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 |
|---|---|---|
| 31502 | HCPCS | Covered |
| 31720 | HCPCS | Covered |
| 94002 | HCPCS | Covered |
| 94003 | HCPCS | Covered |
| 94004 | HCPCS | Covered |
| 94010 | HCPCS | Covered |
| 94011 | HCPCS | Covered |
| 94012 | HCPCS | Covered |
| 94013 | HCPCS | Covered |
| 94060 | HCPCS | Covered |
| 94070 | HCPCS | Covered |
| 94150 | HCPCS | Covered |
| 94200 | HCPCS | Covered |
| 94375 | HCPCS | Covered |
| 94450 | HCPCS | Covered |
| 94617 | HCPCS | Covered |
| 94618 | HCPCS | Covered |
| 94619 | HCPCS | Covered |
| 94621 | HCPCS | Covered |
| 94640 | HCPCS | Covered |
| 94642 | HCPCS | Covered |
| 94660 | HCPCS | Covered |
| 94664 | HCPCS | Covered |
| 94667 | HCPCS | Covered |
| 94668 | HCPCS | Covered |
| 94669 | HCPCS | Covered |
| 94680 | HCPCS | Covered |
| 94681 | HCPCS | Covered |
| 94690 | HCPCS | Covered |
| 94726 | HCPCS | Covered |
| 94727 | HCPCS | Covered |
| 94728 | HCPCS | Covered |
| 94729 | HCPCS | Covered |
| 94772 | HCPCS | Covered |
| G0237 | HCPCS | Covered |
| G0238 | HCPCS | Covered |
| G0239 | HCPCS | Covered |
| A15.0 | ICD10CM | Covered |
| A15.4 | ICD10CM | Covered |
| A15.5 | ICD10CM | Covered |
| A15.6 | ICD10CM | Covered |
| A15.7 | ICD10CM | Covered |
| A15.8 | ICD10CM | Covered |
| A18.01 | ICD10CM | Covered |
| A19.0 | ICD10CM | Covered |
| A19.1 | ICD10CM | Covered |
| A19.8 | ICD10CM | Covered |
| A20.2 | ICD10CM | Covered |
| A20.7 | ICD10CM | Covered |
| A22.1 | ICD10CM | Covered |
| A31.0 | ICD10CM | Covered |
| A36.2 | ICD10CM | Covered |
| A37.00 | ICD10CM | Covered |
| A37.01 | ICD10CM | Covered |
| A37.10 | ICD10CM | Covered |
| A37.11 | ICD10CM | Covered |
| A37.80 | ICD10CM | Covered |
| A37.81 | ICD10CM | Covered |
| A42.0 | ICD10CM | Covered |
| A43.0 | ICD10CM | Covered |
| A52.72 | ICD10CM | Covered |
| A75.3 | ICD10CM | Covered |
| A78 | ICD10CM | Covered |
| A80.39 | ICD10CM | Covered |
| B01.2 | ICD10CM | Covered |
| B05.2 | ICD10CM | Covered |
| B20 | ICD10CM | Covered |
| B25.0 | ICD10CM | Covered |
| B37.1 | ICD10CM | Covered |
| B38.0 | ICD10CM | Covered |
| B38.1 | ICD10CM | Covered |
| B39.0 | ICD10CM | Covered |
| B39.1 | ICD10CM | Covered |
| B40.0 | ICD10CM | Covered |
| B40.1 | ICD10CM | Covered |
| B40.7 | ICD10CM | Covered |
| B40.81 | ICD10CM | Covered |
| B40.89 | ICD10CM | Covered |
| B42.0 | ICD10CM | Covered |
| B42.7 | ICD10CM | Covered |
| B42.81 | ICD10CM | Covered |
| B42.82 | ICD10CM | Covered |
| B42.89 | ICD10CM | Covered |
| B44.0 | ICD10CM | Covered |
| B44.1 | ICD10CM | Covered |
| B44.2 | ICD10CM | Covered |
| B44.7 | ICD10CM | Covered |
| B44.81 | ICD10CM | Covered |
| B44.89 | ICD10CM | Covered |
| B45.0 | ICD10CM | Covered |
| B45.1 | ICD10CM | Covered |
| B45.3 | ICD10CM | Covered |
| B45.7 | ICD10CM | Covered |
| B45.8 | ICD10CM | Covered |
| B48.4 | ICD10CM | Covered |
| B58.3 | ICD10CM | Covered |
| B59 | ICD10CM | Covered |
| B77.81 | ICD10CM | Covered |
| B91 | ICD10CM | Covered |
| C33 | ICD10CM | Covered |
| C34.01 | ICD10CM | Covered |
| C34.02 | ICD10CM | Covered |
| C34.11 | ICD10CM | Covered |
| C34.12 | ICD10CM | Covered |
| C34.2 | ICD10CM | Covered |
| C34.31 | ICD10CM | Covered |
| C34.32 | ICD10CM | Covered |
