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 |
|---|---|---|
| 95925 | HCPCS | Covered |
| 95926 | HCPCS | Covered |
| 95927 | HCPCS | Covered |
| 95938 | HCPCS | Covered |
| A18.01 | ICD10CM | Covered |
| C41.2 | ICD10CM | Covered |
| C70.0 | ICD10CM | Covered |
| C70.1 | ICD10CM | Covered |
| C72.0 | ICD10CM | Covered |
| C72.1 | ICD10CM | Covered |
| C72.21 | ICD10CM | Covered |
| C72.22 | ICD10CM | Covered |
| C72.31 | ICD10CM | Covered |
| C72.32 | ICD10CM | Covered |
| C72.41 | ICD10CM | Covered |
| C72.42 | ICD10CM | Covered |
| C72.59 | ICD10CM | Covered |
| C73 | ICD10CM | Covered |
| C79.31 | ICD10CM | Covered |
| C79.32 | ICD10CM | Covered |
| C79.49 | ICD10CM | Covered |
| D21.0 | ICD10CM | Covered |
| D32.0 | ICD10CM | Covered |
| D32.1 | ICD10CM | Covered |
| D33.0 | ICD10CM | Covered |
| D33.1 | ICD10CM | Covered |
| D33.3 | ICD10CM | Covered |
| D33.4 | ICD10CM | Covered |
| D33.7 | ICD10CM | Covered |
| D42.0 | ICD10CM | Covered |
| D42.1 | ICD10CM | Covered |
| D43.0 | ICD10CM | Covered |
| D43.1 | ICD10CM | Covered |
| D43.3 | ICD10CM | Covered |
| D43.4 | ICD10CM | Covered |
| D43.8 | ICD10CM | Covered |
| D44.3 | ICD10CM | Covered |
| D44.4 | ICD10CM | Covered |
| D44.5 | ICD10CM | Covered |
| D44.6 | ICD10CM | Covered |
| D44.7 | ICD10CM | Covered |
| D49.6 | ICD10CM | Covered |
| E03.5 | ICD10CM | Covered |
| G06.1 | ICD10CM | Covered |
| G11.11 | ICD10CM | Covered |
| G11.19 | ICD10CM | Covered |
| G11.3 | ICD10CM | Covered |
| G11.4 | ICD10CM | Covered |
| G11.8 | ICD10CM | Covered |
| G12.23 | ICD10CM | Covered |
| G12.24 | ICD10CM | Covered |
| G12.25 | ICD10CM | Covered |
| G25.3 | 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 |
| G36.0 | ICD10CM | Covered |
| G37.0 | ICD10CM | Covered |
| G37.3 | ICD10CM | Covered |
| G37.5 | ICD10CM | Covered |
| G40.011 | ICD10CM | Covered |
| G40.019 | ICD10CM | Covered |
| G40.111 | ICD10CM | Covered |
| G40.119 | ICD10CM | Covered |
| G40.211 | ICD10CM | Covered |
| G40.219 | ICD10CM | Covered |
| G45.0 | ICD10CM | Covered |
| G45.1 | ICD10CM | Covered |
| G45.2 | ICD10CM | Covered |
| G45.8 | ICD10CM | Covered |
| G46.0 | ICD10CM | Covered |
| G46.1 | ICD10CM | Covered |
| G46.2 | ICD10CM | Covered |
| G50.0 | ICD10CM | Covered |
| G50.1 | ICD10CM | Covered |
| G53 | ICD10CM | Covered |
| G54.0 | ICD10CM | Covered |
| G54.1 | ICD10CM | Covered |
| G54.2 | ICD10CM | Covered |
| G54.3 | ICD10CM | Covered |
| G54.4 | ICD10CM | Covered |
| G80.4 | ICD10CM | Covered |
| G80.8 | ICD10CM | Covered |
| G93.5 | ICD10CM | Covered |
| G95.0 | ICD10CM | Covered |
| G95.20 | ICD10CM | Covered |
| G95.29 | ICD10CM | Covered |
| G95.9 | ICD10CM | Covered |
| H71.01 | ICD10CM | Covered |
| H71.02 | ICD10CM | Covered |
| H71.03 | ICD10CM | Covered |
| H71.11 | ICD10CM | Covered |
| H71.12 | ICD10CM | Covered |
| H71.13 | ICD10CM | Covered |
| H71.21 | ICD10CM | Covered |
| H71.22 | ICD10CM | Covered |
| H71.23 | ICD10CM | Covered |
| H71.31 | ICD10CM | Covered |
| H71.32 | ICD10CM | Covered |
| H71.33 | ICD10CM | Covered |
| H74.41 | ICD10CM | Covered |
| H74.42 | ICD10CM | Covered |
| H74.43 | ICD10CM | Covered |
| H83.11 | ICD10CM | Covered |
| H83.12 | ICD10CM | Covered |
| H83.13 | ICD10CM | Covered |
