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 |
|---|---|---|
| 90785 | HCPCS | Covered |
| 90791 | HCPCS | Covered |
| 90792 | HCPCS | Covered |
| 90832 | HCPCS | Covered |
| 90833 | HCPCS | Covered |
| 90834 | HCPCS | Covered |
| 90836 | HCPCS | Covered |
| 90837 | HCPCS | Covered |
| 90838 | HCPCS | Covered |
| 90839 | HCPCS | Covered |
| 90840 | HCPCS | Covered |
| 90845 | HCPCS | Covered |
| 90846 | HCPCS | Covered |
| 90847 | HCPCS | Covered |
| 90849 | HCPCS | Covered |
| 90853 | HCPCS | Covered |
| 90863 | HCPCS | Covered |
| 90865 | HCPCS | Covered |
| 90870 | HCPCS | Covered |
| 90880 | HCPCS | Covered |
| 90885 | HCPCS | Covered |
| 90887 | HCPCS | Covered |
| 90889 | HCPCS | Covered |
| 90899 | HCPCS | Covered |
| 96105 | HCPCS | Covered |
| 96110 | HCPCS | Covered |
| 96112 | HCPCS | Covered |
| 96113 | HCPCS | Covered |
| 96116 | HCPCS | Covered |
| 96130 | HCPCS | Covered |
| 96131 | HCPCS | Covered |
| 96132 | HCPCS | Covered |
| 96133 | HCPCS | Covered |
| 96136 | HCPCS | Covered |
| 96137 | HCPCS | Covered |
| 96138 | HCPCS | Covered |
| 96139 | HCPCS | Covered |
| 96146 | HCPCS | Covered |
| A50.40 | ICD10CM | Covered |
| A50.42 | ICD10CM | Covered |
| A50.43 | ICD10CM | Covered |
| A50.45 | ICD10CM | Covered |
| E66.01 | ICD10CM | Covered |
| E66.09 | ICD10CM | Covered |
| E66.1 | ICD10CM | Covered |
| E66.811 | ICD10CM | Covered |
| E66.812 | ICD10CM | Covered |
| E66.813 | ICD10CM | Covered |
| E66.9 | ICD10CM | Covered |
| F01.50 | ICD10CM | Covered |
| F01.511 | ICD10CM | Covered |
| F01.518 | ICD10CM | Covered |
| F01.52 | ICD10CM | Covered |
| F01.53 | ICD10CM | Covered |
| F01.54 | ICD10CM | Covered |
| F02.80 | ICD10CM | Covered |
| F02.811 | ICD10CM | Covered |
| F02.818 | ICD10CM | Covered |
| F02.82 | ICD10CM | Covered |
| F02.83 | ICD10CM | Covered |
| F02.84 | ICD10CM | Covered |
| F03.90 | ICD10CM | Covered |
| F03.911 | ICD10CM | Covered |
| F03.918 | ICD10CM | Covered |
| F03.92 | ICD10CM | Covered |
| F03.93 | ICD10CM | Covered |
| F03.94 | ICD10CM | Covered |
| F04 | ICD10CM | Covered |
| F05 | ICD10CM | Covered |
| F06.0 | ICD10CM | Covered |
| F06.1 | ICD10CM | Covered |
| F06.2 | ICD10CM | Covered |
| F06.30 | ICD10CM | Covered |
| F06.31 | ICD10CM | Covered |
| F06.32 | ICD10CM | Covered |
| F06.33 | ICD10CM | Covered |
| F06.34 | ICD10CM | Covered |
| F06.4 | ICD10CM | Covered |
| F06.8 | ICD10CM | Covered |
| F07.0 | ICD10CM | Covered |
| F07.81 | ICD10CM | Covered |
| F07.89 | ICD10CM | Covered |
| F07.9 | ICD10CM | Covered |
| F09 | ICD10CM | Covered |
| F10.10 | ICD10CM | Covered |
| F10.120 | ICD10CM | Covered |
| F10.121 | ICD10CM | Covered |
| F10.129 | ICD10CM | Covered |
| F10.130 | ICD10CM | Covered |
| F10.131 | ICD10CM | Covered |
| F10.132 | ICD10CM | Covered |
| F10.14 | ICD10CM | Covered |
| F10.150 | ICD10CM | Covered |
| F10.151 | ICD10CM | Covered |
| F10.159 | ICD10CM | Covered |
| F10.180 | ICD10CM | Covered |
| F10.181 | ICD10CM | Covered |
| F10.188 | ICD10CM | Covered |
| F10.19 | ICD10CM | Covered |
| F10.20 | ICD10CM | Covered |
| F10.221 | ICD10CM | Covered |