| C34.81 | ICD10CM | Covered |
| C34.82 | ICD10CM | Covered |
| C37 | ICD10CM | Covered |
| C38.1 | ICD10CM | Covered |
| C38.2 | ICD10CM | Covered |
| C38.4 | ICD10CM | Covered |
| C38.8 | ICD10CM | Covered |
| C45.0 | ICD10CM | Covered |
| C45.2 | ICD10CM | Covered |
| C45.7 | ICD10CM | Covered |
| C46.51 | ICD10CM | Covered |
| C46.52 | ICD10CM | Covered |
| C78.01 | ICD10CM | Covered |
| C78.02 | ICD10CM | Covered |
| C78.1 | ICD10CM | Covered |
| C78.2 | ICD10CM | Covered |
| C78.31 | ICD10CM | Covered |
| C78.32 | ICD10CM | Covered |
| C78.39 | ICD10CM | Covered |
| C96.5 | ICD10CM | Covered |
| C96.6 | ICD10CM | Covered |
| D02.21 | ICD10CM | Covered |
| D02.22 | ICD10CM | Covered |
| D02.3 | ICD10CM | Covered |
| D14.1 | ICD10CM | Covered |
| D14.2 | ICD10CM | Covered |
| D14.31 | ICD10CM | Covered |
| D14.32 | ICD10CM | Covered |
| D15.2 | ICD10CM | Covered |
| D18.1 | ICD10CM | Covered |
| D19.0 | ICD10CM | Covered |
| D37.1 | ICD10CM | Covered |
| D37.2 | ICD10CM | Covered |
| D37.3 | ICD10CM | Covered |
| D37.4 | ICD10CM | Covered |
| D37.5 | ICD10CM | Covered |
| D38.1 | ICD10CM | Covered |
| D38.2 | ICD10CM | Covered |
| D38.3 | ICD10CM | Covered |
| D38.4 | ICD10CM | Covered |
| D38.5 | ICD10CM | Covered |
| D45 | ICD10CM | Covered |
| D57.01 | ICD10CM | Covered |
| D57.04 | ICD10CM | Covered |
| D57.211 | ICD10CM | Covered |
| D57.214 | ICD10CM | Covered |
| D57.411 | ICD10CM | Covered |
| D57.414 | ICD10CM | Covered |
| D57.431 | ICD10CM | Covered |
| D57.434 | ICD10CM | Covered |
| D57.451 | ICD10CM | Covered |
| D57.454 | ICD10CM | Covered |
| D57.811 | ICD10CM | Covered |
| D57.814 | ICD10CM | Covered |
| D75.1 | ICD10CM | Covered |
| D81.810 | ICD10CM | Covered |
| D84.1 | ICD10CM | Covered |
| D86.0 | ICD10CM | Covered |
| D86.1 | ICD10CM | Covered |
| D86.2 | ICD10CM | Covered |
| D86.81 | ICD10CM | Covered |
| D86.82 | ICD10CM | Covered |
| D86.85 | ICD10CM | Covered |
| D86.86 | ICD10CM | Covered |
| D86.87 | ICD10CM | Covered |
| D86.89 | ICD10CM | Covered |
| E66.2 | ICD10CM | Covered |
| E84.0 | ICD10CM | Covered |
| E84.11 | ICD10CM | Covered |
| E84.19 | ICD10CM | Covered |
| E84.8 | ICD10CM | Covered |
| E85.0 | ICD10CM | Covered |
| E85.1 | ICD10CM | Covered |
| E85.3 | ICD10CM | Covered |
| E85.4 | ICD10CM | Covered |
| E85.81 | ICD10CM | Covered |
| E85.82 | ICD10CM | Covered |
| E85.89 | ICD10CM | Covered |
| E87.20 | ICD10CM | Covered |
| E87.21 | ICD10CM | Covered |
| E87.22 | ICD10CM | Covered |
| E87.29 | ICD10CM | Covered |
| E87.3 | ICD10CM | Covered |
| E88.01 | ICD10CM | Covered |
| E88.02 | ICD10CM | Covered |
| E88.3 | ICD10CM | Covered |
| E88.41 | ICD10CM | Covered |
| E88.42 | ICD10CM | Covered |
| E88.49 | ICD10CM | Covered |
| E88.82 | ICD10CM | Covered |
| E88.89 | ICD10CM | Covered |
| G12.21 | ICD10CM | Covered |
| G12.22 | ICD10CM | Covered |
| G14 | ICD10CM | Covered |
| G47.33 | ICD10CM | Covered |
| G61.0 | ICD10CM | Covered |
| G70.00 | ICD10CM | Covered |
| G70.01 | ICD10CM | Covered |
| G70.81 | ICD10CM | Covered |
| G71.00 | ICD10CM | Covered |
| G71.01 | ICD10CM | Covered |
| G71.02 | ICD10CM | Covered |
| G71.036 | ICD10CM | Covered |
| G71.09 | ICD10CM | Covered |
