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 |
|---|---|---|
| 11055 | HCPCS | Covered |
| 11056 | HCPCS | Covered |
| 11057 | HCPCS | Covered |
| 11719 | HCPCS | Covered |
| 11720 | HCPCS | Covered |
| 11721 | HCPCS | Covered |
| G0127 | HCPCS | Covered |
| A30.0 | ICD10CM | Covered |
| A30.1 | ICD10CM | Covered |
| A30.2 | ICD10CM | Covered |
| A30.3 | ICD10CM | Covered |
| A30.4 | ICD10CM | Covered |
| A30.5 | ICD10CM | Covered |
| A30.8 | ICD10CM | Covered |
| A50.41 | ICD10CM | Covered |
| A50.42 | ICD10CM | Covered |
| A50.43 | ICD10CM | Covered |
| A50.45 | ICD10CM | Covered |
| A52.11 | ICD10CM | Covered |
| A52.13 | ICD10CM | Covered |
| A52.14 | ICD10CM | Covered |
| A52.15 | ICD10CM | Covered |
| A52.16 | ICD10CM | Covered |
| A52.17 | ICD10CM | Covered |
| A52.19 | ICD10CM | Covered |
| A52.3 | ICD10CM | Covered |
| B35.1 | ICD10CM | Covered |
| D51.0 | ICD10CM | Covered |
| D81.818 | ICD10CM | Covered |
| E08.21 | ICD10CM | Covered |
| E08.22 | ICD10CM | Covered |
| E08.29 | ICD10CM | Covered |
| E08.3211 | ICD10CM | Covered |
| E08.3212 | ICD10CM | Covered |
| E08.3213 | ICD10CM | Covered |
| E08.3291 | ICD10CM | Covered |
| E08.3292 | ICD10CM | Covered |
| E08.3293 | ICD10CM | Covered |
| E08.3311 | ICD10CM | Covered |
| E08.3312 | ICD10CM | Covered |
| E08.3313 | ICD10CM | Covered |
| E08.3391 | ICD10CM | Covered |
| E08.3392 | ICD10CM | Covered |
| E08.3393 | ICD10CM | Covered |
| E08.3411 | ICD10CM | Covered |
| E08.3412 | ICD10CM | Covered |
| E08.3413 | ICD10CM | Covered |
| E08.3491 | ICD10CM | Covered |
| E08.3492 | ICD10CM | Covered |
| E08.3493 | ICD10CM | Covered |
| E08.3511 | ICD10CM | Covered |
| E08.3512 | ICD10CM | Covered |
| E08.3513 | ICD10CM | Covered |
| E08.3521 | ICD10CM | Covered |
| E08.3522 | ICD10CM | Covered |
| E08.3523 | ICD10CM | Covered |
| E08.3531 | ICD10CM | Covered |
| E08.3532 | ICD10CM | Covered |
| E08.3533 | ICD10CM | Covered |
| E08.3541 | ICD10CM | Covered |
| E08.3542 | ICD10CM | Covered |
| E08.3543 | ICD10CM | Covered |
| E08.3551 | ICD10CM | Covered |
| E08.3552 | ICD10CM | Covered |
| E08.3553 | ICD10CM | Covered |
| E08.3591 | ICD10CM | Covered |
| E08.3592 | ICD10CM | Covered |
| E08.3593 | ICD10CM | Covered |
| E08.36 | ICD10CM | Covered |
| E08.37X1 | ICD10CM | Covered |
| E08.37X2 | ICD10CM | Covered |
| E08.37X3 | ICD10CM | Covered |
| E08.39 | ICD10CM | Covered |
| E08.40 | ICD10CM | Covered |
| E08.41 | ICD10CM | Covered |
| E08.42 | ICD10CM | Covered |
| E08.43 | ICD10CM | Covered |
| E08.44 | ICD10CM | Covered |
| E08.49 | ICD10CM | Covered |
| E08.51 | ICD10CM | Covered |
| E08.52 | ICD10CM | Covered |
| E08.59 | ICD10CM | Covered |
| E08.610 | ICD10CM | Covered |
| E08.65 | ICD10CM | Covered |
| E09.21 | ICD10CM | Covered |
| E09.22 | ICD10CM | Covered |
| E09.29 | ICD10CM | Covered |
| E09.3211 | ICD10CM | Covered |