| F10.230 | ICD10CM | Covered |
| F10.231 | ICD10CM | Covered |
| F10.232 | ICD10CM | Covered |
| F10.239 | ICD10CM | Covered |
| F10.24 | ICD10CM | Covered |
| F10.250 | ICD10CM | Covered |
| F10.251 | ICD10CM | Covered |
| F10.259 | ICD10CM | Covered |
| F10.26 | ICD10CM | Covered |
| F10.280 | ICD10CM | Covered |
| F10.281 | ICD10CM | Covered |
| F10.288 | ICD10CM | Covered |
| F10.29 | ICD10CM | Covered |
| F10.90 | ICD10CM | Covered |
| F10.91 | ICD10CM | Covered |
| F10.921 | ICD10CM | Covered |
| F10.94 | ICD10CM | Covered |
| F10.950 | ICD10CM | Covered |
| F10.951 | ICD10CM | Covered |
| F10.959 | ICD10CM | Covered |
| F10.96 | ICD10CM | Covered |
| F10.97 | ICD10CM | Covered |
| F10.980 | ICD10CM | Covered |
| F10.981 | ICD10CM | Covered |
| F10.988 | ICD10CM | Covered |
| F10.99 | ICD10CM | Covered |
| F11.10 | ICD10CM | Covered |
| F11.120 | ICD10CM | Covered |
| F11.121 | ICD10CM | Covered |
| F11.122 | ICD10CM | Covered |
| F11.129 | ICD10CM | Covered |
| F11.13 | ICD10CM | Covered |
| F11.14 | ICD10CM | Covered |
| F11.150 | ICD10CM | Covered |
| F11.151 | ICD10CM | Covered |
| F11.159 | ICD10CM | Covered |
| F11.181 | ICD10CM | Covered |
| F11.188 | ICD10CM | Covered |
| F11.19 | ICD10CM | Covered |
| F11.20 | ICD10CM | Covered |
| F11.220 | ICD10CM | Covered |
| F11.221 | ICD10CM | Covered |
| F11.222 | ICD10CM | Covered |
| F11.229 | ICD10CM | Covered |
| F11.23 | ICD10CM | Covered |
| F11.24 | ICD10CM | Covered |
| F11.250 | ICD10CM | Covered |
| F11.251 | ICD10CM | Covered |
| F11.259 | ICD10CM | Covered |
| F11.281 | ICD10CM | Covered |
| F11.282 | ICD10CM | Covered |
| F11.288 | ICD10CM | Covered |
| F11.29 | ICD10CM | Covered |
| F11.90 | ICD10CM | Covered |
| F11.91 | ICD10CM | Covered |
| F11.921 | ICD10CM | Covered |
| F11.922 | ICD10CM | Covered |
| F11.93 | ICD10CM | Covered |
| F11.94 | ICD10CM | Covered |
| F11.950 | ICD10CM | Covered |
| F11.951 | ICD10CM | Covered |
| F11.959 | ICD10CM | Covered |
| F11.981 | ICD10CM | Covered |
| F11.988 | ICD10CM | Covered |
| F11.99 | ICD10CM | Covered |
| F12.10 | ICD10CM | Covered |
| F12.121 | ICD10CM | Covered |
| F12.122 | ICD10CM | Covered |
| F12.13 | ICD10CM | Covered |
| F12.150 | ICD10CM | Covered |
| F12.151 | ICD10CM | Covered |
| F12.159 | ICD10CM | Covered |
| F12.180 | ICD10CM | Covered |
| F12.188 | ICD10CM | Covered |
| F12.19 | ICD10CM | Covered |
| F12.20 | ICD10CM | Covered |
| F12.220 | ICD10CM | Covered |
| F12.221 | ICD10CM | Covered |
| F12.222 | ICD10CM | Covered |
| F12.229 | ICD10CM | Covered |
| F12.23 | ICD10CM | Covered |
| F12.250 | ICD10CM | Covered |
| F12.251 | ICD10CM | Covered |
| F12.259 | ICD10CM | Covered |
| F12.280 | ICD10CM | Covered |
| F12.288 | ICD10CM | Covered |
| F12.29 | ICD10CM | Covered |
| F12.90 | ICD10CM | Covered |
| F12.91 | ICD10CM | Covered |
| F12.921 | ICD10CM | Covered |
| F12.922 | ICD10CM | Covered |
| F12.93 | ICD10CM | Covered |
| F12.950 | ICD10CM | Covered |
| F12.951 | ICD10CM | Covered |
| F12.959 | ICD10CM | Covered |
| F12.980 | ICD10CM | Covered |
| F12.988 | ICD10CM | Covered |