| G71.11 | ICD10CM | Covered |
| G71.12 | ICD10CM | Covered |
| G71.13 | ICD10CM | Covered |
| G71.14 | ICD10CM | Covered |
| G71.19 | ICD10CM | Covered |
| G72.41 | ICD10CM | Covered |
| G72.49 | ICD10CM | Covered |
| G73.1 | 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 |
| I27.840 | ICD10CM | Covered |
| I27.841 | ICD10CM | Covered |
| I27.848 | ICD10CM | Covered |
| I27.849 | ICD10CM | Covered |
| I27.89 | ICD10CM | Covered |
| I28.0 | ICD10CM | Covered |
| I28.8 | ICD10CM | Covered |
| I37.0 | ICD10CM | Covered |
| I37.1 | ICD10CM | Covered |
| I37.2 | ICD10CM | Covered |
| I37.8 | ICD10CM | Covered |
| I46.2 | ICD10CM | Covered |
| I46.8 | ICD10CM | Covered |
| I50.1 | ICD10CM | Covered |
| I50.21 | ICD10CM | Covered |
| I50.22 | ICD10CM | Covered |
| I50.23 | ICD10CM | Covered |
| I50.31 | ICD10CM | Covered |
| I50.32 | ICD10CM | Covered |
| I50.33 | ICD10CM | Covered |
| I50.41 | ICD10CM | Covered |
| I50.42 | ICD10CM | Covered |
| I50.43 | ICD10CM | Covered |
| J04.10 | ICD10CM | Covered |
| J04.11 | ICD10CM | Covered |
| J04.2 | ICD10CM | Covered |
| J05.0 | ICD10CM | Covered |
| J05.10 | ICD10CM | Covered |
| J05.11 | ICD10CM | Covered |
| J06.0 | ICD10CM | Covered |
| J09.X1 | ICD10CM | Covered |
| J09.X2 | ICD10CM | Covered |
| J09.X3 | ICD10CM | Covered |
| J09.X9 | ICD10CM | Covered |
| J10.01 | ICD10CM | Covered |
| J10.08 | ICD10CM | Covered |
| J10.1 | ICD10CM | Covered |
| J11.08 | ICD10CM | Covered |
| J11.1 | ICD10CM | Covered |
| J12.0 | ICD10CM | Covered |
| J12.1 | ICD10CM | Covered |
| J12.82 | ICD10CM | Covered |
| J13 | ICD10CM | Covered |
| J15.211 | ICD10CM | Covered |
| J15.212 | ICD10CM | Covered |
| J15.29 | ICD10CM | Covered |
| J15.3 | ICD10CM | Covered |
| J15.4 | ICD10CM | Covered |
| J15.61 | ICD10CM | Covered |
| J15.69 | ICD10CM | Covered |
| J15.7 | ICD10CM | Covered |
| J16.0 | ICD10CM | Covered |
| J17 | 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 |
| J21.0 | ICD10CM | Covered |
| J21.1 | ICD10CM | Covered |
| J21.8 | ICD10CM | Covered |
| J37.1 | ICD10CM | Covered |
| J38.01 | ICD10CM | Covered |
| J38.02 | ICD10CM | Covered |
| J38.4 | ICD10CM | Covered |
| J38.5 | ICD10CM | Covered |
| J38.6 | ICD10CM | Covered |
| J38.7 | ICD10CM | Covered |
| J39.8 | ICD10CM | Covered |
| J40 | ICD10CM | Covered |
| J41.0 | ICD10CM | Covered |
| J41.1 | ICD10CM | Covered |
| J41.8 | ICD10CM | Covered |
| J43.0 | ICD10CM | Covered |
| J43.1 | ICD10CM | Covered |
| J43.2 | ICD10CM | Covered |
| J43.8 | ICD10CM | Covered |
| J44.0 | ICD10CM | Covered |
| J44.1 | ICD10CM | Covered |
| J44.81 | 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 |
| 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 |
| J68.0 | ICD10CM | Covered |
| J68.1 | ICD10CM | Covered |
| J68.2 | ICD10CM | Covered |
| J68.3 | ICD10CM | Covered |
| J68.4 | ICD10CM | Covered |
| J68.8 | 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 |
| J70.5 | ICD10CM | Covered |
| J70.8 | 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 |
| J84.111 | 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 |
| J84.841 | ICD10CM | Covered |
| J84.842 | ICD10CM | Covered |
| J84.843 | ICD10CM | Covered |
| J84.848 | ICD10CM | Covered |