| E09.3212 | ICD10CM | Covered |
| E09.3213 | ICD10CM | Covered |
| E09.3291 | ICD10CM | Covered |
| E09.3292 | ICD10CM | Covered |
| E09.3293 | ICD10CM | Covered |
| E09.3311 | ICD10CM | Covered |
| E09.3312 | ICD10CM | Covered |
| E09.3313 | ICD10CM | Covered |
| E09.3391 | ICD10CM | Covered |
| E09.3392 | ICD10CM | Covered |
| E09.3393 | ICD10CM | Covered |
| E09.3411 | ICD10CM | Covered |
| E09.3412 | ICD10CM | Covered |
| E09.3413 | ICD10CM | Covered |
| E09.3491 | ICD10CM | Covered |
| E09.3492 | ICD10CM | Covered |
| E09.3493 | ICD10CM | Covered |
| E09.3511 | ICD10CM | Covered |
| E09.3512 | ICD10CM | Covered |
| E09.3513 | ICD10CM | Covered |
| E09.3521 | ICD10CM | Covered |
| E09.3522 | ICD10CM | Covered |
| E09.3523 | ICD10CM | Covered |
| E09.3531 | ICD10CM | Covered |
| E09.3532 | ICD10CM | Covered |
| E09.3533 | ICD10CM | Covered |
| E09.3541 | ICD10CM | Covered |
| E09.3542 | ICD10CM | Covered |
| E09.3543 | ICD10CM | Covered |
| E09.3551 | ICD10CM | Covered |
| E09.3552 | ICD10CM | Covered |
| E09.3553 | ICD10CM | Covered |
| E09.3591 | ICD10CM | Covered |
| E09.3592 | ICD10CM | Covered |
| E09.3593 | ICD10CM | Covered |
| E09.36 | ICD10CM | Covered |
| E09.37X1 | ICD10CM | Covered |
| E09.37X2 | ICD10CM | Covered |
| E09.37X3 | ICD10CM | Covered |
| E09.39 | ICD10CM | Covered |
| E09.40 | ICD10CM | Covered |
| E09.41 | ICD10CM | Covered |
| E09.42 | ICD10CM | Covered |
| E09.43 | ICD10CM | Covered |
| E09.44 | ICD10CM | Covered |
| E09.49 | ICD10CM | Covered |
| E09.51 | ICD10CM | Covered |
| E09.52 | ICD10CM | Covered |
| E09.59 | ICD10CM | Covered |
| E09.610 | ICD10CM | Covered |
| E10.21 | ICD10CM | Covered |
| E10.22 | ICD10CM | Covered |
| E10.29 | ICD10CM | Covered |
| E10.311 | ICD10CM | Covered |
| E10.319 | ICD10CM | Covered |
| E10.3211 | ICD10CM | Covered |
| E10.3212 | ICD10CM | Covered |
| E10.3213 | ICD10CM | Covered |
| E10.3291 | ICD10CM | Covered |
| E10.3292 | ICD10CM | Covered |
| E10.3293 | ICD10CM | Covered |
| E10.3311 | ICD10CM | Covered |
| E10.3312 | ICD10CM | Covered |
| E10.3313 | ICD10CM | Covered |
| E10.3391 | ICD10CM | Covered |
| E10.3392 | ICD10CM | Covered |
| E10.3393 | ICD10CM | Covered |
| E10.3411 | ICD10CM | Covered |
| E10.3412 | ICD10CM | Covered |
| E10.3413 | ICD10CM | Covered |
| E10.3491 | ICD10CM | Covered |
| E10.3492 | ICD10CM | Covered |
| E10.3493 | ICD10CM | Covered |
| E10.3511 | ICD10CM | Covered |
| E10.3512 | ICD10CM | Covered |
| E10.3513 | ICD10CM | Covered |
| E10.3521 | ICD10CM | Covered |
| E10.3522 | ICD10CM | Covered |
| E10.3523 | ICD10CM | Covered |
| E10.3531 | ICD10CM | Covered |
| E10.3532 | ICD10CM | Covered |
| E10.3533 | ICD10CM | Covered |
| E10.3541 | ICD10CM | Covered |
| E10.3542 | ICD10CM | Covered |
| E10.3543 | ICD10CM | Covered |
| E10.3551 | ICD10CM | Covered |
| E10.3552 | ICD10CM | Covered |