| F12.99 | ICD10CM | Covered |
| F13.10 | ICD10CM | Covered |
| F13.120 | ICD10CM | Covered |
| F13.121 | ICD10CM | Covered |
| F13.130 | ICD10CM | Covered |
| F13.131 | ICD10CM | Covered |
| F13.132 | ICD10CM | Covered |
| F13.14 | ICD10CM | Covered |
| F13.150 | ICD10CM | Covered |
| F13.151 | ICD10CM | Covered |
| F13.159 | ICD10CM | Covered |
| F13.180 | ICD10CM | Covered |
| F13.181 | ICD10CM | Covered |
| F13.188 | ICD10CM | Covered |
| F13.19 | ICD10CM | Covered |
| F13.20 | ICD10CM | Covered |
| F13.220 | ICD10CM | Covered |
| F13.221 | ICD10CM | Covered |
| F13.229 | ICD10CM | Covered |
| F13.230 | ICD10CM | Covered |
| F13.231 | ICD10CM | Covered |
| F13.232 | ICD10CM | Covered |
| F13.239 | ICD10CM | Covered |
| F13.24 | ICD10CM | Covered |
| F13.250 | ICD10CM | Covered |
| F13.251 | ICD10CM | Covered |
| F13.259 | ICD10CM | Covered |
| F13.26 | ICD10CM | Covered |
| F13.27 | ICD10CM | Covered |
| F13.280 | ICD10CM | Covered |
| F13.281 | ICD10CM | Covered |
| F13.282 | ICD10CM | Covered |
| F13.288 | ICD10CM | Covered |
| F13.29 | ICD10CM | Covered |
| F13.90 | ICD10CM | Covered |
| F13.91 | ICD10CM | Covered |
| F13.921 | ICD10CM | Covered |
| F13.930 | ICD10CM | Covered |
| F13.931 | ICD10CM | Covered |
| F13.932 | ICD10CM | Covered |
| F13.939 | ICD10CM | Covered |
| F13.94 | ICD10CM | Covered |
| F13.950 | ICD10CM | Covered |
| F13.951 | ICD10CM | Covered |
| F13.959 | ICD10CM | Covered |
| F13.96 | ICD10CM | Covered |
| F13.97 | ICD10CM | Covered |
| F13.980 | ICD10CM | Covered |
| F13.981 | ICD10CM | Covered |
| F13.988 | ICD10CM | Covered |
| F13.99 | ICD10CM | Covered |
| F14.10 | ICD10CM | Covered |
| F14.120 | ICD10CM | Covered |
| F14.121 | ICD10CM | Covered |
| F14.122 | ICD10CM | Covered |
| F14.14 | ICD10CM | Covered |
| F14.150 | ICD10CM | Covered |
| F14.151 | ICD10CM | Covered |
| F14.159 | ICD10CM | Covered |
| F14.180 | ICD10CM | Covered |
| F14.181 | ICD10CM | Covered |
| F14.188 | ICD10CM | Covered |
| F14.19 | ICD10CM | Covered |
| F14.20 | ICD10CM | Covered |
| F14.220 | ICD10CM | Covered |
| F14.221 | ICD10CM | Covered |
| F14.222 | ICD10CM | Covered |
| F14.229 | ICD10CM | Covered |
| F14.23 | ICD10CM | Covered |
| F14.24 | ICD10CM | Covered |
| F14.250 | ICD10CM | Covered |
| F14.251 | ICD10CM | Covered |
| F14.259 | ICD10CM | Covered |
| F14.280 | ICD10CM | Covered |
| F14.281 | ICD10CM | Covered |
| F14.282 | ICD10CM | Covered |
| F14.288 | ICD10CM | Covered |
| F14.29 | ICD10CM | Covered |
| F14.90 | ICD10CM | Covered |
| F14.91 | ICD10CM | Covered |
| F14.921 | ICD10CM | Covered |
| F14.922 | ICD10CM | Covered |
| F14.94 | ICD10CM | Covered |
| F14.950 | ICD10CM | Covered |
| F14.951 | ICD10CM | Covered |
| F14.959 | ICD10CM | Covered |
| F14.980 | ICD10CM | Covered |
| F14.981 | ICD10CM | Covered |
| F14.988 | ICD10CM | Covered |
| F14.99 | ICD10CM | Covered |
| F15.10 | ICD10CM | Covered |
| F15.120 | ICD10CM | Covered |
| F15.121 | ICD10CM | Covered |
| F15.122 | ICD10CM | Covered |
| F15.13 | ICD10CM | Covered |
| F15.14 | ICD10CM | Covered |
| F15.150 | ICD10CM | Covered |
| F15.151 | ICD10CM | Covered |