| J84.89 | 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 |
| J94.0 | ICD10CM | Covered |
| J94.1 | ICD10CM | Covered |
| J94.2 | ICD10CM | Covered |
| J94.8 | ICD10CM | Covered |
| J95.01 | ICD10CM | Covered |
| J95.02 | ICD10CM | Covered |
| J95.03 | ICD10CM | Covered |
| J95.04 | ICD10CM | Covered |
| J95.09 | ICD10CM | Covered |
| J95.1 | ICD10CM | Covered |
| J95.2 | ICD10CM | Covered |
| J95.3 | ICD10CM | Covered |
| J95.811 | ICD10CM | Covered |
| J95.812 | ICD10CM | Covered |
| J95.821 | ICD10CM | Covered |
| J95.822 | ICD10CM | Covered |
| J95.84 | ICD10CM | Covered |
| J95.850 | ICD10CM | Covered |
| J95.860 | ICD10CM | Covered |
| J95.861 | ICD10CM | Covered |
| J95.862 | ICD10CM | Covered |
| J95.863 | ICD10CM | Covered |
| J95.89 | ICD10CM | Covered |
| J96.01 | ICD10CM | Covered |
| J96.02 | ICD10CM | Covered |
| J96.11 | ICD10CM | Covered |
| J96.12 | ICD10CM | Covered |
| J96.21 | ICD10CM | Covered |
| J96.22 | 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 |
| J98.51 | ICD10CM | Covered |
| J98.59 | ICD10CM | Covered |
| J98.6 | ICD10CM | Covered |
| J98.8 | ICD10CM | Covered |
| J99 | ICD10CM | Covered |
| K76.81 | ICD10CM | Covered |
| M32.13 | ICD10CM | Covered |
| M33.01 | ICD10CM | Covered |
| M33.11 | ICD10CM | Covered |
| M33.21 | ICD10CM | Covered |
| M34.81 | ICD10CM | Covered |
| M35.02 | ICD10CM | Covered |
| O08.2 | ICD10CM | Covered |
| O74.0 | ICD10CM | Covered |
| O74.1 | ICD10CM | Covered |
| O89.01 | ICD10CM | Covered |
| O89.09 | ICD10CM | Covered |
| P24.00 | ICD10CM | Covered |
| P24.01 | ICD10CM | Covered |
| P24.10 | ICD10CM | Covered |
| P24.11 | ICD10CM | Covered |
| P24.20 | ICD10CM | Covered |
| P24.21 | ICD10CM | Covered |
| P24.80 | ICD10CM | Covered |
| P24.81 | ICD10CM | Covered |
| P28.81 | ICD10CM | Covered |
| P36.0 | ICD10CM | Covered |
| P36.19 | ICD10CM | Covered |
| P36.2 | ICD10CM | Covered |
| P36.39 | ICD10CM | Covered |
| P36.4 | ICD10CM | Covered |
| P36.5 | ICD10CM | Covered |
| P36.8 | ICD10CM | Covered |
| P39.2 | ICD10CM | Covered |
| P39.8 | ICD10CM | Covered |
| R04.2 | ICD10CM | Covered |
| R04.81 | ICD10CM | Covered |
| R04.89 | ICD10CM | Covered |
| R05.1 | ICD10CM | Covered |
| R05.2 | ICD10CM | Covered |
| R05.3 | ICD10CM | Covered |
| R05.4 | ICD10CM | Covered |
| R05.8 | ICD10CM | Covered |
| R05.9 | ICD10CM | Covered |
| R06.01 | ICD10CM | Covered |
| R06.02 | ICD10CM | Covered |
| R06.03 | 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 |
| R07.1 | ICD10CM | Covered |
| R07.81 | ICD10CM | Covered |
| R09.01 | ICD10CM | Covered |
| R09.02 | ICD10CM | Covered |
| R09.1 | ICD10CM | Covered |
| R09.2 | ICD10CM | Covered |
| R09.89 | ICD10CM | Covered |
| R23.0 | ICD10CM | Covered |
| R68.13 | ICD10CM | Covered |
| R78.81 | ICD10CM | Covered |
| R79.81 | ICD10CM | Covered |
| R91.1 | ICD10CM | Covered |
| R91.8 | ICD10CM | Covered |
| R94.2 | ICD10CM | Covered |
| S21.311A | ICD10CM | Covered |
| S21.311D | ICD10CM | Covered |
| S21.311S | ICD10CM | Covered |
| S21.312A | ICD10CM | Covered |
| S21.312D | ICD10CM | Covered |
| S21.312S | ICD10CM | Covered |
| S21.321A | ICD10CM | Covered |
| S21.321D | ICD10CM | Covered |
| S21.321S | ICD10CM | Covered |
