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 3,161 codes. The source has the full list.
| Code | Code system | Status in this policy |
|---|---|---|
| 94760 | HCPCS | Covered |
| 94761 | HCPCS | Covered |
| 94762 | HCPCS | Covered |
| A15.0 | ICD10CM | Covered |
| A15.5 | ICD10CM | Covered |
| A15.8 | ICD10CM | Covered |
| A15.9 | ICD10CM | Covered |
| A20.2 | ICD10CM | Covered |
| A21.2 | ICD10CM | Covered |
| A22.1 | ICD10CM | Covered |
| A37.01 | ICD10CM | Covered |
| A37.11 | ICD10CM | Covered |
| A37.81 | ICD10CM | Covered |
| A37.91 | ICD10CM | Covered |
| A42.0 | ICD10CM | Covered |
| A43.0 | ICD10CM | Covered |
| A48.1 | ICD10CM | Covered |
| A70 | ICD10CM | Covered |
| B01.2 | ICD10CM | Covered |
| B25.0 | ICD10CM | Covered |
| B44.0 | ICD10CM | Covered |
| B44.81 | ICD10CM | Covered |
| B58.3 | ICD10CM | Covered |
| B59 | ICD10CM | Covered |
| C33 | ICD10CM | Covered |
| C34.00 | ICD10CM | Covered |
| C34.01 | ICD10CM | Covered |
| C34.02 | ICD10CM | Covered |
| C34.10 | ICD10CM | Covered |
| C34.11 | ICD10CM | Covered |
| C34.12 | ICD10CM | Covered |
| C34.2 | ICD10CM | Covered |
| C34.30 | ICD10CM | Covered |
| C34.31 | ICD10CM | Covered |
| C34.32 | ICD10CM | Covered |
| C34.80 | ICD10CM | Covered |
| C34.81 | ICD10CM | Covered |
| C34.82 | ICD10CM | Covered |
| C34.90 | ICD10CM | Covered |
| C34.91 | ICD10CM | Covered |
| C34.92 | ICD10CM | Covered |
| C78.00 | ICD10CM | Covered |
| C78.01 | ICD10CM | Covered |
| C78.02 | ICD10CM | Covered |
| D81.810 | ICD10CM | Covered |
| D84.1 | ICD10CM | Covered |
| D86.0 | ICD10CM | Covered |
| D86.1 | ICD10CM | Covered |
| D86.2 | ICD10CM | Covered |
| D86.3 | ICD10CM | Covered |
| D86.81 | ICD10CM | Covered |
| D86.82 | ICD10CM | Covered |
| D86.83 | ICD10CM | Covered |
| D86.84 | ICD10CM | Covered |
| D86.85 | ICD10CM | Covered |
| D86.86 | ICD10CM | Covered |
| D86.87 | ICD10CM | Covered |
| D86.89 | ICD10CM | Covered |
| D86.9 | ICD10CM | Covered |
| E84.0 | ICD10CM | Covered |
| F05 | ICD10CM | Covered |
| F28 | ICD10CM | Covered |
| F29 | ICD10CM | Covered |
| G12.21 | ICD10CM | Covered |
| G12.25 | ICD10CM | Covered |
| G47.10 | ICD10CM | Covered |
| G47.30 | ICD10CM | Covered |
| G47.31 | ICD10CM | Covered |
| G47.32 | ICD10CM | Covered |
| G47.33 | ICD10CM | Covered |
| G47.34 | ICD10CM | Covered |
| G47.35 | ICD10CM | Covered |
| G47.36 | ICD10CM | Covered |
| G47.37 | ICD10CM | Covered |
| G61.0 | ICD10CM | Covered |
| G70.00 | ICD10CM | Covered |
| G70.01 | ICD10CM | Covered |
| G70.80 | ICD10CM | Covered |
| G70.81 | ICD10CM | Covered |
| G73.1 | ICD10CM | Covered |
| G93.31 | ICD10CM | Covered |
| G93.32 | ICD10CM | Covered |
| G93.39 | ICD10CM | Covered |
| I20.89 | ICD10CM | Covered |
| I20.9 | ICD10CM | Covered |
| I26.01 | ICD10CM | Covered |
| I26.02 | ICD10CM | Covered |
| I26.03 | ICD10CM | Covered |
| I26.04 | ICD10CM | Covered |
| I26.09 | ICD10CM | Covered |
| I26.90 | ICD10CM | Covered |
| I26.92 | ICD10CM | Covered |
| I26.93 | ICD10CM | Covered |
| I26.94 | ICD10CM | Covered |
| I26.95 | ICD10CM | Covered |
| I26.96 | ICD10CM | Covered |
| I26.99 | ICD10CM | Covered |
| I27.0 | ICD10CM | Covered |
| I27.1 | ICD10CM | Covered |
| I27.20 | ICD10CM | Covered |
| I27.21 | ICD10CM | Covered |
| I27.22 | ICD10CM | Covered |
| I27.23 | ICD10CM | Covered |
| I27.24 | ICD10CM | Covered |
| I27.29 | ICD10CM | Covered |
| I27.81 | ICD10CM | Covered |
| I27.82 | ICD10CM | Covered |
| I27.83 | ICD10CM | Covered |
| I27.89 | ICD10CM | Covered |
| I27.9 | ICD10CM | Covered |
| I50.1 | ICD10CM | Covered |
| I50.20 | ICD10CM | Covered |
| I50.21 | ICD10CM | Covered |
| I50.22 | ICD10CM | Covered |
| I50.23 | ICD10CM | Covered |
| I50.30 | ICD10CM | Covered |
| I50.31 | ICD10CM | Covered |
| I50.32 | ICD10CM | Covered |
| I50.33 | ICD10CM | Covered |
| I50.40 | ICD10CM | Covered |
| I50.41 | ICD10CM | Covered |
| I50.42 | ICD10CM | Covered |
| I50.43 | ICD10CM | Covered |
| I50.810 | ICD10CM | Covered |
| I50.811 | ICD10CM | Covered |
| I50.812 | ICD10CM | Covered |