| F15.159 | ICD10CM | Covered |
| F15.180 | ICD10CM | Covered |
| F15.181 | ICD10CM | Covered |
| F15.188 | ICD10CM | Covered |
| F15.19 | ICD10CM | Covered |
| F15.20 | ICD10CM | Covered |
| F15.220 | ICD10CM | Covered |
| F15.221 | ICD10CM | Covered |
| F15.222 | ICD10CM | Covered |
| F15.229 | ICD10CM | Covered |
| F15.23 | ICD10CM | Covered |
| F15.24 | ICD10CM | Covered |
| F15.250 | ICD10CM | Covered |
| F15.251 | ICD10CM | Covered |
| F15.259 | ICD10CM | Covered |
| F15.280 | ICD10CM | Covered |
| F15.281 | ICD10CM | Covered |
| F15.282 | ICD10CM | Covered |
| F15.288 | ICD10CM | Covered |
| F15.29 | ICD10CM | Covered |
| F15.90 | ICD10CM | Covered |
| F15.91 | ICD10CM | Covered |
| F15.921 | ICD10CM | Covered |
| F15.922 | ICD10CM | Covered |
| F15.93 | ICD10CM | Covered |
| F15.94 | ICD10CM | Covered |
| F15.950 | ICD10CM | Covered |
| F15.951 | ICD10CM | Covered |
| F15.959 | ICD10CM | Covered |
| F15.980 | ICD10CM | Covered |
| F15.981 | ICD10CM | Covered |
| F15.988 | ICD10CM | Covered |
| F15.99 | ICD10CM | Covered |
| F16.10 | ICD10CM | Covered |
| F16.120 | ICD10CM | Covered |
| F16.121 | ICD10CM | Covered |
| F16.122 | ICD10CM | Covered |
| F16.14 | ICD10CM | Covered |
| F16.150 | ICD10CM | Covered |
| F16.151 | ICD10CM | Covered |
| F16.159 | ICD10CM | Covered |
| F16.180 | ICD10CM | Covered |
| F16.183 | ICD10CM | Covered |
| F16.188 | ICD10CM | Covered |
| F16.19 | ICD10CM | Covered |
| F16.20 | ICD10CM | Covered |
| F16.220 | ICD10CM | Covered |
| F16.221 | ICD10CM | Covered |
| F16.229 | ICD10CM | Covered |
| F16.24 | ICD10CM | Covered |
| F16.250 | ICD10CM | Covered |
| F16.251 | ICD10CM | Covered |
| F16.259 | ICD10CM | Covered |
| F16.280 | ICD10CM | Covered |
| F16.283 | ICD10CM | Covered |
| F16.288 | ICD10CM | Covered |
| F16.29 | ICD10CM | Covered |
| F16.90 | ICD10CM | Covered |
| F16.91 | ICD10CM | Covered |
| F16.921 | ICD10CM | Covered |
| F16.94 | ICD10CM | Covered |
| F16.950 | ICD10CM | Covered |
| F16.951 | ICD10CM | Covered |
| F16.959 | ICD10CM | Covered |
| F16.980 | ICD10CM | Covered |
| F16.983 | ICD10CM | Covered |
| F16.988 | ICD10CM | Covered |
| F16.99 | ICD10CM | Covered |
| F17.203 | ICD10CM | Covered |
| F17.208 | ICD10CM | Covered |
| F17.209 | ICD10CM | Covered |
| F17.213 | ICD10CM | Covered |
| F17.218 | ICD10CM | Covered |
| F17.219 | ICD10CM | Covered |
| F17.223 | ICD10CM | Covered |
| F17.228 | ICD10CM | Covered |
| F17.229 | ICD10CM | Covered |
| F17.293 | ICD10CM | Covered |
| F17.298 | ICD10CM | Covered |
| F17.299 | ICD10CM | Covered |
| F18.10 | ICD10CM | Covered |
| F18.120 | ICD10CM | Covered |
| F18.121 | ICD10CM | Covered |
| F18.14 | ICD10CM | Covered |
| F18.150 | ICD10CM | Covered |
| F18.151 | ICD10CM | Covered |
| F18.159 | ICD10CM | Covered |
| F18.17 | ICD10CM | Covered |
| F18.180 | ICD10CM | Covered |
| F18.188 | ICD10CM | Covered |
| F18.19 | ICD10CM | Covered |
| F18.20 | ICD10CM | Covered |
| F18.220 | ICD10CM | Covered |
| F18.221 | ICD10CM | Covered |
| F18.229 | ICD10CM | Covered |
| F18.24 | ICD10CM | Covered |
| F18.250 | ICD10CM | Covered |
