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 |
|---|---|---|
| 20526 | HCPCS | Covered |
| 20527 | HCPCS | Covered |
| 20550 | HCPCS | Covered |
| 20551 | HCPCS | Covered |
| 20612 | HCPCS | Covered |
| 26341 | HCPCS | Covered |
| 28899 | HCPCS | Covered |
| 64455 | HCPCS | Covered |
| 64632 | HCPCS | Covered |
| G56.01 | ICD10CM | Covered |
| G56.02 | ICD10CM | Covered |
| G56.03 | 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 |
| M24.211 | ICD10CM | Covered |
| M24.212 | ICD10CM | Covered |
| M24.221 | ICD10CM | Covered |
| M24.222 | ICD10CM | Covered |
| M24.231 | ICD10CM | Covered |
| M24.232 | ICD10CM | Covered |
| M24.241 | ICD10CM | Covered |
| M24.242 | ICD10CM | Covered |
| M24.251 | ICD10CM | Covered |
| M24.252 | ICD10CM | Covered |
| M24.271 | ICD10CM | Covered |
| M24.272 | ICD10CM | Covered |
| M24.274 | ICD10CM | Covered |
| M24.275 | ICD10CM | Covered |
| M53.3 | ICD10CM | Covered |
| M65.221 | ICD10CM | Covered |
| M65.222 | ICD10CM | Covered |
| M65.231 | ICD10CM | Covered |
| M65.232 | ICD10CM | Covered |
| M65.241 | ICD10CM | Covered |
| M65.242 | ICD10CM | Covered |
| M65.251 | ICD10CM | Covered |
| M65.252 | ICD10CM | Covered |
| M65.261 | ICD10CM | Covered |
| M65.262 | ICD10CM | Covered |
| M65.271 | ICD10CM | Covered |
| M65.272 | ICD10CM | Covered |
| M65.28 | ICD10CM | Covered |
| M65.29 | ICD10CM | Covered |
| M65.311 | ICD10CM | Covered |
| M65.312 | ICD10CM | Covered |
| M65.321 | ICD10CM | Covered |
| M65.322 | ICD10CM | Covered |
| M65.331 | ICD10CM | Covered |
| M65.332 | ICD10CM | Covered |
| M65.341 | ICD10CM | Covered |
| M65.342 | ICD10CM | Covered |
| M65.351 | ICD10CM | Covered |
| M65.352 | ICD10CM | Covered |
| M65.4 | ICD10CM | Covered |
| M65.811 | ICD10CM | Covered |
| M65.812 | ICD10CM | Covered |
| M65.821 | ICD10CM | Covered |
| M65.822 | ICD10CM | Covered |
| M65.831 | ICD10CM | Covered |
| M65.832 | ICD10CM | Covered |
| M65.841 | ICD10CM | Covered |
| M65.842 | ICD10CM | Covered |
| M65.851 | ICD10CM | Covered |
| M65.852 | ICD10CM | Covered |
| M65.861 | ICD10CM | Covered |
| M65.862 | ICD10CM | Covered |
| M65.871 | ICD10CM | Covered |
| M65.872 | ICD10CM | Covered |
| M65.88 | ICD10CM | Covered |
| M65.89 | ICD10CM | Covered |
| M67.01 | ICD10CM | Covered |
| M67.02 | ICD10CM | Covered |
| M67.411 | ICD10CM | Covered |
| M67.412 | ICD10CM | Covered |
| M67.421 | ICD10CM | Covered |
| M67.422 | ICD10CM | Covered |
| M67.431 | ICD10CM | Covered |
| M67.432 | ICD10CM | Covered |
| M67.441 | ICD10CM | Covered |
| M67.442 | ICD10CM | Covered |
| M67.451 | ICD10CM | Covered |
| M67.452 | ICD10CM | Covered |
| M67.461 | ICD10CM | Covered |
| M67.462 | ICD10CM | Covered |
| M67.471 | ICD10CM | Covered |