| I50.813 | ICD10CM | Covered |
| I50.814 | ICD10CM | Covered |
| I50.82 | ICD10CM | Covered |
| I50.83 | ICD10CM | Covered |
| I50.84 | ICD10CM | Covered |
| I50.89 | ICD10CM | Covered |
| I50.9 | ICD10CM | Covered |
| J04.0 | ICD10CM | Covered |
| J04.10 | ICD10CM | Covered |
| J04.11 | ICD10CM | Covered |
| J04.2 | ICD10CM | Covered |
| J04.30 | ICD10CM | Covered |
| J04.31 | ICD10CM | Covered |
| J05.0 | ICD10CM | Covered |
| J05.10 | ICD10CM | Covered |
| J05.11 | ICD10CM | Covered |
| J10.00 | ICD10CM | Covered |
| J10.01 | ICD10CM | Covered |
| J10.08 | ICD10CM | Covered |
| J10.1 | ICD10CM | Covered |
| J11.00 | ICD10CM | Covered |
| J11.08 | ICD10CM | Covered |
| J11.1 | ICD10CM | Covered |
| J12.0 | ICD10CM | Covered |
| J12.1 | ICD10CM | Covered |
| J12.2 | ICD10CM | Covered |
| J12.3 | ICD10CM | Covered |
| J12.81 | ICD10CM | Covered |
| J12.89 | ICD10CM | Covered |
| J12.9 | ICD10CM | Covered |
| J13 | ICD10CM | Covered |
| J15.1 | ICD10CM | Covered |
| J15.20 | ICD10CM | Covered |
| J15.211 | ICD10CM | Covered |
| J15.212 | ICD10CM | Covered |
| J15.29 | ICD10CM | Covered |
| J15.3 | ICD10CM | Covered |
| J15.4 | ICD10CM | Covered |
| J15.5 | ICD10CM | Covered |
| J15.69 | ICD10CM | Covered |
| J15.7 | ICD10CM | Covered |
| J15.8 | ICD10CM | Covered |
| J16.0 | ICD10CM | Covered |
| J16.8 | ICD10CM | Covered |
| J17 | ICD10CM | Covered |
| J18.0 | ICD10CM | Covered |
| J18.1 | ICD10CM | Covered |
| J18.2 | ICD10CM | Covered |
| J18.8 | ICD10CM | Covered |
| J18.9 | ICD10CM | Covered |
| J20.0 | ICD10CM | Covered |
| J20.1 | ICD10CM | Covered |
| J20.2 | ICD10CM | Covered |
| J20.3 | ICD10CM | Covered |
| J20.4 | ICD10CM | Covered |
| J20.5 | ICD10CM | Covered |
| J20.6 | ICD10CM | Covered |
| J20.7 | ICD10CM | Covered |
| J20.8 | ICD10CM | Covered |
| J20.9 | ICD10CM | Covered |
| J21.0 | ICD10CM | Covered |
| J21.1 | ICD10CM | Covered |
| J21.8 | ICD10CM | Covered |
| J21.9 | ICD10CM | Covered |
| J38.5 | ICD10CM | Covered |
| J38.6 | ICD10CM | Covered |
| J38.7 | ICD10CM | Covered |
| J39.3 | ICD10CM | Covered |
| J39.8 | ICD10CM | Covered |
| J39.9 | ICD10CM | Covered |
| J40 | ICD10CM | Covered |
| J41.1 | ICD10CM | Covered |
| J43.0 | ICD10CM | Covered |
| J43.1 | ICD10CM | Covered |
| J43.2 | ICD10CM | Covered |
| J43.8 | ICD10CM | Covered |
| J43.9 | ICD10CM | Covered |
| J44.0 | ICD10CM | Covered |
| J44.1 | ICD10CM | Covered |
| J44.89 | ICD10CM | Covered |
| J44.9 | ICD10CM | Covered |
| J45.20 | ICD10CM | Covered |
| J45.21 | ICD10CM | Covered |
| J45.22 | ICD10CM | Covered |
| J45.30 | ICD10CM | Covered |
| J45.31 | ICD10CM | Covered |
| J45.32 | ICD10CM | Covered |
| J45.40 | ICD10CM | Covered |
| J45.41 | ICD10CM | Covered |
| J45.42 | ICD10CM | Covered |
| J45.50 | ICD10CM | Covered |
| J45.51 | ICD10CM | Covered |
| J45.52 | ICD10CM | Covered |
| J45.901 | ICD10CM | Covered |
| J45.902 | ICD10CM | Covered |
| J45.909 | ICD10CM | Covered |
| J45.990 | ICD10CM | Covered |
| J45.991 | ICD10CM | Covered |
| J45.998 | ICD10CM | Covered |
| J47.0 | ICD10CM | Covered |
| J47.1 | ICD10CM | Covered |
| J47.9 | ICD10CM | Covered |
| J60 | ICD10CM | Covered |
| J61 | ICD10CM | Covered |
| J62.0 | ICD10CM | Covered |
| J62.8 | ICD10CM | Covered |
| J63.0 | ICD10CM | Covered |
| J63.1 | ICD10CM | Covered |
| J63.2 | ICD10CM | Covered |
| J63.3 | ICD10CM | Covered |
| J63.4 | ICD10CM | Covered |
| J63.5 | ICD10CM | Covered |
| J63.6 | ICD10CM | Covered |
| J64 | ICD10CM | Covered |
| J65 | ICD10CM | Covered |
| J66.0 | ICD10CM | Covered |
| J66.1 | ICD10CM | Covered |
| J66.2 | ICD10CM | Covered |
| J66.8 | ICD10CM | Covered |
| J67.0 | ICD10CM | Covered |
| J67.1 | ICD10CM | Covered |
| J67.2 | ICD10CM | Covered |
| J67.3 | ICD10CM | Covered |
| J67.4 | ICD10CM | Covered |
| J67.5 | ICD10CM | Covered |
| J67.6 | ICD10CM | Covered |
| J67.7 | ICD10CM | Covered |
| J67.8 | ICD10CM | Covered |
| J67.9 | ICD10CM | Covered |
| J68.0 | ICD10CM | Covered |
| J68.1 | ICD10CM | Covered |
| J68.2 | ICD10CM | Covered |
| J68.3 | ICD10CM | Covered |