| F18.251 | ICD10CM | Covered |
| F18.259 | ICD10CM | Covered |
| F18.27 | ICD10CM | Covered |
| F18.280 | ICD10CM | Covered |
| F18.288 | ICD10CM | Covered |
| F18.29 | ICD10CM | Covered |
| F18.90 | ICD10CM | Covered |
| F18.91 | ICD10CM | Covered |
| F18.921 | ICD10CM | Covered |
| F18.94 | ICD10CM | Covered |
| F18.950 | ICD10CM | Covered |
| F18.951 | ICD10CM | Covered |
| F18.959 | ICD10CM | Covered |
| F18.97 | ICD10CM | Covered |
| F18.980 | ICD10CM | Covered |
| F18.988 | ICD10CM | Covered |
| F18.99 | ICD10CM | Covered |
| F19.121 | ICD10CM | Covered |
| F19.122 | ICD10CM | Covered |
| F19.130 | ICD10CM | Covered |
| F19.131 | ICD10CM | Covered |
| F19.132 | ICD10CM | Covered |
| F19.14 | ICD10CM | Covered |
| F19.150 | ICD10CM | Covered |
| F19.151 | ICD10CM | Covered |
| F19.159 | ICD10CM | Covered |
| F19.16 | ICD10CM | Covered |
| F19.17 | ICD10CM | Covered |
| F19.180 | ICD10CM | Covered |
| F19.181 | ICD10CM | Covered |
| F19.188 | ICD10CM | Covered |
| F19.19 | ICD10CM | Covered |
| F19.20 | ICD10CM | Covered |
| F19.220 | ICD10CM | Covered |
| F19.221 | ICD10CM | Covered |
| F19.222 | ICD10CM | Covered |
| F19.229 | ICD10CM | Covered |
| F19.230 | ICD10CM | Covered |
| F19.231 | ICD10CM | Covered |
| F19.232 | ICD10CM | Covered |
| F19.239 | ICD10CM | Covered |
| F19.24 | ICD10CM | Covered |
| F19.250 | ICD10CM | Covered |
| F19.251 | ICD10CM | Covered |
| F19.259 | ICD10CM | Covered |
| F19.26 | ICD10CM | Covered |
| F19.27 | ICD10CM | Covered |
| F19.280 | ICD10CM | Covered |
| F19.281 | ICD10CM | Covered |
| F19.282 | ICD10CM | Covered |
| F19.288 | ICD10CM | Covered |
| F19.29 | ICD10CM | Covered |
| F19.91 | ICD10CM | Covered |
| F19.921 | ICD10CM | Covered |
| F19.922 | ICD10CM | Covered |
| F19.930 | ICD10CM | Covered |
| F19.931 | ICD10CM | Covered |
| F19.932 | ICD10CM | Covered |
| F19.939 | ICD10CM | Covered |
| F19.94 | ICD10CM | Covered |
| F19.950 | ICD10CM | Covered |
| F19.951 | ICD10CM | Covered |
| F19.959 | ICD10CM | Covered |
| F19.96 | ICD10CM | Covered |
| F19.97 | ICD10CM | Covered |
| F19.980 | ICD10CM | Covered |
| F19.981 | ICD10CM | Covered |
| F19.988 | ICD10CM | Covered |
| F19.99 | ICD10CM | Covered |
| F20.0 | ICD10CM | Covered |
| F20.1 | ICD10CM | Covered |
| F20.2 | ICD10CM | Covered |
| F20.3 | ICD10CM | Covered |
| F20.5 | ICD10CM | Covered |
| F20.81 | ICD10CM | Covered |
| F20.9 | ICD10CM | Covered |
| F21 | ICD10CM | Covered |
| F22 | ICD10CM | Covered |
| F23 | ICD10CM | Covered |
| F24 | ICD10CM | Covered |
| F25.0 | ICD10CM | Covered |
| F25.1 | ICD10CM | Covered |
| F25.8 | ICD10CM | Covered |
| F25.9 | ICD10CM | Covered |
| F28 | ICD10CM | Covered |
| F29 | ICD10CM | Covered |
| F30.10 | ICD10CM | Covered |
| F30.11 | ICD10CM | Covered |
| F30.12 | ICD10CM | Covered |
| F30.13 | ICD10CM | Covered |
| F30.2 | ICD10CM | Covered |
| F30.3 | ICD10CM | Covered |
| F30.4 | ICD10CM | Covered |
| F30.9 | ICD10CM | Covered |
| F31.0 | ICD10CM | Covered |
| F31.10 | ICD10CM | Covered |
| F31.11 | ICD10CM | Covered |
| F31.12 | ICD10CM | Covered |
| F31.13 | ICD10CM | Covered |