| S21.322A | ICD10CM | Covered |
| S21.322D | ICD10CM | Covered |
| S21.322S | ICD10CM | Covered |
| S21.331A | ICD10CM | Covered |
| S21.331D | ICD10CM | Covered |
| S21.331S | ICD10CM | Covered |
| S21.332A | ICD10CM | Covered |
| S21.332D | ICD10CM | Covered |
| S21.332S | ICD10CM | Covered |
| S21.341A | ICD10CM | Covered |
| S21.341D | ICD10CM | Covered |
| S21.341S | ICD10CM | Covered |
| S21.342A | ICD10CM | Covered |
| S21.342D | ICD10CM | Covered |
| S21.342S | ICD10CM | Covered |
| S21.351A | ICD10CM | Covered |
| S21.351D | ICD10CM | Covered |
| S21.351S | ICD10CM | Covered |
| S21.352A | ICD10CM | Covered |
| S21.352D | ICD10CM | Covered |
| S21.352S | ICD10CM | Covered |
| S21.411A | ICD10CM | Covered |
| S21.411D | ICD10CM | Covered |
| S21.411S | ICD10CM | Covered |
| S21.412A | ICD10CM | Covered |
| S21.412D | ICD10CM | Covered |
| S21.412S | ICD10CM | Covered |
| S21.421A | ICD10CM | Covered |
| S21.421D | ICD10CM | Covered |
| S21.421S | ICD10CM | Covered |
| S21.422A | ICD10CM | Covered |
| S21.422D | ICD10CM | Covered |
| S21.422S | ICD10CM | Covered |
| S21.431A | ICD10CM | Covered |
| S21.431D | ICD10CM | Covered |
| S21.431S | ICD10CM | Covered |
| S21.432A | ICD10CM | Covered |
| S21.432D | ICD10CM | Covered |
| S21.432S | ICD10CM | Covered |
| S21.441A | ICD10CM | Covered |
| S21.441D | ICD10CM | Covered |
| S21.441S | ICD10CM | Covered |
| S21.442A | ICD10CM | Covered |
| S21.442D | ICD10CM | Covered |
| S21.442S | ICD10CM | Covered |
| S21.451A | ICD10CM | Covered |
| S21.451D | ICD10CM | Covered |
| S21.451S | ICD10CM | Covered |
| S21.452A | ICD10CM | Covered |
| S21.452D | ICD10CM | Covered |
| S21.452S | ICD10CM | Covered |
| S26.01XA | ICD10CM | Covered |
| S26.01XD | ICD10CM | Covered |
| S26.01XS | ICD10CM | Covered |
| S26.020A | ICD10CM | Covered |
| S26.020D | ICD10CM | Covered |
| S26.020S | ICD10CM | Covered |
| S26.021A | ICD10CM | Covered |
| S26.021D | ICD10CM | Covered |
| S26.021S | ICD10CM | Covered |
| S26.022A | ICD10CM | Covered |
| S26.022D | ICD10CM | Covered |
| S26.022S | ICD10CM | Covered |
| S26.09XA | ICD10CM | Covered |
| S26.09XD | ICD10CM | Covered |
| S26.09XS | ICD10CM | Covered |
| S26.11XA | ICD10CM | Covered |
| S26.11XD | ICD10CM | Covered |
| S26.11XS | ICD10CM | Covered |
| S26.12XA | ICD10CM | Covered |
| S26.12XD | ICD10CM | Covered |
| S26.12XS | ICD10CM | Covered |
| S26.19XA | ICD10CM | Covered |
| S26.19XD | ICD10CM | Covered |
| S26.19XS | ICD10CM | Covered |
| S27.0XXA | ICD10CM | Covered |
| S27.0XXD | ICD10CM | Covered |
| S27.0XXS | ICD10CM | Covered |
| S27.1XXA | ICD10CM | Covered |
| S27.1XXD | ICD10CM | Covered |
| S27.1XXS | ICD10CM | Covered |
| S27.2XXA | ICD10CM | Covered |
| S27.2XXD | ICD10CM | Covered |
| S27.2XXS | ICD10CM | Covered |
| S27.311A | ICD10CM | Covered |
| S27.311D | ICD10CM | Covered |
| S27.311S | ICD10CM | Covered |
| S27.312A | ICD10CM | Covered |
| S27.312D | ICD10CM | Covered |
| S27.312S | ICD10CM | Covered |
| S27.321A | ICD10CM | Covered |
| S27.321D | ICD10CM | Covered |
| S27.321S | ICD10CM | Covered |
| S27.322A | ICD10CM | Covered |
| S27.322D | ICD10CM | Covered |
| S27.322S | ICD10CM | Covered |
| S27.331A | ICD10CM | Covered |