| M67.472 | ICD10CM | Covered |
| M67.48 | ICD10CM | Covered |
| M67.49 | ICD10CM | Covered |
| M67.51 | ICD10CM | Covered |
| M67.52 | ICD10CM | Covered |
| M67.813 | ICD10CM | Covered |
| M67.814 | ICD10CM | Covered |
| M67.823 | ICD10CM | Covered |
| M67.824 | ICD10CM | Covered |
| M67.833 | ICD10CM | Covered |
| M67.834 | ICD10CM | Covered |
| M67.843 | ICD10CM | Covered |
| M67.844 | ICD10CM | Covered |
| M67.853 | ICD10CM | Covered |
| M67.854 | ICD10CM | Covered |
| M67.863 | ICD10CM | Covered |
| M67.864 | ICD10CM | Covered |
| M67.873 | ICD10CM | Covered |
| M67.874 | ICD10CM | Covered |
| M67.88 | ICD10CM | Covered |
| M67.89 | ICD10CM | Covered |
| M67.A01 | ICD10CM | Covered |
| M67.A02 | ICD10CM | Covered |
| M72.0 | ICD10CM | Covered |
| M72.21 | ICD10CM | Covered |
| M72.22 | ICD10CM | Covered |
| M72.4 | ICD10CM | Covered |
| M75.01 | ICD10CM | Covered |
| M75.02 | ICD10CM | Covered |
| M75.111 | ICD10CM | Covered |
| M75.112 | ICD10CM | Covered |
| M75.21 | ICD10CM | Covered |
| M75.22 | ICD10CM | Covered |
| M75.31 | ICD10CM | Covered |
| M75.32 | ICD10CM | Covered |
| M75.41 | ICD10CM | Covered |
| M75.42 | ICD10CM | Covered |
| M75.81 | ICD10CM | Covered |
| M75.82 | ICD10CM | Covered |
| M76.01 | ICD10CM | Covered |
| M76.02 | ICD10CM | Covered |
| M76.11 | ICD10CM | Covered |
| M76.12 | ICD10CM | Covered |
| M76.21 | ICD10CM | Covered |
| M76.22 | ICD10CM | Covered |
| M76.31 | ICD10CM | Covered |
| M76.32 | ICD10CM | Covered |
| M76.51 | ICD10CM | Covered |
| M76.52 | ICD10CM | Covered |
| M76.61 | ICD10CM | Covered |
| M76.62 | ICD10CM | Covered |
| M76.71 | ICD10CM | Covered |
| M76.72 | ICD10CM | Covered |
| M76.811 | ICD10CM | Covered |
| M76.812 | ICD10CM | Covered |
| M76.821 | ICD10CM | Covered |
| M76.822 | ICD10CM | Covered |
| M76.891 | ICD10CM | Covered |
| M76.892 | ICD10CM | Covered |
| M77.01 | ICD10CM | Covered |
| M77.02 | ICD10CM | Covered |
| M77.11 | ICD10CM | Covered |
| M77.12 | ICD10CM | Covered |
| M77.21 | ICD10CM | Covered |
| M77.22 | ICD10CM | Covered |
| M77.31 | ICD10CM | Covered |
| M77.32 | ICD10CM | Covered |
| M77.41 | ICD10CM | Covered |
| M77.42 | ICD10CM | Covered |
| M77.51 | ICD10CM | Covered |
| M77.52 | ICD10CM | Covered |
| M77.8 | ICD10CM | Covered |
| S03.41XA | ICD10CM | Covered |
| S03.41XD | ICD10CM | Covered |
| S03.41XS | ICD10CM | Covered |
| S03.42XA | ICD10CM | Covered |
| S03.42XD | ICD10CM | Covered |
| S03.42XS | ICD10CM | Covered |
| S03.43XA | ICD10CM | Covered |
| S03.43XD | ICD10CM | Covered |
| S03.43XS | ICD10CM | Covered |
| S03.8XXA | ICD10CM | Covered |
| S03.8XXD | ICD10CM | Covered |
| S03.8XXS | ICD10CM | Covered |
| S13.4XXA | ICD10CM | Covered |
| S13.4XXD | ICD10CM | Covered |
| S13.4XXS | ICD10CM | Covered |