| E10.3553 | ICD10CM | Covered |
| E10.3591 | ICD10CM | Covered |
| E10.3592 | ICD10CM | Covered |
| E10.3593 | ICD10CM | Covered |
| E10.36 | ICD10CM | Covered |
| E10.37X1 | ICD10CM | Covered |
| E10.37X2 | ICD10CM | Covered |
| E10.37X3 | ICD10CM | Covered |
| E10.39 | ICD10CM | Covered |
| E10.40 | ICD10CM | Covered |
| E10.41 | ICD10CM | Covered |
| E10.42 | ICD10CM | Covered |
| E10.43 | ICD10CM | Covered |
| E10.44 | ICD10CM | Covered |
| E10.49 | ICD10CM | Covered |
| E10.51 | ICD10CM | Covered |
| E10.52 | ICD10CM | Covered |
| E10.59 | ICD10CM | Covered |
| E10.610 | ICD10CM | Covered |
| E10.65 | ICD10CM | Covered |
| E11.21 | ICD10CM | Covered |
| E11.22 | ICD10CM | Covered |
| E11.29 | ICD10CM | Covered |
| E11.3211 | ICD10CM | Covered |
| E11.3212 | ICD10CM | Covered |
| E11.3213 | ICD10CM | Covered |
| E11.3291 | ICD10CM | Covered |
| E11.3292 | ICD10CM | Covered |
| E11.3293 | ICD10CM | Covered |
| E11.3311 | ICD10CM | Covered |
| E11.3312 | ICD10CM | Covered |
| E11.3313 | ICD10CM | Covered |
| E11.3391 | ICD10CM | Covered |
| E11.3392 | ICD10CM | Covered |
| E11.3393 | ICD10CM | Covered |
| E11.3411 | ICD10CM | Covered |
| E11.3412 | ICD10CM | Covered |
| E11.3413 | ICD10CM | Covered |
| E11.3491 | ICD10CM | Covered |
| E11.3492 | ICD10CM | Covered |
| E11.3493 | ICD10CM | Covered |
| E11.3511 | ICD10CM | Covered |
| E11.3512 | ICD10CM | Covered |
| E11.3513 | ICD10CM | Covered |
| E11.3521 | ICD10CM | Covered |
| E11.3522 | ICD10CM | Covered |
| E11.3523 | ICD10CM | Covered |
| E11.3531 | ICD10CM | Covered |
| E11.3532 | ICD10CM | Covered |
| E11.3533 | ICD10CM | Covered |
| E11.3541 | ICD10CM | Covered |
| E11.3542 | ICD10CM | Covered |
| E11.3543 | ICD10CM | Covered |
| E11.3551 | ICD10CM | Covered |
| E11.3552 | ICD10CM | Covered |
| E11.3553 | ICD10CM | Covered |
| E11.3591 | ICD10CM | Covered |
| E11.3592 | ICD10CM | Covered |
| E11.3593 | ICD10CM | Covered |
| E11.36 | ICD10CM | Covered |
| E11.37X1 | ICD10CM | Covered |
| E11.37X2 | ICD10CM | Covered |
| E11.37X3 | ICD10CM | Covered |
| E11.39 | ICD10CM | Covered |
| E11.40 | ICD10CM | Covered |
| E11.41 | ICD10CM | Covered |
| E11.42 | ICD10CM | Covered |
| E11.43 | ICD10CM | Covered |
| E11.44 | ICD10CM | Covered |
| E11.49 | ICD10CM | Covered |
| E11.51 | ICD10CM | Covered |
| E11.52 | ICD10CM | Covered |
| E11.59 | ICD10CM | Covered |
| E11.610 | ICD10CM | Covered |
| E11.65 | ICD10CM | Covered |
| E13.21 | ICD10CM | Covered |
| E13.22 | ICD10CM | Covered |
| E13.29 | ICD10CM | Covered |
| E13.3211 | ICD10CM | Covered |
| E13.3212 | ICD10CM | Covered |
| E13.3213 | ICD10CM | Covered |
| E13.3291 | ICD10CM | Covered |
| E13.3292 | ICD10CM | Covered |
| E13.3293 | ICD10CM | Covered |
| E13.3311 | ICD10CM | Covered |
| E13.3312 | ICD10CM | Covered |
| E13.3313 | ICD10CM | Covered |
| E13.3391 | ICD10CM | Covered |