| J68.4 | ICD10CM | Covered |
| J68.8 | ICD10CM | Covered |
| J68.9 | ICD10CM | Covered |
| J69.0 | ICD10CM | Covered |
| J69.1 | ICD10CM | Covered |
| J69.8 | ICD10CM | Covered |
| J70.0 | ICD10CM | Covered |
| J70.1 | ICD10CM | Covered |
| J70.2 | ICD10CM | Covered |
| J70.3 | ICD10CM | Covered |
| J70.4 | ICD10CM | Covered |
| J70.5 | ICD10CM | Covered |
| J70.8 | ICD10CM | Covered |
| J70.9 | ICD10CM | Covered |
| J80 | ICD10CM | Covered |
| J81.0 | ICD10CM | Covered |
| J81.1 | ICD10CM | Covered |
| J82.81 | ICD10CM | Covered |
| J82.82 | ICD10CM | Covered |
| J82.83 | ICD10CM | Covered |
| J82.89 | ICD10CM | Covered |
| J84.01 | ICD10CM | Covered |
| J84.02 | ICD10CM | Covered |
| J84.03 | ICD10CM | Covered |
| J84.09 | ICD10CM | Covered |
| J84.10 | ICD10CM | Covered |
| J84.111 | ICD10CM | Covered |
| J84.112 | ICD10CM | Covered |
| J84.113 | ICD10CM | Covered |
| J84.114 | ICD10CM | Covered |
| J84.115 | ICD10CM | Covered |
| J84.116 | ICD10CM | Covered |
| J84.117 | ICD10CM | Covered |
| J84.170 | ICD10CM | Covered |
| J84.178 | ICD10CM | Covered |
| J84.2 | ICD10CM | Covered |
| J84.81 | ICD10CM | Covered |
| J84.82 | ICD10CM | Covered |
| J84.83 | ICD10CM | Covered |
| J84.843 | ICD10CM | Covered |
| J84.848 | ICD10CM | Covered |
| J84.89 | ICD10CM | Covered |
| J84.9 | ICD10CM | Covered |
| J85.0 | ICD10CM | Covered |
| J85.1 | ICD10CM | Covered |
| J85.2 | ICD10CM | Covered |
| J85.3 | ICD10CM | Covered |
| J86.0 | ICD10CM | Covered |
| J86.9 | ICD10CM | Covered |
| J90 | ICD10CM | Covered |
| J91.0 | ICD10CM | Covered |
| J91.8 | ICD10CM | Covered |
| J92.0 | ICD10CM | Covered |
| J92.9 | ICD10CM | Covered |
| J93.0 | ICD10CM | Covered |
| J93.11 | ICD10CM | Covered |
| J93.12 | ICD10CM | Covered |
| J93.81 | ICD10CM | Covered |
| J93.82 | ICD10CM | Covered |
| J93.83 | ICD10CM | Covered |
| J93.9 | ICD10CM | Covered |
| J94.0 | ICD10CM | Covered |
| J94.1 | ICD10CM | Covered |
| J94.2 | ICD10CM | Covered |
| J94.8 | ICD10CM | Covered |
| J94.9 | ICD10CM | Covered |
| J95.1 | ICD10CM | Covered |
| J95.2 | ICD10CM | Covered |
| J95.3 | ICD10CM | Covered |
| J95.4 | ICD10CM | Covered |
| J95.5 | ICD10CM | Covered |
| J95.811 | ICD10CM | Covered |
| J95.812 | ICD10CM | Covered |
| J95.821 | ICD10CM | Covered |
| J95.822 | ICD10CM | Covered |
| J95.84 | ICD10CM | Covered |
| J95.851 | ICD10CM | Covered |
| J95.859 | ICD10CM | Covered |
| J95.87 | ICD10CM | Covered |
| J95.88 | ICD10CM | Covered |
| J95.89 | ICD10CM | Covered |
| J96.00 | ICD10CM | Covered |
| J96.01 | ICD10CM | Covered |
| J96.02 | ICD10CM | Covered |
| J96.10 | ICD10CM | Covered |
| J96.11 | ICD10CM | Covered |
| J96.12 | ICD10CM | Covered |
| J96.20 | ICD10CM | Covered |
| J96.21 | ICD10CM | Covered |
| J96.22 | ICD10CM | Covered |
| J96.90 | ICD10CM | Covered |
| J96.91 | ICD10CM | Covered |
| J96.92 | ICD10CM | Covered |
| J98.01 | ICD10CM | Covered |
| J98.09 | ICD10CM | Covered |
| J98.11 | ICD10CM | Covered |
| J98.19 | ICD10CM | Covered |
| J98.2 | ICD10CM | Covered |
| J98.3 | ICD10CM | Covered |
| J98.4 | ICD10CM | Covered |
| J98.6 | ICD10CM | Covered |
| J99 | ICD10CM | Covered |
| M1A.10X0 | ICD10CM | Covered |
| M1A.10X1 | ICD10CM | Covered |
| M1A.1110 | ICD10CM | Covered |
| M1A.1111 | ICD10CM | Covered |
| M1A.1120 | ICD10CM | Covered |
| M1A.1121 | ICD10CM | Covered |
| M1A.1190 | ICD10CM | Covered |
| M1A.1191 | ICD10CM | Covered |
| M1A.1210 | ICD10CM | Covered |
| M1A.1211 | ICD10CM | Covered |
| M1A.1220 | ICD10CM | Covered |
| M1A.1221 | ICD10CM | Covered |
| M1A.1290 | ICD10CM | Covered |
| M1A.1291 | ICD10CM | Covered |
| M1A.1310 | ICD10CM | Covered |
| M1A.1311 | ICD10CM | Covered |
| M1A.1320 | ICD10CM | Covered |
| M1A.1321 | ICD10CM | Covered |
| M1A.1390 | ICD10CM | Covered |
| M1A.1391 | ICD10CM | Covered |
| M1A.1410 | ICD10CM | Covered |
| M1A.1411 | ICD10CM | Covered |
| M1A.1420 | ICD10CM | Covered |
| M1A.1421 | ICD10CM | Covered |
| M1A.1490 | ICD10CM | Covered |
| M1A.1491 | ICD10CM | Covered |
| M1A.1510 | ICD10CM | Covered |
| M1A.1511 | ICD10CM | Covered |
| M1A.1520 | ICD10CM | Covered |
| M1A.1521 | ICD10CM | Covered |
| M1A.1590 | ICD10CM | Covered |
| M1A.1591 | ICD10CM | Covered |
| M1A.1610 | ICD10CM | Covered |
| M1A.1611 | ICD10CM | Covered |
| M1A.1620 | ICD10CM | Covered |
| M1A.1621 | ICD10CM | Covered |
| M1A.1690 | ICD10CM | Covered |
| M1A.1691 | ICD10CM | Covered |
| M1A.1710 | ICD10CM | Covered |
| M1A.1711 | ICD10CM | Covered |
| M1A.1720 | ICD10CM | Covered |
| M1A.1721 | ICD10CM | Covered |
| M1A.1790 | ICD10CM | Covered |
| M1A.1791 | ICD10CM | Covered |
| M1A.18X0 | ICD10CM | Covered |
| M1A.18X1 | ICD10CM | Covered |
| M1A.19X0 | ICD10CM | Covered |
| M1A.19X1 | ICD10CM | Covered |
| M34.0 | ICD10CM | Covered |
| M34.1 | ICD10CM | Covered |
| M34.2 | ICD10CM | Covered |
| M34.81 | ICD10CM | Covered |
| M34.82 | ICD10CM | Covered |
| M34.83 | ICD10CM | Covered |
| M34.89 | ICD10CM | Covered |
| M34.9 | ICD10CM | Covered |
| R04.2 | ICD10CM | Covered |
| R04.89 | ICD10CM | Covered |
| R04.9 | ICD10CM | Covered |
| R06.00 | ICD10CM | Covered |
| R06.01 | ICD10CM | Covered |
| R06.02 | ICD10CM | Covered |
| R06.09 | ICD10CM | Covered |
| R06.1 | ICD10CM | Covered |
| R06.2 | ICD10CM | Covered |
| R06.3 | ICD10CM | Covered |
| R06.4 | ICD10CM | Covered |
| R06.81 | ICD10CM | Covered |
| R06.82 | ICD10CM | Covered |
| R06.83 | ICD10CM | Covered |
| R06.89 | ICD10CM | Covered |
| R06.9 | ICD10CM | Covered |
| R07.1 | ICD10CM | Covered |
| R07.2 | ICD10CM | Covered |
| R07.81 | ICD10CM | Covered |
| R07.82 | ICD10CM | Covered |
| R07.89 | ICD10CM | Covered |
| R07.9 | ICD10CM | Covered |
| R09.01 | ICD10CM | Covered |
| R09.02 | ICD10CM | Covered |
| R09.1 | ICD10CM | Covered |
| R23.0 | ICD10CM | Covered |
| R40.0 | ICD10CM | Covered |
| R40.1 | ICD10CM | Covered |
| R53.0 | ICD10CM | Covered |
| R53.1 | ICD10CM | Covered |
| R53.81 | ICD10CM | Covered |
| R53.83 | ICD10CM | Covered |
| R55 | ICD10CM | Covered |
| R56.00 | ICD10CM | Covered |
| R56.01 | ICD10CM | Covered |
| R56.1 | ICD10CM | Covered |
| R56.9 | ICD10CM | Covered |
| R57.0 | ICD10CM | Covered |
| R57.1 | ICD10CM | Covered |
| R57.8 | ICD10CM | Covered |
| R57.9 | ICD10CM | Covered |
| R65.21 | ICD10CM | Covered |
| R68.13 | ICD10CM | Covered |
| R91.8 | ICD10CM | Covered |
| R93.1 | ICD10CM | Covered |
| R93.89 | ICD10CM | Covered |
| S01.90XA | ICD10CM | Covered |
| S06.0X0A | ICD10CM | Covered |
| S06.1X0A | ICD10CM | Covered |
| S06.1X1A | ICD10CM | Covered |
| S06.1X2A | ICD10CM | Covered |
| S06.1X3A | ICD10CM | Covered |
| S06.1X4A | ICD10CM | Covered |
| S06.1X5A | ICD10CM | Covered |
| S06.1X6A | ICD10CM | Covered |
| S06.1X7A | ICD10CM | Covered |
| S06.1X8A | ICD10CM | Covered |
| S06.1X9A | ICD10CM | Covered |
| S06.2X0A | ICD10CM | Covered |
| S06.2X1A | ICD10CM | Covered |
| S06.2X2A | ICD10CM | Covered |
| S06.2X3A | ICD10CM | Covered |
| S06.2X4A | ICD10CM | Covered |
| S06.2X5A | ICD10CM | Covered |
| S06.2X6A | ICD10CM | Covered |
| S06.2X7A | ICD10CM | Covered |
| S06.2X8A | ICD10CM | Covered |
| S06.2X9A | ICD10CM | Covered |
| S06.300A | ICD10CM | Covered |
| S06.301A | ICD10CM | Covered |
| S06.302A | ICD10CM | Covered |
| S06.303A | ICD10CM | Covered |
| S06.304A | ICD10CM | Covered |
| S06.305A | ICD10CM | Covered |
| S06.306A | ICD10CM | Covered |
| S06.307A | ICD10CM | Covered |
| S06.308A | ICD10CM | Covered |
| S06.309A | ICD10CM | Covered |
| S06.810A | ICD10CM | Covered |
| S06.811A | ICD10CM | Covered |
| S06.812A | ICD10CM | Covered |
| S06.813A | ICD10CM | Covered |
| S06.814A | ICD10CM | Covered |
| S06.815A | ICD10CM | Covered |
| S06.816A | ICD10CM | Covered |
| S06.817A | ICD10CM | Covered |
| S06.818A | ICD10CM | Covered |
| S06.819A | ICD10CM | Covered |
| S06.820A | ICD10CM | Covered |
| S06.821A | ICD10CM | Covered |
| S06.822A | ICD10CM | Covered |
| S06.823A | ICD10CM | Covered |
| S06.824A | ICD10CM | Covered |
| S06.825A | ICD10CM | Covered |
| S06.826A | ICD10CM | Covered |
| S06.827A | ICD10CM | Covered |