| S27.331D | ICD10CM | Covered |
| S27.331S | ICD10CM | Covered |
| S27.332A | ICD10CM | Covered |
| S27.332D | ICD10CM | Covered |
| S27.332S | ICD10CM | Covered |
| S27.391A | ICD10CM | Covered |
| S27.391D | ICD10CM | Covered |
| S27.391S | ICD10CM | Covered |
| S27.392A | ICD10CM | Covered |
| S27.392D | ICD10CM | Covered |
| S27.392S | ICD10CM | Covered |
| S27.411A | ICD10CM | Covered |
| S27.411D | ICD10CM | Covered |
| S27.411S | ICD10CM | Covered |
| S27.412A | ICD10CM | Covered |
| S27.412D | ICD10CM | Covered |
| S27.412S | ICD10CM | Covered |
| S27.421A | ICD10CM | Covered |
| S27.421D | ICD10CM | Covered |
| S27.421S | ICD10CM | Covered |
| S27.422A | ICD10CM | Covered |
| S27.422D | ICD10CM | Covered |
| S27.422S | ICD10CM | Covered |
| S27.431A | ICD10CM | Covered |
| S27.431D | ICD10CM | Covered |
| S27.431S | ICD10CM | Covered |
| S27.432A | ICD10CM | Covered |
| S27.432D | ICD10CM | Covered |
| S27.432S | ICD10CM | Covered |
| S27.491A | ICD10CM | Covered |
| S27.491D | ICD10CM | Covered |
| S27.491S | ICD10CM | Covered |
| S27.492A | ICD10CM | Covered |
| S27.492D | ICD10CM | Covered |
| S27.492S | ICD10CM | Covered |
| S27.51XA | ICD10CM | Covered |
| S27.51XD | ICD10CM | Covered |
| S27.51XS | ICD10CM | Covered |
| S27.52XA | ICD10CM | Covered |
| S27.52XD | ICD10CM | Covered |
| S27.52XS | ICD10CM | Covered |
| S27.53XA | ICD10CM | Covered |
| S27.53XD | ICD10CM | Covered |
| S27.53XS | ICD10CM | Covered |
| S27.59XA | ICD10CM | Covered |
| S27.59XD | ICD10CM | Covered |
| S27.59XS | ICD10CM | Covered |
| S27.63XA | ICD10CM | Covered |
| S27.63XD | ICD10CM | Covered |
| S27.63XS | ICD10CM | Covered |
| S27.69XA | ICD10CM | Covered |
| S27.69XD | ICD10CM | Covered |
| S27.69XS | ICD10CM | Covered |
| S27.802A | ICD10CM | Covered |
| S27.802D | ICD10CM | Covered |
| S27.802S | ICD10CM | Covered |
| S27.803A | ICD10CM | Covered |
| S27.803D | ICD10CM | Covered |
| S27.803S | ICD10CM | Covered |
| S27.808A | ICD10CM | Covered |
| S27.808D | ICD10CM | Covered |
| S27.808S | ICD10CM | Covered |
| S27.812A | ICD10CM | Covered |
| S27.812D | ICD10CM | Covered |
| S27.812S | ICD10CM | Covered |
| S27.813A | ICD10CM | Covered |
| S27.813D | ICD10CM | Covered |
| S27.813S | ICD10CM | Covered |
| S27.818A | ICD10CM | Covered |
| S27.818D | ICD10CM | Covered |
| S27.818S | ICD10CM | Covered |
| S27.892A | ICD10CM | Covered |
| S27.892D | ICD10CM | Covered |
| S27.892S | ICD10CM | Covered |
| S27.893A | ICD10CM | Covered |
| S27.893D | ICD10CM | Covered |
| S27.893S | ICD10CM | Covered |
| S27.898A | ICD10CM | Covered |
| S27.898D | ICD10CM | Covered |
| S27.898S | ICD10CM | Covered |
| S32.411S | ICD10CM | Covered |
| T53.5X1A | ICD10CM | Covered |
| T53.5X1D | ICD10CM | Covered |
| T53.5X1S | ICD10CM | Covered |
| T53.5X2A | ICD10CM | Covered |
| T53.5X2D | ICD10CM | Covered |
| T53.5X2S | ICD10CM | Covered |
| T53.5X3A | ICD10CM | Covered |
| T53.5X3D | ICD10CM | Covered |
| T53.5X3S | ICD10CM | Covered |
| T53.5X4A | ICD10CM | Covered |
| T53.5X4D | ICD10CM | Covered |
| T53.5X4S | ICD10CM | Covered |
| T56.821A | ICD10CM | Covered |
| T56.821D | ICD10CM | Covered |
| T56.821S | ICD10CM | Covered |
| T56.822A | ICD10CM | Covered |