| F31.2 | ICD10CM | Covered |
| F31.30 | ICD10CM | Covered |
| F31.31 | ICD10CM | Covered |
| F31.32 | ICD10CM | Covered |
| F31.4 | ICD10CM | Covered |
| F31.5 | ICD10CM | Covered |
| F31.60 | ICD10CM | Covered |
| F31.61 | ICD10CM | Covered |
| F31.62 | ICD10CM | Covered |
| F31.63 | ICD10CM | Covered |
| F31.64 | ICD10CM | Covered |
| F31.70 | ICD10CM | Covered |
| F31.71 | ICD10CM | Covered |
| F31.72 | ICD10CM | Covered |
| F31.73 | ICD10CM | Covered |
| F31.74 | ICD10CM | Covered |
| F31.75 | ICD10CM | Covered |
| F31.76 | ICD10CM | Covered |
| F31.77 | ICD10CM | Covered |
| F31.78 | ICD10CM | Covered |
| F31.81 | ICD10CM | Covered |
| F31.89 | ICD10CM | Covered |
| F31.9 | ICD10CM | Covered |
| F32.0 | ICD10CM | Covered |
| F32.1 | ICD10CM | Covered |
| F32.2 | ICD10CM | Covered |
| F32.3 | ICD10CM | Covered |
| F32.4 | ICD10CM | Covered |
| F32.5 | ICD10CM | Covered |
| F32.9 | ICD10CM | Covered |
| F33.0 | ICD10CM | Covered |
| F33.1 | ICD10CM | Covered |
| F33.2 | ICD10CM | Covered |
| F33.3 | ICD10CM | Covered |
| F33.40 | ICD10CM | Covered |
| F33.41 | ICD10CM | Covered |
| F33.42 | ICD10CM | Covered |
| F33.9 | ICD10CM | Covered |
| F34.0 | ICD10CM | Covered |
| F34.1 | ICD10CM | Covered |
| F39 | ICD10CM | Covered |
| F40.00 | ICD10CM | Covered |
| F40.01 | ICD10CM | Covered |
| F40.02 | ICD10CM | Covered |
| F40.10 | ICD10CM | Covered |
| F40.11 | ICD10CM | Covered |
| F40.210 | ICD10CM | Covered |
| F40.218 | ICD10CM | Covered |
| F40.220 | ICD10CM | Covered |
| F40.228 | ICD10CM | Covered |
| F40.230 | ICD10CM | Covered |
| F40.231 | ICD10CM | Covered |
| F40.232 | ICD10CM | Covered |
| F40.233 | ICD10CM | Covered |
| F40.240 | ICD10CM | Covered |
| F40.241 | ICD10CM | Covered |
| F40.242 | ICD10CM | Covered |
| F40.243 | ICD10CM | Covered |
| F40.248 | ICD10CM | Covered |
| F40.290 | ICD10CM | Covered |
| F40.291 | ICD10CM | Covered |
| F40.298 | ICD10CM | Covered |
| F40.8 | ICD10CM | Covered |
| F41.0 | ICD10CM | Covered |
| F41.1 | ICD10CM | Covered |
| F41.9 | ICD10CM | Covered |
| F42.2 | ICD10CM | Covered |
| F42.3 | ICD10CM | Covered |
| F42.4 | ICD10CM | Covered |
| F42.8 | ICD10CM | Covered |
| F42.9 | ICD10CM | Covered |
| F43.0 | ICD10CM | Covered |
| F43.10 | ICD10CM | Covered |
| F43.11 | ICD10CM | Covered |
| F43.12 | ICD10CM | Covered |
| F43.21 | ICD10CM | Covered |
| F43.22 | ICD10CM | Covered |
| F43.23 | ICD10CM | Covered |
| F43.24 | ICD10CM | Covered |
| F43.25 | ICD10CM | Covered |
| F44.0 | ICD10CM | Covered |
| F44.1 | ICD10CM | Covered |
| F44.2 | ICD10CM | Covered |
| F44.4 | ICD10CM | Covered |
| F44.5 | ICD10CM | Covered |
| F44.6 | ICD10CM | Covered |
| F44.7 | ICD10CM | Covered |
| F44.81 | ICD10CM | Covered |
| F44.89 | ICD10CM | Covered |
| F44.9 | ICD10CM | Covered |
| F45.0 | ICD10CM | Covered |
| F45.1 | ICD10CM | Covered |
| F45.20 | ICD10CM | Covered |
| F45.21 | ICD10CM | Covered |
| F45.22 | ICD10CM | Covered |
| F45.29 | ICD10CM | Covered |
| F45.41 | ICD10CM | Covered |
| F45.42 | ICD10CM | Covered |
| F45.9 | ICD10CM | Covered |
| F48.1 | ICD10CM | Covered |
| F48.2 | ICD10CM | Covered |