| S06.828A | ICD10CM | Covered |
| S06.829A | ICD10CM | Covered |
| S06.890A | ICD10CM | Covered |
| S06.891A | ICD10CM | Covered |
| S06.892A | ICD10CM | Covered |
| S06.893A | ICD10CM | Covered |
| S06.894A | ICD10CM | Covered |
| S06.895A | ICD10CM | Covered |
| S06.896A | ICD10CM | Covered |
| S06.897A | ICD10CM | Covered |
| S06.898A | ICD10CM | Covered |
| S06.899A | ICD10CM | Covered |
| S06.9X0A | ICD10CM | Covered |
| S06.9X1A | ICD10CM | Covered |
| S06.9X2A | ICD10CM | Covered |
| S06.9X3A | ICD10CM | Covered |
| S06.9X4A | ICD10CM | Covered |
| S06.9X5A | ICD10CM | Covered |
| S06.9X6A | ICD10CM | Covered |
| S06.9X7A | ICD10CM | Covered |
| S06.9X8A | ICD10CM | Covered |
| S06.9X9A | ICD10CM | Covered |
| S12.000A | ICD10CM | Covered |
| S12.000B | ICD10CM | Covered |
| S12.001A | ICD10CM | Covered |
| S12.001B | ICD10CM | Covered |
| S12.01XA | ICD10CM | Covered |
| S12.01XB | ICD10CM | Covered |
| S12.02XA | ICD10CM | Covered |
| S12.02XB | ICD10CM | Covered |
| S12.030A | ICD10CM | Covered |
| S12.030B | ICD10CM | Covered |
| S12.031A | ICD10CM | Covered |
| S12.031B | ICD10CM | Covered |
| S12.040A | ICD10CM | Covered |
| S12.040B | ICD10CM | Covered |
| S12.041A | ICD10CM | Covered |
| S12.041B | ICD10CM | Covered |
| S12.090A | ICD10CM | Covered |
| S12.090B | ICD10CM | Covered |
| S12.091A | ICD10CM | Covered |
| S12.091B | ICD10CM | Covered |
| S12.100A | ICD10CM | Covered |
| S12.100B | ICD10CM | Covered |
| S12.101A | ICD10CM | Covered |
| S12.101B | ICD10CM | Covered |
| S12.110A | ICD10CM | Covered |
| S12.110B | ICD10CM | Covered |
| S12.111A | ICD10CM | Covered |
| S12.111B | ICD10CM | Covered |
| S12.112A | ICD10CM | Covered |
| S12.112B | ICD10CM | Covered |
| S12.120A | ICD10CM | Covered |
| S12.120B | ICD10CM | Covered |
| S12.121A | ICD10CM | Covered |
| S12.121B | ICD10CM | Covered |
| S12.130A | ICD10CM | Covered |
| S12.130B | ICD10CM | Covered |
| S12.131A | ICD10CM | Covered |
| S12.131B | ICD10CM | Covered |
| S12.14XA | ICD10CM | Covered |
| S12.14XB | ICD10CM | Covered |
| S12.150A | ICD10CM | Covered |
| S12.150B | ICD10CM | Covered |
| S12.151A | ICD10CM | Covered |
| S12.151B | ICD10CM | Covered |
| S12.190A | ICD10CM | Covered |
| S12.190B | ICD10CM | Covered |
| S12.191A | ICD10CM | Covered |
| S12.191B | ICD10CM | Covered |
| S12.200A | ICD10CM | Covered |
| S12.200B | ICD10CM | Covered |
| S12.201A | ICD10CM | Covered |
| S12.201B | ICD10CM | Covered |
| S12.230A | ICD10CM | Covered |
| S12.230B | ICD10CM | Covered |
| S12.231A | ICD10CM | Covered |
| S12.231B | ICD10CM | Covered |
| S12.24XA | ICD10CM | Covered |
| S12.24XB | ICD10CM | Covered |
| S12.250A | ICD10CM | Covered |
| S12.250B | ICD10CM | Covered |
| S12.251A | ICD10CM | Covered |
| S12.251B | ICD10CM | Covered |
| S12.290A | ICD10CM | Covered |
| S12.290B | ICD10CM | Covered |
| S12.291A | ICD10CM | Covered |
| S12.291B | ICD10CM | Covered |
| S12.300A | ICD10CM | Covered |
| S12.300B | ICD10CM | Covered |
| S12.301A | ICD10CM | Covered |
| S12.301B | ICD10CM | Covered |
| S12.330A | ICD10CM | Covered |
| S12.330B | ICD10CM | Covered |
| S12.331A | ICD10CM | Covered |
| S12.331B | ICD10CM | Covered |
| S12.34XA | ICD10CM | Covered |
| S12.34XB | ICD10CM | Covered |
| S12.350A | ICD10CM | Covered |
| S12.350B | ICD10CM | Covered |
| S12.351A | ICD10CM | Covered |
| S12.351B | ICD10CM | Covered |
| S12.390A | ICD10CM | Covered |
| S12.390B | ICD10CM | Covered |
| S12.391A | ICD10CM | Covered |
| S12.391B | ICD10CM | Covered |
| S12.400A | ICD10CM | Covered |
| S12.400B | ICD10CM | Covered |
| S12.401A | ICD10CM | Covered |
| S12.401B | ICD10CM | Covered |
| S12.430A | ICD10CM | Covered |
| S12.430B | ICD10CM | Covered |
| S12.431A | ICD10CM | Covered |
| S12.431B | ICD10CM | Covered |
| S12.44XA | ICD10CM | Covered |
| S12.44XB | ICD10CM | Covered |
| S12.450A | ICD10CM | Covered |
| S12.450B | ICD10CM | Covered |
| S12.451A | ICD10CM | Covered |
| S12.451B | ICD10CM | Covered |
| S12.490A | ICD10CM | Covered |
| S12.490B | ICD10CM | Covered |