| S13.8XXA | ICD10CM | Covered |
| S13.8XXD | ICD10CM | Covered |
| S13.8XXS | ICD10CM | Covered |
| S16.1XXA | ICD10CM | Covered |
| S16.1XXD | ICD10CM | Covered |
| S16.1XXS | ICD10CM | Covered |
| S23.3XXA | ICD10CM | Covered |
| S23.3XXD | ICD10CM | Covered |
| S23.3XXS | ICD10CM | Covered |
| S23.41XA | ICD10CM | Covered |
| S23.41XD | ICD10CM | Covered |
| S23.41XS | ICD10CM | Covered |
| S29.011A | ICD10CM | Covered |
| S29.011D | ICD10CM | Covered |
| S29.011S | ICD10CM | Covered |
| S29.012A | ICD10CM | Covered |
| S29.012D | ICD10CM | Covered |
| S29.012S | ICD10CM | Covered |
| S33.5XXA | ICD10CM | Covered |
| S33.5XXD | ICD10CM | Covered |
| S33.5XXS | ICD10CM | Covered |
| S39.011A | ICD10CM | Covered |
| S39.011D | ICD10CM | Covered |
| S39.011S | ICD10CM | Covered |
| S39.012A | ICD10CM | Covered |
| S39.012D | ICD10CM | Covered |
| S39.012S | ICD10CM | Covered |
| S39.013A | ICD10CM | Covered |
| S39.013D | ICD10CM | Covered |
| S39.013S | ICD10CM | Covered |
| S43.411A | ICD10CM | Covered |
| S43.411D | ICD10CM | Covered |
| S43.411S | ICD10CM | Covered |
| S43.412A | ICD10CM | Covered |
| S43.412D | ICD10CM | Covered |
| S43.412S | ICD10CM | Covered |
| S43.421A | ICD10CM | Covered |
| S43.421D | ICD10CM | Covered |
| S43.421S | ICD10CM | Covered |
| S43.422A | ICD10CM | Covered |
| S43.422D | ICD10CM | Covered |
| S43.422S | ICD10CM | Covered |
| S43.81XA | ICD10CM | Covered |
| S43.81XD | ICD10CM | Covered |
| S43.81XS | ICD10CM | Covered |
| S43.82XA | ICD10CM | Covered |
| S43.82XD | ICD10CM | Covered |
| S43.82XS | ICD10CM | Covered |
| S46.011A | ICD10CM | Covered |
| S46.011D | ICD10CM | Covered |
| S46.011S | ICD10CM | Covered |
| S46.012A | ICD10CM | Covered |
| S46.012D | ICD10CM | Covered |
| S46.012S | ICD10CM | Covered |
| S46.111A | ICD10CM | Covered |
| S46.111D | ICD10CM | Covered |
| S46.111S | ICD10CM | Covered |
| S46.112A | ICD10CM | Covered |
| S46.112D | ICD10CM | Covered |
| S46.112S | ICD10CM | Covered |
| S46.211A | ICD10CM | Covered |
| S46.211D | ICD10CM | Covered |
| S46.211S | ICD10CM | Covered |
| S46.212A | ICD10CM | Covered |
| S46.212D | ICD10CM | Covered |
| S46.212S | ICD10CM | Covered |
| S46.311A | ICD10CM | Covered |
| S46.311D | ICD10CM | Covered |
| S46.311S | ICD10CM | Covered |
| S46.312A | ICD10CM | Covered |
| S46.312D | ICD10CM | Covered |
| S46.312S | ICD10CM | Covered |
| S46.811A | ICD10CM | Covered |
| S46.811D | ICD10CM | Covered |
| S46.811S | ICD10CM | Covered |
| S46.812A | ICD10CM | Covered |
| S46.812D | ICD10CM | Covered |
| S46.812S | ICD10CM | Covered |
| S53.431A | ICD10CM | Covered |
| S53.431D | ICD10CM | Covered |
| S53.431S | ICD10CM | Covered |
| S53.432A | ICD10CM | Covered |