| E13.3392 | ICD10CM | Covered |
| E13.3393 | ICD10CM | Covered |
| E13.3411 | ICD10CM | Covered |
| E13.3412 | ICD10CM | Covered |
| E13.3413 | ICD10CM | Covered |
| E13.3491 | ICD10CM | Covered |
| E13.3492 | ICD10CM | Covered |
| E13.3493 | ICD10CM | Covered |
| E13.3511 | ICD10CM | Covered |
| E13.3512 | ICD10CM | Covered |
| E13.3513 | ICD10CM | Covered |
| E13.3521 | ICD10CM | Covered |
| E13.3522 | ICD10CM | Covered |
| E13.3523 | ICD10CM | Covered |
| E13.3531 | ICD10CM | Covered |
| E13.3532 | ICD10CM | Covered |
| E13.3533 | ICD10CM | Covered |
| E13.3541 | ICD10CM | Covered |
| E13.3542 | ICD10CM | Covered |
| E13.3543 | ICD10CM | Covered |
| E13.3551 | ICD10CM | Covered |
| E13.3552 | ICD10CM | Covered |
| E13.3553 | ICD10CM | Covered |
| E13.3591 | ICD10CM | Covered |
| E13.3592 | ICD10CM | Covered |
| E13.3593 | ICD10CM | Covered |
| E13.36 | ICD10CM | Covered |
| E13.37X1 | ICD10CM | Covered |
| E13.37X2 | ICD10CM | Covered |
| E13.37X3 | ICD10CM | Covered |
| E13.39 | ICD10CM | Covered |
| E13.40 | ICD10CM | Covered |
| E13.41 | ICD10CM | Covered |
| E13.42 | ICD10CM | Covered |
| E13.43 | ICD10CM | Covered |
| E13.44 | ICD10CM | Covered |
| E13.49 | ICD10CM | Covered |
| E13.51 | ICD10CM | Covered |
| E13.52 | ICD10CM | Covered |
| E13.59 | ICD10CM | Covered |
| E13.610 | ICD10CM | Covered |
| E46 | ICD10CM | Covered |
| E51.11 | ICD10CM | Covered |
| E51.12 | ICD10CM | Covered |
| E52 | ICD10CM | Covered |
| E53.1 | ICD10CM | Covered |
| E53.8 | ICD10CM | Covered |
| E64.0 | ICD10CM | Covered |
| E75.21 | ICD10CM | Covered |
| E75.22 | ICD10CM | Covered |
| E75.240 | ICD10CM | Covered |
| E75.241 | ICD10CM | Covered |
| E75.242 | ICD10CM | Covered |
| E75.243 | ICD10CM | Covered |
| E75.244 | ICD10CM | Covered |
| E75.248 | ICD10CM | Covered |
| E75.26 | ICD10CM | Covered |
| E75.3 | ICD10CM | Covered |
| E77.0 | ICD10CM | Covered |
| E77.1 | ICD10CM | Covered |
| E77.8 | ICD10CM | Covered |
| E85.1 | ICD10CM | Covered |
| E85.2 | ICD10CM | Covered |
| E85.3 | ICD10CM | Covered |
| E85.4 | ICD10CM | Covered |
| E85.81 | ICD10CM | Covered |
| E85.82 | ICD10CM | Covered |
| E85.89 | ICD10CM | Covered |
| G04.1 | ICD10CM | Covered |
| G11.10 | ICD10CM | Covered |
| G11.11 | ICD10CM | Covered |
| G12.21 | ICD10CM | Covered |
| G13.0 | ICD10CM | Covered |
| G13.1 | 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 |
| 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 |
| G70.1 | ICD10CM | Covered |
| G73.3 | ICD10CM | Covered |
| G82.21 | ICD10CM | Covered |
| G82.22 | ICD10CM | Covered |
| G82.51 | ICD10CM | Covered |
| G82.52 | ICD10CM | Covered |
| G82.53 | ICD10CM | Covered |
| G82.54 | ICD10CM | Covered |
| I70.201 | ICD10CM | Covered |
| I70.202 | ICD10CM | Covered |
| I70.203 | ICD10CM | Covered |
| I70.208 | ICD10CM | Covered |
| I70.211 | ICD10CM | Covered |
| I70.212 | ICD10CM | Covered |
| I70.213 | ICD10CM | Covered |
| I70.218 | ICD10CM | Covered |
| I70.221 | ICD10CM | Covered |
| I70.222 | ICD10CM | Covered |
| I70.223 | ICD10CM | Covered |
| I70.228 | ICD10CM | Covered |
| I70.231 | ICD10CM | Covered |
| I70.232 | ICD10CM | Covered |
| I70.233 | ICD10CM | Covered |
| I70.234 | ICD10CM | Covered |
| I70.235 | ICD10CM | Covered |
| I70.238 | ICD10CM | Covered |
| I70.241 | ICD10CM | Covered |
| I70.242 | ICD10CM | Covered |
| I70.243 | ICD10CM | Covered |
| I70.244 | ICD10CM | Covered |
| I70.245 | ICD10CM | Covered |
| I70.248 | ICD10CM | Covered |
| I70.25 | ICD10CM | Covered |
| I70.261 | ICD10CM | Covered |
| I70.262 | ICD10CM | Covered |
| I70.263 | ICD10CM | Covered |
| I70.268 | ICD10CM | Covered |
| I70.90 | ICD10CM | Covered |
| I70.91 | ICD10CM | Covered |
| I73.00 | ICD10CM | Covered |
| I73.01 | ICD10CM | Covered |
| I73.1 | ICD10CM | Covered |
| I73.81 | ICD10CM | Covered |
| I73.89 | ICD10CM | Covered |
| I77.6 | ICD10CM | Covered |
| I79.1 | ICD10CM | Covered |
| I79.8 | ICD10CM | Covered |
| I80.01 | ICD10CM | Covered |
| I80.02 | ICD10CM | Covered |
| I80.03 | ICD10CM | Covered |
| I80.11 | ICD10CM | Covered |
| I80.12 | ICD10CM | Covered |
| I80.13 | ICD10CM | Covered |
| I80.201 | ICD10CM | Covered |
| I80.202 | ICD10CM | Covered |
| I80.203 | ICD10CM | Covered |
| I80.211 | ICD10CM | Covered |
| I80.212 | ICD10CM | Covered |
| I80.213 | ICD10CM | Covered |
| I80.221 | ICD10CM | Covered |
| I80.222 | ICD10CM | Covered |
| I80.223 | ICD10CM | Covered |
| I80.231 | ICD10CM | Covered |
| I80.232 | ICD10CM | Covered |
| I80.233 | ICD10CM | Covered |
| I80.241 | ICD10CM | Covered |
| I80.242 | ICD10CM | Covered |
| I80.243 | ICD10CM | Covered |
| I80.249 | ICD10CM | Covered |
| I80.251 | ICD10CM | Covered |
| I80.252 | ICD10CM | Covered |
| I80.253 | ICD10CM | Covered |
| I80.259 | ICD10CM | Covered |
| I80.291 | ICD10CM | Covered |
| I80.292 | ICD10CM | Covered |
| I80.293 | ICD10CM | Covered |
| I80.3 | ICD10CM | Covered |
| I82.541 | ICD10CM | Covered |
| I82.542 | ICD10CM | Covered |
| I82.543 | ICD10CM | Covered |
| I82.551 | ICD10CM | Covered |
| I82.552 | ICD10CM | Covered |
| I82.553 | ICD10CM | Covered |
| I82.559 | ICD10CM | Covered |
| I82.561 | ICD10CM | Covered |
| I82.562 | ICD10CM | Covered |
| I82.563 | ICD10CM | Covered |
| I82.569 | ICD10CM | Covered |
| I82.5Z1 | ICD10CM | Covered |
| I82.5Z2 | ICD10CM | Covered |
| I82.5Z3 | ICD10CM | Covered |
| I82.811 | ICD10CM | Covered |
| I82.812 | ICD10CM | Covered |
| I82.813 | ICD10CM | Covered |
| I82.891 | ICD10CM | Covered |
| I82.91 | ICD10CM | Covered |
| I89.0 | ICD10CM | Covered |
| K90.0 | ICD10CM | Covered |
| K90.1 | ICD10CM | Covered |
| K90.2 | ICD10CM | Covered |
| K90.3 | ICD10CM | Covered |
| K91.2 | ICD10CM | Covered |
| L02.611 | ICD10CM | Covered |
| L02.612 | ICD10CM | Covered |