| I60.01 | ICD10CM | Covered |
| I60.02 | ICD10CM | Covered |
| I60.11 | ICD10CM | Covered |
| I60.12 | ICD10CM | Covered |
| I60.2 | ICD10CM | Covered |
| I60.31 | ICD10CM | Covered |
| I60.32 | ICD10CM | Covered |
| I60.4 | ICD10CM | Covered |
| I60.51 | ICD10CM | Covered |
| I60.52 | ICD10CM | Covered |
| I60.6 | ICD10CM | Covered |
| I60.8 | ICD10CM | Covered |
| I61.0 | ICD10CM | Covered |
| I61.1 | ICD10CM | Covered |
| I61.3 | ICD10CM | Covered |
| I61.4 | ICD10CM | Covered |
| I61.5 | ICD10CM | Covered |
| I61.6 | ICD10CM | Covered |
| I61.8 | ICD10CM | Covered |
| I62.01 | ICD10CM | Covered |
| I62.02 | ICD10CM | Covered |
| I62.03 | ICD10CM | Covered |
| I62.1 | ICD10CM | Covered |
| I63.00 | ICD10CM | Covered |
| I63.011 | ICD10CM | Covered |
| I63.012 | ICD10CM | Covered |
| I63.013 | ICD10CM | Covered |
| I63.02 | ICD10CM | Covered |
| I63.031 | ICD10CM | Covered |
| I63.032 | ICD10CM | Covered |
| I63.033 | ICD10CM | Covered |
| I63.09 | ICD10CM | Covered |
| I63.10 | ICD10CM | Covered |
| I63.111 | ICD10CM | Covered |
| I63.112 | ICD10CM | Covered |
| I63.113 | ICD10CM | Covered |
| I63.12 | ICD10CM | Covered |
| I63.131 | ICD10CM | Covered |
| I63.132 | ICD10CM | Covered |
| I63.133 | ICD10CM | Covered |
| I63.19 | ICD10CM | Covered |
| I63.20 | ICD10CM | Covered |
| I63.211 | ICD10CM | Covered |
| I63.212 | ICD10CM | Covered |
| I63.213 | ICD10CM | Covered |
| I63.22 | ICD10CM | Covered |
| I63.231 | ICD10CM | Covered |
| I63.232 | ICD10CM | Covered |
| I63.233 | ICD10CM | Covered |
| I63.29 | ICD10CM | Covered |
| I63.311 | ICD10CM | Covered |
| I63.312 | ICD10CM | Covered |
| I63.313 | ICD10CM | Covered |
| I63.321 | ICD10CM | Covered |
| I63.322 | ICD10CM | Covered |
| I63.323 | ICD10CM | Covered |
| I63.331 | ICD10CM | Covered |
| I63.332 | ICD10CM | Covered |
| I63.333 | ICD10CM | Covered |
| I63.341 | ICD10CM | Covered |
| I63.342 | ICD10CM | Covered |
| I63.343 | ICD10CM | Covered |
| I63.39 | ICD10CM | Covered |
| I63.411 | ICD10CM | Covered |
| I63.412 | ICD10CM | Covered |
| I63.413 | ICD10CM | Covered |
| I63.421 | ICD10CM | Covered |
| I63.422 | ICD10CM | Covered |
| I63.423 | ICD10CM | Covered |
| I63.431 | ICD10CM | Covered |
| I63.432 | ICD10CM | Covered |
| I63.433 | ICD10CM | Covered |
| I63.441 | ICD10CM | Covered |
| I63.442 | ICD10CM | Covered |
| I63.443 | ICD10CM | Covered |
| I63.49 | ICD10CM | Covered |
| I63.511 | ICD10CM | Covered |
| I63.512 | ICD10CM | Covered |
| I63.513 | ICD10CM | Covered |
| I63.521 | ICD10CM | Covered |
| I63.522 | ICD10CM | Covered |
| I63.523 | ICD10CM | Covered |
| I63.531 | ICD10CM | Covered |
| I63.532 | ICD10CM | Covered |
| I63.533 | ICD10CM | Covered |
| I63.541 | ICD10CM | Covered |
| I63.542 | ICD10CM | Covered |
| I63.543 | ICD10CM | Covered |
| I63.59 | ICD10CM | Covered |
| I63.6 | ICD10CM | Covered |
| I63.81 | ICD10CM | Covered |
| I63.89 | ICD10CM | Covered |
| I65.01 | ICD10CM | Covered |
| I65.02 | ICD10CM | Covered |
| I65.03 | ICD10CM | Covered |
| I65.1 | ICD10CM | Covered |
| I65.21 | ICD10CM | Covered |
| I65.22 | ICD10CM | Covered |
| I65.23 | ICD10CM | Covered |
| I65.8 | ICD10CM | Covered |
| I65.9 | ICD10CM | Covered |
| I66.01 | ICD10CM | Covered |
| I66.02 | ICD10CM | