S | ICD10CM | Covered |
| S06.314S | ICD10CM | Covered |
| S06.315S | ICD10CM | Covered |
| S06.319S | ICD10CM | Covered |
| S06.31AA | ICD10CM | Covered |
| S06.31AD | ICD10CM | Covered |
| S06.31AS | ICD10CM | Covered |
| S06.320S | ICD10CM | Covered |
| S06.321S | ICD10CM | Covered |
| S06.322S | ICD10CM | Covered |
| S06.323S | ICD10CM | Covered |
| S06.324S | ICD10CM | Covered |
| S06.325S | ICD10CM | Covered |
| S06.329S | ICD10CM | Covered |
| S06.32AA | ICD10CM | Covered |
| S06.32AD | ICD10CM | Covered |
| S06.32AS | ICD10CM | Covered |
| S06.33AA | ICD10CM | Covered |
| S06.33AD | ICD10CM | Covered |
| S06.33AS | ICD10CM | Covered |
| S06.340S | ICD10CM | Covered |
| S06.341S | ICD10CM | Covered |
| S06.342S | ICD10CM | Covered |
| S06.343S | ICD10CM | Covered |
| S06.344S | ICD10CM | Covered |
| S06.345S | ICD10CM | Covered |
| S06.346S | ICD10CM | Covered |
| S06.349S | ICD10CM | Covered |
| S06.34AA | ICD10CM | Covered |
| S06.34AD | ICD10CM | Covered |
| S06.34AS | ICD10CM | Covered |
| S06.350S | ICD10CM | Covered |
| S06.351S | ICD10CM | Covered |
| S06.352S | ICD10CM | Covered |
| S06.353S | ICD10CM | Covered |
| S06.354S | ICD10CM | Covered |
| S06.355S | ICD10CM | Covered |
| S06.359S | ICD10CM | Covered |
| S06.35AA | ICD10CM | Covered |
| S06.35AD | ICD10CM | Covered |
| S06.35AS | ICD10CM | Covered |
| S06.36AA | ICD10CM | Covered |
| S06.36AD | ICD10CM | Covered |
| S06.36AS | ICD10CM | Covered |
| S06.370S | ICD10CM | Covered |
| S06.371S | ICD10CM | Covered |
| S06.372S | ICD10CM | Covered |
| S06.373S | ICD10CM | Covered |
| S06.374S | ICD10CM | Covered |
| S06.375S | ICD10CM | Covered |
| S06.379S | ICD10CM | Covered |
| S06.37AA | ICD10CM | Covered |
| S06.37AD | ICD10CM | Covered |
| S06.37AS | ICD10CM | Covered |
| S06.380S | ICD10CM | Covered |
| S06.381S | ICD10CM | Covered |
| S06.382S | ICD10CM | Covered |
| S06.383S | ICD10CM | Covered |
| S06.384S | ICD10CM | Covered |
| S06.385S | ICD10CM | Covered |
| S06.389S | ICD10CM | Covered |
| S06.38AA | ICD10CM | Covered |
| S06.38AD | ICD10CM | Covered |
| S06.38AS | ICD10CM | Covered |
| S06.4X0S | ICD10CM | Covered |
| S06.4X1S | ICD10CM | Covered |
| S06.4X2S | ICD10CM | Covered |
| S06.4X3S | ICD10CM | Covered |
| S06.4X4S | ICD10CM | Covered |
| S06.4X5S | ICD10CM | Covered |
| S06.4X9S | ICD10CM | Covered |
| S06.4XAA | ICD10CM | Covered |
| S06.4XAD | ICD10CM | Covered |
| S06.4XAS | ICD10CM | Covered |
| S06.5X0S | ICD10CM | Covered |
| S06.5X1S | ICD10CM | Covered |
| S06.5X2S | ICD10CM | Covered |
| S06.5X3S | ICD10CM | Covered |
| S06.5X4S | ICD10CM | Covered |
| S06.5X5S | ICD10CM | Covered |
| S06.5X9S | ICD10CM | Covered |
| S06.5XAA | ICD10CM | Covered |
| S06.5XAD | ICD10CM | Covered |
| S06.5XAS | ICD10CM | Covered |
| S06.6X0S | ICD10CM | Covered |
| S06.6X1S | ICD10CM | Covered |
| S06.6X2S | ICD10CM | Covered |
| S06.6X3S | ICD10CM | Covered |
| S06.6X4S | ICD10CM | Covered |
| S06.6X5S | ICD10CM | Covered |