| L03.031 | ICD10CM | Covered |
| L03.032 | ICD10CM | Covered |
| L03.041 | ICD10CM | Covered |
| L03.042 | ICD10CM | Covered |
| L11.0 | ICD10CM | Covered |
| L60.1 | ICD10CM | Covered |
| L60.2 | ICD10CM | Covered |
| L60.3 | ICD10CM | Covered |
| L60.4 | ICD10CM | Covered |
| L60.5 | ICD10CM | Covered |
| L62 | ICD10CM | Covered |
| L84 | ICD10CM | Covered |
| L85.0 | ICD10CM | Covered |
| L85.1 | ICD10CM | Covered |
| L85.2 | ICD10CM | Covered |
| L85.8 | ICD10CM | Covered |
| M05.411 | ICD10CM | Covered |
| M05.412 | ICD10CM | Covered |
| M05.421 | ICD10CM | Covered |
| M05.422 | ICD10CM | Covered |
| M05.431 | ICD10CM | Covered |
| M05.432 | ICD10CM | Covered |
| M05.441 | ICD10CM | Covered |
| M05.442 | ICD10CM | Covered |
| M05.451 | ICD10CM | Covered |
| M05.452 | ICD10CM | Covered |
| M05.461 | ICD10CM | Covered |
| M05.462 | ICD10CM | Covered |
| M05.471 | ICD10CM | Covered |
| M05.472 | ICD10CM | Covered |
| M05.49 | ICD10CM | Covered |
| M05.511 | ICD10CM | Covered |
| M05.512 | ICD10CM | Covered |
| M05.521 | ICD10CM | Covered |
| M05.522 | ICD10CM | Covered |
| M05.531 | ICD10CM | Covered |
| M05.532 | ICD10CM | Covered |
| M05.541 | ICD10CM | Covered |
| M05.542 | ICD10CM | Covered |
| M05.551 | ICD10CM | Covered |
| M05.552 | ICD10CM | Covered |
| M05.561 | ICD10CM | Covered |
| M05.562 | ICD10CM | Covered |
| M05.571 | ICD10CM | Covered |
| M05.572 | ICD10CM | Covered |
| M05.59 | ICD10CM | Covered |
| M05.711 | ICD10CM | Covered |
| M05.712 | ICD10CM | Covered |
| M05.721 | ICD10CM | Covered |
| M05.722 | ICD10CM | Covered |
| M05.731 | ICD10CM | Covered |
| M05.732 | ICD10CM | Covered |
| M05.741 | ICD10CM | Covered |
| M05.742 | ICD10CM | Covered |
| M05.751 | ICD10CM | Covered |
| M05.752 | ICD10CM | Covered |
| M05.759 | ICD10CM | Covered |
| M05.761 | ICD10CM | Covered |
| M05.762 | ICD10CM | Covered |
| M05.771 | ICD10CM | Covered |
| M05.772 | ICD10CM | Covered |
| M05.79 | ICD10CM | Covered |
| M05.811 | ICD10CM | Covered |
| M05.812 | ICD10CM | Covered |
| M05.821 | ICD10CM | Covered |
| M05.822 | ICD10CM | Covered |
| M05.831 | ICD10CM | Covered |
| M05.832 | ICD10CM | Covered |
| M05.841 | ICD10CM | Covered |
| M05.842 | ICD10CM | Covered |
| M05.851 | ICD10CM | Covered |
| M05.852 | ICD10CM | Covered |
| M05.861 | ICD10CM | Covered |
| M05.862 | ICD10CM | Covered |
| M05.871 | ICD10CM | Covered |
| M05.872 | ICD10CM | Covered |
| M05.89 | ICD10CM | Covered |
| M06.011 | ICD10CM | Covered |
| M06.012 | ICD10CM | Covered |
| M06.021 | ICD10CM | Covered |
| M06.022 | ICD10CM | Covered |
| M06.031 | ICD10CM | Covered |
| M06.032 | ICD10CM | Covered |
| M06.041 | ICD10CM | Covered |
| M06.042 | ICD10CM | Covered |
| M06.051 | ICD10CM | Covered |
| M06.052 | ICD10CM | Covered |
| M06.061 | ICD10CM | Covered |
| M06.062 | ICD10CM | Covered |
| M06.071 | ICD10CM | Covered |