| S53.432D | ICD10CM | Covered |
| S53.432S | ICD10CM | Covered |
| S53.441A | ICD10CM | Covered |
| S53.441D | ICD10CM | Covered |
| S53.441S | ICD10CM | Covered |
| S53.442A | ICD10CM | Covered |
| S53.442D | ICD10CM | Covered |
| S53.442S | ICD10CM | Covered |
| S53.491A | ICD10CM | Covered |
| S53.491D | ICD10CM | Covered |
| S53.491S | ICD10CM | Covered |
| S53.492A | ICD10CM | Covered |
| S53.492D | ICD10CM | Covered |
| S53.492S | ICD10CM | Covered |
| S56.011A | ICD10CM | Covered |
| S56.011D | ICD10CM | Covered |
| S56.011S | ICD10CM | Covered |
| S56.012A | ICD10CM | Covered |
| S56.012D | ICD10CM | Covered |
| S56.012S | ICD10CM | Covered |
| S56.111A | ICD10CM | Covered |
| S56.111D | ICD10CM | Covered |
| S56.111S | ICD10CM | Covered |
| S56.112A | ICD10CM | Covered |
| S56.112D | ICD10CM | Covered |
| S56.112S | ICD10CM | Covered |
| S56.113A | ICD10CM | Covered |
| S56.113D | ICD10CM | Covered |
| S56.113S | ICD10CM | Covered |
| S56.114A | ICD10CM | Covered |
| S56.114D | ICD10CM | Covered |
| S56.114S | ICD10CM | Covered |
| S56.115A | ICD10CM | Covered |
| S56.115D | ICD10CM | Covered |
| S56.115S | ICD10CM | Covered |
| S56.116A | ICD10CM | Covered |
| S56.116D | ICD10CM | Covered |
| S56.116S | ICD10CM | Covered |
| S56.117A | ICD10CM | Covered |
| S56.117D | ICD10CM | Covered |
| S56.117S | ICD10CM | Covered |
| S56.118A | ICD10CM | Covered |
| S56.118D | ICD10CM | Covered |
| S56.118S | ICD10CM | Covered |
| S56.211A | ICD10CM | Covered |
| S56.211D | ICD10CM | Covered |
| S56.211S | ICD10CM | Covered |
| S56.212A | ICD10CM | Covered |
| S56.212D | ICD10CM | Covered |
| S56.212S | ICD10CM | Covered |
| S56.311A | ICD10CM | Covered |
| S56.311D | ICD10CM | Covered |
| S56.311S | ICD10CM | Covered |
| S56.312A | ICD10CM | Covered |
| S56.312D | ICD10CM | Covered |
| S56.312S | ICD10CM | Covered |
| S56.411A | ICD10CM | Covered |
| S56.411D | ICD10CM | Covered |
| S56.411S | ICD10CM | Covered |
| S56.412A | ICD10CM | Covered |
| S56.412D | ICD10CM | Covered |
| S56.412S | ICD10CM | Covered |
| S56.413A | ICD10CM | Covered |
| S56.413D | ICD10CM | Covered |
| S56.413S | ICD10CM | Covered |
| S56.414A | ICD10CM | Covered |
| S56.414D | ICD10CM | Covered |
| S56.414S | ICD10CM | Covered |
| S56.415A | ICD10CM | Covered |
| S56.415D | ICD10CM | Covered |
| S56.415S | ICD10CM | Covered |
| S56.416A | ICD10CM | Covered |
| S56.416D | ICD10CM | Covered |
| S56.416S | ICD10CM | Covered |
| S56.417A | ICD10CM | Covered |
| S56.417D | ICD10CM | Covered |
| S56.417S | ICD10CM | Covered |
| S56.418A | ICD10CM | Covered |
| S56.418D | ICD10CM | Covered |
| S56.418S | ICD10CM | Covered |
| S56.511A | ICD10CM | Covered |
| S56.511D | ICD10CM | Covered |
| S56.511S | ICD10CM | Covered |