| S12.491A | ICD10CM | Covered |
| S12.491B | ICD10CM | Covered |
| S12.500A | ICD10CM | Covered |
| S12.500B | ICD10CM | Covered |
| S12.501A | ICD10CM | Covered |
| S12.501B | ICD10CM | Covered |
| S12.530A | ICD10CM | Covered |
| S12.530B | ICD10CM | Covered |
| S12.531A | ICD10CM | Covered |
| S12.531B | ICD10CM | Covered |
| S12.54XA | ICD10CM | Covered |
| S12.54XB | ICD10CM | Covered |
| S12.550A | ICD10CM | Covered |
| S12.550B | ICD10CM | Covered |
| S12.551A | ICD10CM | Covered |
| S12.551B | ICD10CM | Covered |
| S12.590A | ICD10CM | Covered |
| S12.590B | ICD10CM | Covered |
| S12.591A | ICD10CM | Covered |
| S12.591B | ICD10CM | Covered |
| S12.600A | ICD10CM | Covered |
| S12.600B | ICD10CM | Covered |
| S12.601A | ICD10CM | Covered |
| S12.601B | ICD10CM | Covered |
| S12.630A | ICD10CM | Covered |
| S12.630B | ICD10CM | Covered |
| S12.631A | ICD10CM | Covered |
| S12.631B | ICD10CM | Covered |
| S12.64XA | ICD10CM | Covered |
| S12.64XB | ICD10CM | Covered |
| S12.650A | ICD10CM | Covered |
| S12.650B | ICD10CM | Covered |
| S12.651A | ICD10CM | Covered |
| S12.651B | ICD10CM | Covered |
| S12.690A | ICD10CM | Covered |
| S12.690B | ICD10CM | Covered |
| S12.691A | ICD10CM | Covered |
| S12.691B | ICD10CM | Covered |
| S12.8XXA | ICD10CM | Covered |
| S12.9XXA | ICD10CM | Covered |
| S14.101A | ICD10CM | Covered |
| S14.102A | ICD10CM | Covered |
| S14.103A | ICD10CM | Covered |
| S14.104A | ICD10CM | Covered |
| S14.105A | ICD10CM | Covered |
| S14.106A | ICD10CM | Covered |
| S14.107A | ICD10CM | Covered |
| S14.111A | ICD10CM | Covered |
| S14.112A | ICD10CM | Covered |
| S14.113A | ICD10CM | Covered |
| S14.114A | ICD10CM | Covered |
| S14.115A | ICD10CM | Covered |
| S14.116A | ICD10CM | Covered |
| S14.117A | ICD10CM | Covered |
| S14.121A | ICD10CM | Covered |
| S14.122A | ICD10CM | Covered |
| S14.123A | ICD10CM | Covered |
| S14.124A | ICD10CM | Covered |
| S14.125A | ICD10CM | Covered |
| S14.126A | ICD10CM | Covered |
| S14.127A | ICD10CM | Covered |
| S14.131A | ICD10CM | Covered |
| S14.132A | ICD10CM | Covered |
| S14.133A | ICD10CM | Covered |
| S14.134A | ICD10CM | Covered |
| S14.135A | ICD10CM | Covered |
| S14.136A | ICD10CM | Covered |
| S14.137A | ICD10CM | Covered |
| S14.151A | ICD10CM | Covered |
| S14.152A | ICD10CM | Covered |
| S14.153A | ICD10CM | Covered |
| S14.154A | ICD10CM | Covered |
| S14.155A | ICD10CM | Covered |
| S14.156A | ICD10CM | Covered |
| S14.157A | ICD10CM | Covered |
| S21.301A | ICD10CM | Covered |
| S21.302A | ICD10CM | Covered |
| S21.309A | ICD10CM | Covered |
| S21.311A | ICD10CM | Covered |
| S21.312A | ICD10CM | Covered |
| S21.319A | ICD10CM | Covered |
| S21.321A | ICD10CM | Covered |
| S21.322A | ICD10CM | Covered |
| S21.329A | ICD10CM | Covered |
| S21.331A | ICD10CM | Covered |
| S21.332A | ICD10CM | Covered |
| S21.339A | ICD10CM | Covered |
| S21.341A | ICD10CM | Covered |
| S21.342A | ICD10CM | Covered |
| S21.349A | ICD10CM | Covered |
| S21.351A | ICD10CM | Covered |
| S21.352A | ICD10CM | Covered |
| S21.359A | ICD10CM | Covered |
| S21.401A | ICD10CM | Covered |
| S21.402A | ICD10CM | Covered |
| S21.409A | ICD10CM | Covered |
| S21.411A | ICD10CM | Covered |
| S21.412A | ICD10CM | Covered |
| S21.419A | ICD10CM | Covered |
| S21.421A | ICD10CM | Covered |
| S21.422A | ICD10CM | Covered |
| S21.429A | ICD10CM | Covered |
| S21.431A | ICD10CM | Covered |
| S21.432A | ICD10CM | Covered |
| S21.439A | ICD10CM | Covered |
| S21.441A | ICD10CM | Covered |
| S21.442A | ICD10CM | Covered |
| S21.449A | ICD10CM | Covered |
| S21.451A | ICD10CM | Covered |
| S21.452A | ICD10CM | Covered |
| S21.459A | ICD10CM | Covered |
| S22.000A | ICD10CM | Covered |
| S22.000B | ICD10CM | Covered |
| S22.001A | ICD10CM | Covered |
| S22.001B | ICD10CM | Covered |
| S22.002A | ICD10CM | Covered |
| S22.002B | ICD10CM | Covered |
| S22.008A | ICD10CM | Covered |
| S22.008B | ICD10CM | Covered |
| S22.009A | ICD10CM | Covered |
| S22.009B | ICD10CM | Covered |
| S22.010A | ICD10CM | Covered |