| M06.072 | ICD10CM | Covered |
| M06.08 | ICD10CM | Covered |
| M06.09 | ICD10CM | Covered |
| M06.211 | ICD10CM | Covered |
| M06.212 | ICD10CM | Covered |
| M06.221 | ICD10CM | Covered |
| M06.222 | ICD10CM | Covered |
| M06.231 | ICD10CM | Covered |
| M06.232 | ICD10CM | Covered |
| M06.241 | ICD10CM | Covered |
| M06.242 | ICD10CM | Covered |
| M06.251 | ICD10CM | Covered |
| M06.252 | ICD10CM | Covered |
| M06.261 | ICD10CM | Covered |
| M06.262 | ICD10CM | Covered |
| M06.271 | ICD10CM | Covered |
| M06.272 | ICD10CM | Covered |
| M06.28 | ICD10CM | Covered |
| M06.29 | ICD10CM | Covered |
| M06.311 | ICD10CM | Covered |
| M06.312 | ICD10CM | Covered |
| M06.321 | ICD10CM | Covered |
| M06.322 | ICD10CM | Covered |
| M06.331 | ICD10CM | Covered |
| M06.332 | ICD10CM | Covered |
| M06.341 | ICD10CM | Covered |
| M06.342 | ICD10CM | Covered |
| M06.351 | ICD10CM | Covered |
| M06.352 | ICD10CM | Covered |
| M06.361 | ICD10CM | Covered |
| M06.362 | ICD10CM | Covered |
| M06.371 | ICD10CM | Covered |
| M06.372 | ICD10CM | Covered |
| M06.38 | ICD10CM | Covered |
| M06.39 | ICD10CM | Covered |
| M06.811 | ICD10CM | Covered |
| M06.812 | ICD10CM | Covered |
| M06.821 | ICD10CM | Covered |
| M06.822 | ICD10CM | Covered |
| M06.831 | ICD10CM | Covered |
| M06.832 | ICD10CM | Covered |
| M06.841 | ICD10CM | Covered |
| M06.842 | ICD10CM | Covered |
| M06.851 | ICD10CM | Covered |
| M06.852 | ICD10CM | Covered |
| M06.861 | ICD10CM | Covered |
| M06.862 | ICD10CM | Covered |
| M06.871 | ICD10CM | Covered |
| M06.872 | ICD10CM | Covered |
| M06.88 | ICD10CM | Covered |
| M06.89 | ICD10CM | Covered |
| M30.0 | ICD10CM | Covered |
| M30.2 | ICD10CM | Covered |
| M30.8 | ICD10CM | Covered |
| M31.4 | ICD10CM | Covered |
| M31.7 | ICD10CM | Covered |
| M34.83 | ICD10CM | Covered |
| M79.601 | ICD10CM | Covered |
| M79.602 | ICD10CM | Covered |
| M79.603 | ICD10CM | Covered |
| M79.604 | ICD10CM | Covered |
| M79.605 | ICD10CM | Covered |
| M79.621 | ICD10CM | Covered |
| M79.622 | ICD10CM | Covered |
| M79.631 | ICD10CM | Covered |
| M79.632 | ICD10CM | Covered |
| M79.641 | ICD10CM | Covered |
| M79.642 | ICD10CM | Covered |
| M79.643 | ICD10CM | Covered |
| M79.644 | ICD10CM | Covered |
| M79.645 | ICD10CM | Covered |
| M79.651 | ICD10CM | Covered |
| M79.652 | ICD10CM | Covered |
| M79.661 | ICD10CM | Covered |
| M79.662 | ICD10CM | Covered |
| M79.671 | ICD10CM | Covered |
| M79.672 | ICD10CM | Covered |
| M79.673 | ICD10CM | Covered |
| M79.674 | ICD10CM | Covered |
| M79.675 | ICD10CM | Covered |
| N18.1 | ICD10CM | Covered |
| N18.2 | ICD10CM | Covered |
| N18.30 | ICD10CM | Covered |
| N18.31 | ICD10CM | Covered |
| N18.32 | ICD10CM | Covered |
| N18.4 | ICD10CM | Covered |
| N18.5 | ICD10CM | Covered |
| N18.6 | ICD10CM | Covered |
| R26.81 | ICD10CM | Covered |
| R26.89 | ICD10CM | Covered |