| S56.512A | ICD10CM | Covered |
| S56.512D | ICD10CM | Covered |
| S56.512S | ICD10CM | Covered |
| S56.811A | ICD10CM | Covered |
| S56.811D | ICD10CM | Covered |
| S56.811S | ICD10CM | Covered |
| S56.812A | ICD10CM | Covered |
| S56.812D | ICD10CM | Covered |
| S56.812S | ICD10CM | Covered |
| S63.591A | ICD10CM | Covered |
| S63.591D | ICD10CM | Covered |
| S63.591S | ICD10CM | Covered |
| S63.592A | ICD10CM | Covered |
| S63.592D | ICD10CM | Covered |
| S63.592S | ICD10CM | Covered |
| S63.681A | ICD10CM | Covered |
| S63.681D | ICD10CM | Covered |
| S63.681S | ICD10CM | Covered |
| S63.682A | ICD10CM | Covered |
| S63.682D | ICD10CM | Covered |
| S63.682S | ICD10CM | Covered |
| S63.690A | ICD10CM | Covered |
| S63.690D | ICD10CM | Covered |
| S63.690S | ICD10CM | Covered |
| S63.691A | ICD10CM | Covered |
| S63.691D | ICD10CM | Covered |
| S63.691S | ICD10CM | Covered |
| S63.692A | ICD10CM | Covered |
| S63.692D | ICD10CM | Covered |
| S63.692S | ICD10CM | Covered |
| S63.693A | ICD10CM | Covered |
| S63.693D | ICD10CM | Covered |
| S63.693S | ICD10CM | Covered |
| S63.694A | ICD10CM | Covered |
| S63.694D | ICD10CM | Covered |
| S63.694S | ICD10CM | Covered |
| S63.695A | ICD10CM | Covered |
| S63.695D | ICD10CM | Covered |
| S63.695S | ICD10CM | Covered |
| S63.696A | ICD10CM | Covered |
| S63.696D | ICD10CM | Covered |
| S63.696S | ICD10CM | Covered |
| S63.697A | ICD10CM | Covered |
| S63.697D | ICD10CM | Covered |
| S63.697S | ICD10CM | Covered |
| S63.8X1A | ICD10CM | Covered |
| S63.8X1D | ICD10CM | Covered |
| S63.8X1S | ICD10CM | Covered |
| S63.8X2A | ICD10CM | Covered |
| S63.8X2D | ICD10CM | Covered |
| S63.8X2S | ICD10CM | Covered |
| S66.011A | ICD10CM | Covered |
| S66.011D | ICD10CM | Covered |
| S66.011S | ICD10CM | Covered |
| S66.012A | ICD10CM | Covered |
| S66.012D | ICD10CM | Covered |
| S66.012S | ICD10CM | Covered |
| S66.110A | ICD10CM | Covered |
| S66.110D | ICD10CM | Covered |
| S66.110S | ICD10CM | Covered |
| S66.111A | ICD10CM | Covered |
| S66.111D | ICD10CM | Covered |
| S66.111S | ICD10CM | Covered |
| S66.112A | ICD10CM | Covered |
| S66.112D | ICD10CM | Covered |
| S66.112S | ICD10CM | Covered |
| S66.113A | ICD10CM | Covered |
| S66.113D | ICD10CM | Covered |
| S66.113S | ICD10CM | Covered |
| S66.114A | ICD10CM | Covered |
| S66.114D | ICD10CM | Covered |
| S66.114S | ICD10CM | Covered |
| S66.115A | ICD10CM | Covered |
| S66.115D | ICD10CM | Covered |
| S66.115S | ICD10CM | Covered |
| S66.116A | ICD10CM | Covered |
| S66.116D | ICD10CM | Covered |
| S66.116S | ICD10CM | Covered |
| S66.117A | ICD10CM | Covered |
| S66.117D | ICD10CM | Covered |
| S66.117S | ICD10CM | Covered |
| S66.211A | ICD10CM | Covered |
| S66.211D | ICD10CM | Covered |
| S66.211S | ICD10CM | Covered |
| S66.212A | ICD10CM | Covered |
| S66.212D | ICD10CM | Covered |
| S66.212S | ICD10CM | Covered |
| S66.310A | ICD10CM | Covered |
| S66.310D | ICD10CM | Covered |
| S66.310S | ICD10CM | Covered |
| S66.311A | ICD10CM | Covered |
| S66.311D | ICD10CM | Covered |
| S66.311S | ICD10CM | Covered |
| S66.312A | ICD10CM | Covered |
| S66.312D | ICD10CM | Covered |
| S66.312S | ICD10CM | Covered |
| S66.313A | ICD10CM | Covered |
| S66.313D | ICD10CM | Covered |
| S66.313S | ICD10CM | Covered |
| S66.314A | ICD10CM | Covered |
| S66.314D | ICD10CM | Covered |
| S66.314S | ICD10CM | Covered |
| S66.315A | ICD10CM | Covered |
| S66.315D | ICD10CM | Covered |
| S66.315S | ICD10CM | Covered |
| S66.316A | ICD10CM | Covered |
| S66.316D | ICD10CM | Covered |
| S66.316S | ICD10CM | Covered |
| S66.317A | ICD10CM | Covered |
| S66.317D | ICD10CM | Covered |
| S66.317S | ICD10CM | Covered |
| S66.411A | ICD10CM | Covered |
| S66.411D | ICD10CM | Covered |
| S66.411S | ICD10CM | Covered |
| S66.412A | ICD10CM | Covered |
| S66.412D | ICD10CM | Covered |
| S66.412S | ICD10CM | Covered |
| S66.510A | ICD10CM | Covered |
| S66.510D | ICD10CM | Covered |
| S66.510S | ICD10CM | Covered |
| S66.511A | ICD10CM | Covered |
| S66.511D | ICD10CM | Covered |
| S66.511S | ICD10CM | Covered |
| S66.512A | ICD10CM | Covered |
| S66.512D | ICD10CM | Covered |
| S66.512S | ICD10CM | Covered |
| S66.513A | ICD10CM | Covered |
| S66.513D | ICD10CM | Covered |
| S66.513S | ICD10CM | Covered |
| S66.514A | ICD10CM | Covered |
| S66.514D | ICD10CM | Covered |
| S66.514S | ICD10CM | Covered |
| S66.515A | ICD10CM | Covered |
| S66.515D | ICD10CM | Covered |
| S66.515S | ICD10CM | Covered |
| S66.516A | ICD10CM | Covered |
| S66.516D | ICD10CM | Covered |
| S66.516S | ICD10CM | Covered |
| S66.517A | ICD10CM | Covered |
| S66.517D | ICD10CM | Covered |
| S66.517S | ICD10CM | Covered |
| S66.811A | ICD10CM | Covered |
| S66.811D | ICD10CM | Covered |
| S66.811S | ICD10CM | Covered |
| S66.812A | ICD10CM | Covered |
| S66.812D | ICD10CM | Covered |
| S66.812S | ICD10CM | Covered |
| S73.111A | ICD10CM | Covered |
| S73.111D | ICD10CM | Covered |
| S73.111S | ICD10CM | Covered |
| S73.112A | ICD10CM | Covered |
| S73.112D | ICD10CM | Covered |
| S73.112S | ICD10CM | Covered |
| S73.121A | ICD10CM | Covered |
| S73.121D | ICD10CM | Covered |
| S73.121S | ICD10CM | Covered |
| S73.122A | ICD10CM | Covered |
| S73.122D | ICD10CM | Covered |
| S73.122S | ICD10CM | Covered |
| S73.191A | ICD10CM | Covered |
| S73.191D | ICD10CM | Covered |
| S73.191S | ICD10CM | Covered |
| S73.192A | ICD10CM | Covered |
| S73.192D | ICD10CM | Covered |
| S73.192S | ICD10CM | Covered |
| S76.011A | ICD10CM | Covered |
| S76.011D | ICD10CM | Covered |
| S76.011S | ICD10CM | Covered |
| S76.012A | ICD10CM | Covered |
| S76.012D | ICD10CM | Covered |
| S76.012S | ICD10CM | Covered |
| S76.111A | ICD10CM | Covered |
| S76.111D | ICD10CM | Covered |
| S76.111S | ICD10CM | Covered |
| S76.112A | ICD10CM | Covered |
| S76.112D | ICD10CM | Covered |
| S76.112S | ICD10CM | Covered |
| S76.211A | ICD10CM | Covered |
| S76.211D | ICD10CM | Covered |
| S76.211S | ICD10CM | Covered |
| S76.212A | ICD10CM | Covered |
| S76.212D | ICD10CM | Covered |
| S76.212S | ICD10CM | Covered |
| S76.311A | ICD10CM | Covered |
| S76.311D | ICD10CM | Covered |
| S76.311S | ICD10CM | Covered |
| S76.312A | ICD10CM | Covered |
| S76.312D | ICD10CM | Covered |
| S76.312S | ICD10CM | Covered |
| S76.811A | ICD10CM | Covered |
| S76.811D | ICD10CM | Covered |
| S76.811S | ICD10CM | Covered |
| S76.812A | ICD10CM | Covered |
| S76.812D | ICD10CM | Covered |
| S76.812S | ICD10CM | Covered |
| S83.411A | ICD10CM | Covered |
| S83.411D | ICD10CM | Covered |
| S83.411S | ICD10CM | Covered |
| S83.412A | ICD10CM | Covered |
| S83.412D | ICD10CM | Covered |
| S83.412S | ICD10CM | Covered |
| S83.421A | ICD10CM | Covered |
| S83.421D | ICD10CM | Covered |
| S83.421S | ICD10CM | Covered |
| S83.422A | ICD10CM | Covered |
| S83.422D | ICD10CM | Covered |
| S83.422S | ICD10CM | Covered |
| S83.511A | ICD10CM | Covered |
| S83.511D | ICD10CM | Covered |
| S83.511S | ICD10CM | Covered |
| S83.512A | ICD10CM | Covered |
| S83.512D | ICD10CM | Covered |
| S83.512S | ICD10CM | Covered |
| S83.521A | ICD10CM | Covered |
| S83.521D | ICD10CM | Covered |
| S83.521S | ICD10CM | Covered |
| S83.522A | ICD10CM | Covered |
| S83.522D | ICD10CM | Covered |
| S83.522S | ICD10CM | Covered |
| S83.61XA | ICD10CM | Covered |
| S83.61XD | ICD10CM | Covered |
| S83.61XS | ICD10CM | Covered |
| S83.62XA | ICD10CM | Covered |
| S83.62XD | ICD10CM | Covered |
| S83.62XS | ICD10CM | Covered |
| S83.8X1A | ICD10CM | Covered |
| S83.8X1D | ICD10CM | Covered |
| S83.8X1S | ICD10CM | Covered |
| S83.8X2A | ICD10CM | Covered |
| S83.8X2D | ICD10CM | Covered |
| S83.8X2S | ICD10CM | Covered |
| S86.011A | ICD10CM | Covered |
| S86.011D | ICD10CM | Covered |
| S86.011S | ICD10CM | Covered |
| S86.012A | ICD10CM | Covered |
| S86.012D | ICD10CM | Covered |
| S86.012S | ICD10CM | Covered |
| S86.111A | ICD10CM | Covered |
| S86.111D | ICD10CM | Covered |
| S86.111S | ICD10CM | Covered |
| S86.112A | ICD10CM | Covered |
| S86.112D | ICD10CM | Covered |
| S86.112S | ICD10CM | Covered |
| S86.211A | ICD10CM | Covered |
| S86.211D | ICD10CM | Covered |
| S86.211S | ICD10CM | Covered |
| S86.212A | ICD10CM | Covered |