| S22.010B | ICD10CM | Covered |
| S22.011A | ICD10CM | Covered |
| S22.011B | ICD10CM | Covered |
| S22.012A | ICD10CM | Covered |
| S22.012B | ICD10CM | Covered |
| S22.018A | ICD10CM | Covered |
| S22.018B | ICD10CM | Covered |
| S22.019A | ICD10CM | Covered |
| S22.019B | ICD10CM | Covered |
| S22.020A | ICD10CM | Covered |
| S22.020B | ICD10CM | Covered |
| S22.021A | ICD10CM | Covered |
| S22.021B | ICD10CM | Covered |
| S22.022A | ICD10CM | Covered |
| S22.022B | ICD10CM | Covered |
| S22.028A | ICD10CM | Covered |
| S22.028B | ICD10CM | Covered |
| S22.029A | ICD10CM | Covered |
| S22.029B | ICD10CM | Covered |
| S22.030A | ICD10CM | Covered |
| S22.030B | ICD10CM | Covered |
| S22.031A | ICD10CM | Covered |
| S22.031B | ICD10CM | Covered |
| S22.032A | ICD10CM | Covered |
| S22.032B | ICD10CM | Covered |
| S22.038A | ICD10CM | Covered |
| S22.038B | ICD10CM | Covered |
| S22.039A | ICD10CM | Covered |
| S22.039B | ICD10CM | Covered |
| S22.040A | ICD10CM | Covered |
| S22.040B | ICD10CM | Covered |
| S22.041A | ICD10CM | Covered |
| S22.041B | ICD10CM | Covered |
| S22.042A | ICD10CM | Covered |
| S22.042B | ICD10CM | Covered |
| S22.048A | ICD10CM | Covered |
| S22.048B | ICD10CM | Covered |
| S22.049A | ICD10CM | Covered |
| S22.049B | ICD10CM | Covered |
| S22.050A | ICD10CM | Covered |
| S22.050B | ICD10CM | Covered |
| S22.051A | ICD10CM | Covered |
| S22.051B | ICD10CM | Covered |
| S22.052A | ICD10CM | Covered |
| S22.052B | ICD10CM | Covered |
| S22.058A | ICD10CM | Covered |
| S22.058B | ICD10CM | Covered |
| S22.059A | ICD10CM | Covered |
| S22.059B | ICD10CM | Covered |
| S22.060A | ICD10CM | Covered |
| S22.060B | ICD10CM | Covered |
| S22.061A | ICD10CM | Covered |
| S22.061B | ICD10CM | Covered |
| S22.062A | ICD10CM | Covered |
| S22.062B | ICD10CM | Covered |
| S22.068A | ICD10CM | Covered |
| S22.068B | ICD10CM | Covered |
| S22.069A | ICD10CM | Covered |
| S22.069B | ICD10CM | Covered |
| S22.070A | ICD10CM | Covered |
| S22.070B | ICD10CM | Covered |
| S22.071A | ICD10CM | Covered |
| S22.071B | ICD10CM | Covered |
| S22.072A | ICD10CM | Covered |
| S22.072B | ICD10CM | Covered |
| S22.078A | ICD10CM | Covered |
| S22.078B | ICD10CM | Covered |
| S22.079A | ICD10CM | Covered |
| S22.079B | ICD10CM | Covered |
| S22.080A | ICD10CM | Covered |
| S22.080B | ICD10CM | Covered |
| S22.081A | ICD10CM | Covered |
| S22.081B | ICD10CM | Covered |
| S22.082A | ICD10CM | Covered |
| S22.082B | ICD10CM | Covered |
| S22.088A | ICD10CM | Covered |
| S22.088B | ICD10CM | Covered |
| S22.089A | ICD10CM | Covered |
| S22.089B | ICD10CM | Covered |
| S22.20XA | ICD10CM | Covered |
| S22.20XB | ICD10CM | Covered |
| S22.21XA | ICD10CM | Covered |
| S22.21XB | ICD10CM | Covered |
| S22.22XA | ICD10CM | Covered |
| S22.22XB | ICD10CM | Covered |
| S22.23XA | ICD10CM | Covered |
| S22.23XB | ICD10CM | Covered |
| S22.24XA | ICD10CM | Covered |
| S22.24XB | ICD10CM | Covered |
| S22.31XA | ICD10CM | Covered |
| S22.31XB | ICD10CM | Covered |
| S22.32XA | ICD10CM | Covered |
| S22.32XB | ICD10CM | Covered |
| S22.39XA | ICD10CM | Covered |
| S22.39XB | ICD10CM | Covered |
| S22.41XA | ICD10CM | Covered |
| S22.41XB | ICD10CM | Covered |
| S22.42XA | ICD10CM | Covered |
| S22.42XB | ICD10CM | Covered |
| S22.43XA | ICD10CM | Covered |
| S22.43XB | ICD10CM | Covered |
| S22.49XA | ICD10CM | Covered |
| S22.49XB | ICD10CM | Covered |
| S22.5XXA | ICD10CM | Covered |
| S22.5XXB | ICD10CM | Covered |
| S24.101A | ICD10CM | Covered |
| S24.102A | ICD10CM | Covered |
| S24.103A | ICD10CM | Covered |
| S24.104A | ICD10CM | Covered |
| S24.111A | ICD10CM | Covered |
| S24.112A | ICD10CM | Covered |
| S24.113A | ICD10CM | Covered |
| S24.114A | ICD10CM | Covered |
| S24.131A | ICD10CM | Covered |
| S24.132A | ICD10CM | Covered |
| S24.133A | ICD10CM | Covered |
| S24.134A | ICD10CM | Covered |
| S24.151A | ICD10CM | Covered |
| S24.152A | ICD10CM | Covered |
| S24.153A | ICD10CM | Covered |
| S24.154A | ICD10CM | Covered |