| S06.6X9S | ICD10CM | Covered |
| S06.6XAA | ICD10CM | Covered |
| S06.6XAD | ICD10CM | Covered |
| S06.6XAS | ICD10CM | Covered |
| S06.810S | ICD10CM | Covered |
| S06.811S | ICD10CM | Covered |
| S06.812S | ICD10CM | Covered |
| S06.813S | ICD10CM | Covered |
| S06.814S | ICD10CM | Covered |
| S06.815S | ICD10CM | Covered |
| S06.819S | ICD10CM | Covered |
| S06.820S | ICD10CM | Covered |
| S06.821S | ICD10CM | Covered |
| S06.822S | ICD10CM | Covered |
| S06.823S | ICD10CM | Covered |
| S06.824S | ICD10CM | Covered |
| S06.825S | ICD10CM | Covered |
| S06.829S | ICD10CM | Covered |
| S06.890S | ICD10CM | Covered |
| S06.891S | ICD10CM | Covered |
| S06.892S | ICD10CM | Covered |
| S06.893S | ICD10CM | Covered |
| S06.894S | ICD10CM | Covered |
| S06.895S | ICD10CM | Covered |
| S06.899S | ICD10CM | Covered |
| S06.89AA | ICD10CM | Covered |
| S06.89AD | ICD10CM | Covered |
| S06.89AS | ICD10CM | Covered |
| S06.8A0A | ICD10CM | Covered |
| S06.8A0D | ICD10CM | Covered |
| S06.8A0S | ICD10CM | Covered |
| S06.8A1A | ICD10CM | Covered |
| S06.8A1D | ICD10CM | Covered |
| S06.8A1S | ICD10CM | Covered |
| S06.8A2A | ICD10CM | Covered |
| S06.8A2D | ICD10CM | Covered |
| S06.8A2S | ICD10CM | Covered |
| S06.8A3A | ICD10CM | Covered |
| S06.8A3D | ICD10CM | Covered |
| S06.8A3S | ICD10CM | Covered |
| S06.8A4A | ICD10CM | Covered |
| S06.8A4D | ICD10CM | Covered |
| S06.8A4S | ICD10CM | Covered |
| S06.8A5A | ICD10CM | Covered |
| S06.8A5D | ICD10CM | Covered |
| S06.8A5S | ICD10CM | Covered |
| S06.8A6A | ICD10CM | Covered |
| S06.8A6D | ICD10CM | Covered |
| S06.8A6S | ICD10CM | Covered |
| S06.8A7A | ICD10CM | Covered |
| S06.8A8A | ICD10CM | Covered |
| S06.8A9A | ICD10CM | Covered |
| S06.8A9D | ICD10CM | Covered |
| S06.8A9S | ICD10CM | Covered |
| S06.8AAA | ICD10CM | Covered |
| S06.8AAD | ICD10CM | Covered |
| S06.8AAS | ICD10CM | Covered |
| S06.9X0S | ICD10CM | Covered |
| S06.9X1S | ICD10CM | Covered |
| S06.9X2S | ICD10CM | Covered |
| S06.9X3S | ICD10CM | Covered |
| S06.9X4S | ICD10CM | Covered |
| S06.9X5S | ICD10CM | Covered |
| S06.9X9S | ICD10CM | Covered |
| S11.012S | ICD10CM | Covered |
| S11.014S | ICD10CM | Covered |
| S11.019S | ICD10CM | Covered |
| S11.022S | ICD10CM | Covered |
| S11.029S | ICD10CM | Covered |
| S11.032S | ICD10CM | Covered |
| S11.034S | ICD10CM | Covered |
| S11.22XS | ICD10CM | Covered |
| S11.24XS | ICD10CM | Covered |
| S12.8XXS | ICD10CM | Covered |
| T17.308S | ICD10CM | Covered |
| T17.318S | ICD10CM | Covered |
| T17.328S | ICD10CM | Covered |
| T17.398S | ICD10CM | Covered |
| T17.408S | ICD10CM | Covered |
| T17.418S | ICD10CM | Covered |
| T17.428S | ICD10CM | Covered |
| T17.498S | ICD10CM | Covered |
| T17.508S | ICD10CM | Covered |
| T17.518S | ICD10CM | Covered |
| T17.528S | ICD10CM | Covered |
| T17.598S | ICD10CM | Covered |
| Z43.0 | ICD10CM | Covered |
| Z44.8 | ICD10CM | Covered |
| Z85.21 | ICD10CM | Covered |
| Z96.3 | ICD10CM | Covered |
| Z97.4 | ICD10CM | Covered |