| S86.212D | ICD10CM | Covered |
| S86.212S | ICD10CM | Covered |
| S86.311A | ICD10CM | Covered |
| S86.311D | ICD10CM | Covered |
| S86.311S | ICD10CM | Covered |
| S86.312A | ICD10CM | Covered |
| S86.312D | ICD10CM | Covered |
| S86.312S | ICD10CM | Covered |
| S86.811A | ICD10CM | Covered |
| S86.811D | ICD10CM | Covered |
| S86.811S | ICD10CM | Covered |
| S86.812A | ICD10CM | Covered |
| S86.812D | ICD10CM | Covered |
| S86.812S | ICD10CM | Covered |
| S93.411A | ICD10CM | Covered |
| S93.411D | ICD10CM | Covered |
| S93.411S | ICD10CM | Covered |
| S93.412A | ICD10CM | Covered |
| S93.412D | ICD10CM | Covered |
| S93.412S | ICD10CM | Covered |
| S93.421A | ICD10CM | Covered |
| S93.421D | ICD10CM | Covered |
| S93.421S | ICD10CM | Covered |
| S93.422A | ICD10CM | Covered |
| S93.422D | ICD10CM | Covered |
| S93.422S | ICD10CM | Covered |
| S93.431A | ICD10CM | Covered |
| S93.431D | ICD10CM | Covered |
| S93.431S | ICD10CM | Covered |
| S93.432A | ICD10CM | Covered |
| S93.432D | ICD10CM | Covered |
| S93.432S | ICD10CM | Covered |
| S93.491A | ICD10CM | Covered |
| S93.491D | ICD10CM | Covered |
| S93.491S | ICD10CM | Covered |
| S93.492A | ICD10CM | Covered |
| S93.492D | ICD10CM | Covered |
| S93.492S | ICD10CM | Covered |
| S93.611A | ICD10CM | Covered |
| S93.611D | ICD10CM | Covered |
| S93.611S | ICD10CM | Covered |
| S93.612A | ICD10CM | Covered |
| S93.612D | ICD10CM | Covered |
| S93.612S | ICD10CM | Covered |
| S93.621A | ICD10CM | Covered |
| S93.621D | ICD10CM | Covered |
| S93.621S | ICD10CM | Covered |
| S93.622A | ICD10CM | Covered |
| S93.622D | ICD10CM | Covered |
| S93.622S | ICD10CM | Covered |
| S93.691A | ICD10CM | Covered |
| S93.691D | ICD10CM | Covered |
| S93.691S | ICD10CM | Covered |
| S93.692A | ICD10CM | Covered |
| S93.692D | ICD10CM | Covered |
| S93.692S | ICD10CM | Covered |
| S96.011A | ICD10CM | Covered |
| S96.011D | ICD10CM | Covered |
| S96.011S | ICD10CM | Covered |
| S96.012A | ICD10CM | Covered |
| S96.012D | ICD10CM | Covered |
| S96.012S | ICD10CM | Covered |
| S96.111A | ICD10CM | Covered |
| S96.111D | ICD10CM | Covered |
| S96.111S | ICD10CM | Covered |
| S96.112A | ICD10CM | Covered |
| S96.112D | ICD10CM | Covered |
| S96.112S | ICD10CM | Covered |
| S96.211A | ICD10CM | Covered |
| S96.211D | ICD10CM | Covered |
| S96.211S | ICD10CM | Covered |
| S96.212A | ICD10CM | Covered |
| S96.212D | ICD10CM | Covered |
| S96.212S | ICD10CM | Covered |
| S96.221A | ICD10CM | Covered |
| S96.221D | ICD10CM | Covered |
| S96.221S | ICD10CM | Covered |
| S96.811A | ICD10CM | Covered |
| S96.811D | ICD10CM | Covered |
| S96.811S | ICD10CM | Covered |
| S96.812A | ICD10CM | Covered |
| S96.812D | ICD10CM | Covered |
| S96.812S | ICD10CM | Covered |