| F50.00 | ICD10CM | Covered |
| F50.010 | ICD10CM | Covered |
| F50.011 | ICD10CM | Covered |
| F50.012 | ICD10CM | Covered |
| F50.013 | ICD10CM | Covered |
| F50.014 | ICD10CM | Covered |
| F50.019 | ICD10CM | Covered |
| F50.020 | ICD10CM | Covered |
| F50.021 | ICD10CM | Covered |
| F50.022 | ICD10CM | Covered |
| F50.023 | ICD10CM | Covered |
| F50.024 | ICD10CM | Covered |
| F50.029 | ICD10CM | Covered |
| F50.20 | ICD10CM | Covered |
| F50.21 | ICD10CM | Covered |
| F50.22 | ICD10CM | Covered |
| F50.23 | ICD10CM | Covered |
| F50.24 | ICD10CM | Covered |
| F50.25 | ICD10CM | Covered |
| F50.810 | ICD10CM | Covered |
| F50.811 | ICD10CM | Covered |
| F50.812 | ICD10CM | Covered |
| F50.813 | ICD10CM | Covered |
| F50.814 | ICD10CM | Covered |
| F50.819 | ICD10CM | Covered |
| F50.82 | ICD10CM | Covered |
| F50.83 | ICD10CM | Covered |
| F50.84 | ICD10CM | Covered |
| F50.89 | ICD10CM | Covered |
| F50.9 | ICD10CM | Covered |
| F51.01 | ICD10CM | Covered |
| F51.03 | ICD10CM | Covered |
| F51.04 | ICD10CM | Covered |
| F51.05 | ICD10CM | Covered |
| F51.09 | ICD10CM | Covered |
| F51.11 | ICD10CM | Covered |
| F51.12 | ICD10CM | Covered |
| F51.13 | ICD10CM | Covered |
| F51.3 | ICD10CM | Covered |
| F51.4 | ICD10CM | Covered |
| F51.8 | ICD10CM | Covered |
| F52.0 | ICD10CM | Covered |
| F52.1 | ICD10CM | Covered |
| F52.21 | ICD10CM | Covered |
| F52.22 | ICD10CM | Covered |
| F52.31 | ICD10CM | Covered |
| F52.32 | ICD10CM | Covered |
| F52.4 | ICD10CM | Covered |
| F52.5 | ICD10CM | Covered |
| F52.6 | ICD10CM | Covered |
| F52.8 | ICD10CM | Covered |
| F52.9 | ICD10CM | Covered |
| F53.0 | ICD10CM | Covered |
| F53.1 | ICD10CM | Covered |
| F54 | ICD10CM | Covered |
| F55.0 | ICD10CM | Covered |
| F55.1 | ICD10CM | Covered |
| F55.2 | ICD10CM | Covered |
| F55.3 | ICD10CM | Covered |
| F55.4 | ICD10CM | Covered |
| F55.8 | ICD10CM | Covered |
| F60.1 | ICD10CM | Covered |
| F60.2 | ICD10CM | Covered |
| F60.3 | ICD10CM | Covered |
| F60.5 | ICD10CM | Covered |
| F60.6 | ICD10CM | Covered |
| F60.7 | ICD10CM | Covered |
| F60.81 | ICD10CM | Covered |
| F63.0 | ICD10CM | Covered |
| F63.1 | ICD10CM | Covered |
| F63.2 | ICD10CM | Covered |
| F63.81 | ICD10CM | Covered |
| F63.9 | ICD10CM | Covered |
| F64.2 | ICD10CM | Covered |
| F64.8 | ICD10CM | Covered |
| F64.9 | ICD10CM | Covered |
| F65.1 | ICD10CM | Covered |
| F65.2 | ICD10CM | Covered |
| F65.4 | ICD10CM | Covered |
| F68.11 | ICD10CM | Covered |
| F68.13 | ICD10CM | Covered |
| F68.8 | ICD10CM | Covered |
| F70 | ICD10CM | Covered |
| F71 | ICD10CM | Covered |
| F72 | ICD10CM | Covered |
| F73 | ICD10CM | Covered |
| F80.0 | ICD10CM | Covered |
| F80.1 | ICD10CM | Covered |
| F80.2 | ICD10CM | Covered |
| F80.81 | ICD10CM | Covered |
| F80.89 | ICD10CM | Covered |
| F80.9 | ICD10CM | Covered |
| F81.0 | ICD10CM | Covered |
| F81.2 | ICD10CM | Covered |
| F81.81 | ICD10CM | Covered |
| F81.89 | ICD10CM | Covered |
| F81.9 | ICD10CM | Covered |
| F82 | ICD10CM | Covered |
| F84.0 | ICD10CM | Covered |
| F84.3 | ICD10CM | Covered |
| F84.5 | ICD10CM | Covered |