| T56.822D | ICD10CM | Covered |
| T56.822S | ICD10CM | Covered |
| T56.823A | ICD10CM | Covered |
| T56.823D | ICD10CM | Covered |
| T56.823S | ICD10CM | Covered |
| T56.824A | ICD10CM | Covered |
| T56.824D | ICD10CM | Covered |
| T56.824S | ICD10CM | Covered |
| T57.3X1A | ICD10CM | Covered |
| T57.3X1D | ICD10CM | Covered |
| T57.3X1S | ICD10CM | Covered |
| T57.3X2A | ICD10CM | Covered |
| T57.3X2D | ICD10CM | Covered |
| T57.3X2S | ICD10CM | Covered |
| T57.3X3A | ICD10CM | Covered |
| T57.3X3D | ICD10CM | Covered |
| T57.3X3S | ICD10CM | Covered |
| T57.3X4A | ICD10CM | Covered |
| T57.3X4D | ICD10CM | Covered |
| T57.3X4S | ICD10CM | Covered |
| T59.0X1A | ICD10CM | Covered |
| T59.0X1D | ICD10CM | Covered |
| T59.0X1S | ICD10CM | Covered |
| T59.0X2A | ICD10CM | Covered |
| T59.0X2D | ICD10CM | Covered |
| T59.0X2S | ICD10CM | Covered |
| T59.0X3A | ICD10CM | Covered |
| T59.0X3D | ICD10CM | Covered |
| T59.0X3S | ICD10CM | Covered |
| T59.0X4A | ICD10CM | Covered |
| T59.0X4D | ICD10CM | Covered |
| T59.0X4S | ICD10CM | Covered |
| T59.1X1A | ICD10CM | Covered |
| T59.1X1D | ICD10CM | Covered |
| T59.1X1S | ICD10CM | Covered |
| T59.1X2A | ICD10CM | Covered |
| T59.1X2D | ICD10CM | Covered |
| T59.1X2S | ICD10CM | Covered |
| T59.1X3A | ICD10CM | Covered |
| T59.1X3D | ICD10CM | Covered |
| T59.1X3S | ICD10CM | Covered |
| T59.1X4A | ICD10CM | Covered |
| T59.1X4D | ICD10CM | Covered |
| T59.1X4S | ICD10CM | Covered |
| T59.2X1A | ICD10CM | Covered |
| T59.2X1D | ICD10CM | Covered |
| T59.2X1S | ICD10CM | Covered |
| T59.2X2A | ICD10CM | Covered |
| T59.2X2D | ICD10CM | Covered |
| T59.2X2S | ICD10CM | Covered |
| T59.2X3A | ICD10CM | Covered |
| T59.2X3D | ICD10CM | Covered |
| T59.2X3S | ICD10CM | Covered |
| T59.2X4A | ICD10CM | Covered |
| T59.2X4D | ICD10CM | Covered |
| T59.2X4S | ICD10CM | Covered |
| T59.3X1A | ICD10CM | Covered |
| T59.3X1D | ICD10CM | Covered |
| T59.3X1S | ICD10CM | Covered |
| T59.3X2A | ICD10CM | Covered |
| T59.3X2D | ICD10CM | Covered |
| T59.3X2S | ICD10CM | Covered |
| T59.3X3A | ICD10CM | Covered |
| T59.3X3D | ICD10CM | Covered |
| T59.3X3S | ICD10CM | Covered |
| T59.3X4A | ICD10CM | Covered |
| T59.3X4D | ICD10CM | Covered |
| T59.3X4S | ICD10CM | Covered |
| T59.4X1A | ICD10CM | Covered |
| T59.4X1D | ICD10CM | Covered |
| T59.4X1S | ICD10CM | Covered |
| T59.4X2A | ICD10CM | Covered |
| T59.4X2D | ICD10CM | Covered |
| T59.4X2S | ICD10CM | Covered |
| T59.4X3A | ICD10CM | Covered |
| T59.4X3D | ICD10CM | Covered |
| T59.4X3S | ICD10CM | Covered |
| T59.4X4A | ICD10CM | Covered |
| T59.4X4D | ICD10CM | Covered |
| T59.4X4S | ICD10CM | Covered |
| T59.5X1A | ICD10CM | Covered |
| T59.5X1D | ICD10CM | Covered |
| T59.5X1S | ICD10CM | Covered |
| T59.5X2A | ICD10CM | Covered |
| T59.5X2D | ICD10CM | Covered |
| T59.5X2S | ICD10CM | Covered |
| T59.5X3A | ICD10CM | Covered |
| T59.5X3D | ICD10CM | Covered |
| T59.5X3S | ICD10CM | Covered |
| T59.5X4A | ICD10CM | Covered |
| T59.5X4D | ICD10CM | Covered |
| T59.5X4S | ICD10CM | Covered |
| T59.6X1A | ICD10CM | Covered |
| T59.6X1D | ICD10CM | Covered |
| T59.6X1S | ICD10CM | Covered |
| T59.6X2A | ICD10CM | Covered |
| T59.6X2D | ICD10CM | Covered |
| T59.6X2S | ICD10CM | Covered |