| S26.00XA | ICD10CM | Covered |
| S26.01XA | ICD10CM | Covered |
| S26.020A | ICD10CM | Covered |
| S26.021A | ICD10CM | Covered |
| S26.022A | ICD10CM | Covered |
| S26.09XA | ICD10CM | Covered |
| S26.10XA | ICD10CM | Covered |
| S26.11XA | ICD10CM | Covered |
| S26.12XA | ICD10CM | Covered |
| S26.19XA | ICD10CM | Covered |
| S26.90XA | ICD10CM | Covered |
| S26.91XA | ICD10CM | Covered |
| S26.92XA | ICD10CM | Covered |
| S26.99XA | ICD10CM | Covered |
| S27.0XXA | ICD10CM | Covered |
| S27.1XXA | ICD10CM | Covered |
| S27.2XXA | ICD10CM | Covered |
| S27.301A | ICD10CM | Covered |
| S27.302A | ICD10CM | Covered |
| S27.309A | ICD10CM | Covered |
| S27.311A | ICD10CM | Covered |
| S27.312A | ICD10CM | Covered |
| S27.319A | ICD10CM | Covered |
| S27.321A | ICD10CM | Covered |
| S27.322A | ICD10CM | Covered |
| S27.329A | ICD10CM | Covered |
| S27.331A | ICD10CM | Covered |
| S27.332A | ICD10CM | Covered |
| S27.339A | ICD10CM | Covered |
| S27.391A | ICD10CM | Covered |
| S27.392A | ICD10CM | Covered |
| S27.399A | ICD10CM | Covered |
| S27.401A | ICD10CM | Covered |
| S27.402A | ICD10CM | Covered |
| S27.409A | ICD10CM | Covered |
| S27.411A | ICD10CM | Covered |
| S27.412A | ICD10CM | Covered |
| S27.419A | ICD10CM | Covered |
| S27.421A | ICD10CM | Covered |
| S27.422A | ICD10CM | Covered |
| S27.429A | ICD10CM | Covered |
| S27.431A | ICD10CM | Covered |
| S27.432A | ICD10CM | Covered |
| S27.439A | ICD10CM | Covered |
| S27.491A | ICD10CM | Covered |
| S27.492A | ICD10CM | Covered |
| S27.499A | ICD10CM | Covered |
| S27.50XA | ICD10CM | Covered |
| S27.51XA | ICD10CM | Covered |
| S27.52XA | ICD10CM | Covered |
| S27.53XA | ICD10CM | Covered |
| S27.59XA | ICD10CM | Covered |
| S27.60XA | ICD10CM | Covered |
| S27.63XA | ICD10CM | Covered |
| S27.69XA | ICD10CM | Covered |
| S27.802A | ICD10CM | Covered |
| S27.803A | ICD10CM | Covered |
| S27.808A | ICD10CM | Covered |
| S27.809A | ICD10CM | Covered |
| S27.812A | ICD10CM | Covered |
| S27.813A | ICD10CM | Covered |
| S27.818A | ICD10CM | Covered |
| S27.819A | ICD10CM | Covered |
| S27.892A | ICD10CM | Covered |
| S27.893A | ICD10CM | Covered |
| S27.898A | ICD10CM | Covered |
| S27.899A | ICD10CM | Covered |
| S27.9XXA | ICD10CM | Covered |
| S31.001A | ICD10CM | Covered |
| S31.011A | ICD10CM | Covered |
| S31.021A | ICD10CM | Covered |
| S31.031A | ICD10CM | Covered |
| S31.041A | ICD10CM | Covered |
| S31.051A | ICD10CM | Covered |
| S31.600A | ICD10CM | Covered |
| S31.601A | ICD10CM | Covered |
| S31.602A | ICD10CM | Covered |
| S31.603A | ICD10CM | Covered |
| S31.604A | ICD10CM | Covered |
| S31.605A | ICD10CM | Covered |
| S31.606A | ICD10CM | Covered |
| S31.607A | ICD10CM | Covered |
| S31.609A | ICD10CM | Covered |
| S31.610A | ICD10CM | Covered |
| S31.611A | ICD10CM | Covered |
| S31.612A | ICD10CM | Covered |
| S31.613A | ICD10CM | Covered |
| S31.614A | ICD10CM | Covered |
| S31.615A | ICD10CM | Covered |
| S31.616A | ICD10CM | Covered |
| S31.617A | ICD10CM | Covered |
| S31.619A | ICD10CM | Covered |
| S31.620A | ICD10CM | Covered |
| S31.621A | ICD10CM | Covered |
| S31.622A | ICD10CM | Covered |
| S31.623A | ICD10CM | Covered |
| S31.624A | ICD10CM | Covered |
| S31.625A | ICD10CM | Covered |
| S31.626A | ICD10CM | Covered |
| S31.627A | ICD10CM | Covered |
| S31.629A | ICD10CM | Covered |
| S31.630A | ICD10CM | Covered |
| S31.631A | ICD10CM | Covered |
| S31.632A | ICD10CM | Covered |
| S31.633A | ICD10CM | Covered |
| S31.634A | ICD10CM | Covered |
| S31.635A | ICD10CM | Covered |
| S31.636A | ICD10CM | Covered |
| S31.637A | ICD10CM | Covered |
| S31.639A | ICD10CM | Covered |
| S31.640A | ICD10CM | Covered |
| S31.641A | ICD10CM | Covered |
| S31.642A | ICD10CM | Covered |
| S31.643A | ICD10CM | Covered |
| S31.644A | ICD10CM | Covered |
| S31.645A | ICD10CM | Covered |
| S31.646A | ICD10CM | Covered |
| S31.647A | ICD10CM | Covered |
| S31.649A | ICD10CM | Covered |
| S31.650A | ICD10CM | Covered |
| S31.651A | ICD10CM | Covered |
| S31.652A | ICD10CM | Covered |