| F84.8 | ICD10CM | Covered |
| F89 | ICD10CM | Covered |
| F90.0 | ICD10CM | Covered |
| F90.1 | ICD10CM | Covered |
| F90.2 | ICD10CM | Covered |
| F90.8 | ICD10CM | Covered |
| F90.9 | ICD10CM | Covered |
| F91.0 | ICD10CM | Covered |
| F91.1 | ICD10CM | Covered |
| F91.2 | ICD10CM | Covered |
| F91.3 | ICD10CM | Covered |
| F91.8 | ICD10CM | Covered |
| F93.0 | ICD10CM | Covered |
| F93.8 | ICD10CM | Covered |
| F94.0 | ICD10CM | Covered |
| F94.1 | ICD10CM | Covered |
| F94.2 | ICD10CM | Covered |
| F94.8 | ICD10CM | Covered |
| F94.9 | ICD10CM | Covered |
| F95.0 | ICD10CM | Covered |
| F95.1 | ICD10CM | Covered |
| F95.2 | ICD10CM | Covered |
| F95.8 | ICD10CM | Covered |
| F95.9 | ICD10CM | Covered |
| F98.0 | ICD10CM | Covered |
| F98.1 | ICD10CM | Covered |
| F98.21 | ICD10CM | Covered |
| F98.29 | ICD10CM | Covered |
| F98.3 | ICD10CM | Covered |
| F98.4 | ICD10CM | Covered |
| F98.8 | ICD10CM | Covered |
| G21.0 | ICD10CM | Covered |
| G21.11 | ICD10CM | Covered |
| G21.19 | ICD10CM | Covered |
| G21.2 | ICD10CM | Covered |
| G21.3 | ICD10CM | Covered |
| G21.8 | ICD10CM | Covered |
| G21.9 | ICD10CM | Covered |
| G24.02 | ICD10CM | Covered |
| G24.4 | ICD10CM | Covered |
| G25.70 | ICD10CM | Covered |
| G25.71 | ICD10CM | Covered |
| G25.79 | ICD10CM | Covered |
| G25.89 | ICD10CM | Covered |
| G25.9 | ICD10CM | Covered |
| G26 | ICD10CM | Covered |
| G30.0 | ICD10CM | Covered |
| G30.1 | ICD10CM | Covered |
| G30.8 | ICD10CM | Covered |
| G30.9 | ICD10CM | Covered |
| G31.01 | ICD10CM | Covered |
| G31.09 | ICD10CM | Covered |
| G31.83 | ICD10CM | Covered |
| G31.87 | ICD10CM | Covered |
| G47.00 | ICD10CM | Covered |
| G47.411 | ICD10CM | Covered |
| G47.419 | ICD10CM | Covered |
| G47.421 | ICD10CM | Covered |
| G47.429 | ICD10CM | Covered |
| G47.51 | 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 |
| H91.01 | ICD10CM | Covered |
| H91.02 | ICD10CM | Covered |
| H91.03 | ICD10CM | Covered |
| H91.09 | ICD10CM | Covered |
| H91.3 | ICD10CM | Covered |
| H91.8X1 | ICD10CM | Covered |
| H91.8X2 | ICD10CM | Covered |
| H91.8X3 | ICD10CM | Covered |
| H91.8X9 | ICD10CM | Covered |
| H93.25 | ICD10CM | Covered |
| R07.0 | ICD10CM | Covered |
| R37 | ICD10CM | Covered |
| R40.0 | ICD10CM | Covered |
| R40.1 | ICD10CM | Covered |
| R41.0 | ICD10CM | Covered |
| R41.1 | ICD10CM | Covered |
| R41.2 | ICD10CM | Covered |
| R41.3 | ICD10CM | Covered |
| R41.82 | ICD10CM | Covered |
| R41.85 | ICD10CM | Covered |
| R45.7 | ICD10CM | Covered |
| R45.850 | ICD10CM | Covered |
| R45.851 | ICD10CM | Covered |
| R45.88 | 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 |
| R47.9 | ICD10CM | Covered |
| R48.0 | ICD10CM | Covered |
| R49.1 | ICD10CM | Covered |
| T74.02XA | ICD10CM | Covered |
| T74.11XA | ICD10CM | Covered |
| T74.12XA | ICD10CM | Covered |
| T74.21XA | ICD10CM | Covered |
| T74.22XA | ICD10CM | Covered |
| T76.02XA | ICD10CM | Covered |
| T76.11XA | ICD10CM | Covered |
| T76.12XA | ICD10CM | Covered |
| T76.21XA | ICD10CM | Covered |
| T76.22XA | ICD10CM | Covered |
| Z71.0 | ICD10CM | Covered |