| T59.6X3A | ICD10CM | Covered |
| T59.6X3D | ICD10CM | Covered |
| T59.6X3S | ICD10CM | Covered |
| T59.6X4A | ICD10CM | Covered |
| T59.6X4D | ICD10CM | Covered |
| T59.6X4S | ICD10CM | Covered |
| T59.7X1A | ICD10CM | Covered |
| T59.7X1D | ICD10CM | Covered |
| T59.7X1S | ICD10CM | Covered |
| T59.7X2A | ICD10CM | Covered |
| T59.7X2D | ICD10CM | Covered |
| T59.7X2S | ICD10CM | Covered |
| T59.7X3A | ICD10CM | Covered |
| T59.7X3D | ICD10CM | Covered |
| T59.7X3S | ICD10CM | Covered |
| T59.7X4A | ICD10CM | Covered |
| T59.7X4D | ICD10CM | Covered |
| T59.7X4S | ICD10CM | Covered |
| T59.811A | ICD10CM | Covered |
| T59.811D | ICD10CM | Covered |
| T59.811S | ICD10CM | Covered |
| T59.812A | ICD10CM | Covered |
| T59.812D | ICD10CM | Covered |
| T59.812S | ICD10CM | Covered |
| T59.813A | ICD10CM | Covered |
| T59.813D | ICD10CM | Covered |
| T59.813S | ICD10CM | Covered |
| T59.814A | ICD10CM | Covered |
| T59.814D | ICD10CM | Covered |
| T59.814S | ICD10CM | Covered |
| T59.891A | ICD10CM | Covered |
| T59.891D | ICD10CM | Covered |
| T59.891S | ICD10CM | Covered |
| T59.892A | ICD10CM | Covered |
| T59.892D | ICD10CM | Covered |
| T59.892S | ICD10CM | Covered |
| T59.893A | ICD10CM | Covered |
| T59.893D | ICD10CM | Covered |
| T59.893S | ICD10CM | Covered |
| T59.894A | ICD10CM | Covered |
| T59.894D | ICD10CM | Covered |
| T59.894S | ICD10CM | Covered |
| T65.211A | ICD10CM | Covered |
| T65.211D | ICD10CM | Covered |
| T65.211S | ICD10CM | Covered |
| T65.212A | ICD10CM | Covered |
| T65.212D | ICD10CM | Covered |
| T65.212S | ICD10CM | Covered |
| T65.213A | ICD10CM | Covered |
| T65.213D | ICD10CM | Covered |
| T65.213S | ICD10CM | Covered |
| T65.214A | ICD10CM | Covered |
| T65.214D | ICD10CM | Covered |
| T65.214S | ICD10CM | Covered |
| T65.221A | ICD10CM | Covered |
| T65.221D | ICD10CM | Covered |
| T65.221S | ICD10CM | Covered |
| T65.222A | ICD10CM | Covered |
| T65.222D | ICD10CM | Covered |
| T65.222S | ICD10CM | Covered |
| T65.223A | ICD10CM | Covered |
| T65.223D | ICD10CM | Covered |
| T65.223S | ICD10CM | Covered |
| T65.224A | ICD10CM | Covered |
| T65.224D | ICD10CM | Covered |
| T65.224S | ICD10CM | Covered |
| T65.291A | ICD10CM | Covered |
| T65.291D | ICD10CM | Covered |
| T65.291S | ICD10CM | Covered |
| T65.292A | ICD10CM | Covered |
| T65.292D | ICD10CM | Covered |
| T65.292S | ICD10CM | Covered |
| T65.293A | ICD10CM | Covered |
| T65.293D | ICD10CM | Covered |
| T65.293S | ICD10CM | Covered |
| T65.294A | ICD10CM | Covered |
| T65.294D | ICD10CM | Covered |
| T65.294S | ICD10CM | Covered |
| Z09 | ICD10CM | Covered |
| Z43.0 | ICD10CM | Covered |
| Z48.21 | ICD10CM | Covered |
| Z48.24 | ICD10CM | Covered |
| Z48.280 | ICD10CM | Covered |
| Z48.290 | ICD10CM | Covered |
| Z76.82 | ICD10CM | Covered |
| Z79.899 | ICD10CM | Covered |
| Z86.11 | ICD10CM | Covered |
| Z86.12 | ICD10CM | Covered |
| Z86.15 | ICD10CM | Covered |
| Z86.16 | ICD10CM | Covered |
| Z87.01 | ICD10CM | Covered |
| Z87.09 | ICD10CM | Covered |
| Z93.0 | ICD10CM | Covered |
| Z94.2 | ICD10CM | Covered |
| Z94.3 | ICD10CM | Covered |
| Z94.81 | ICD10CM | Covered |
| Z94.84 | ICD10CM | Covered |
| Z99.11 | ICD10CM | Covered |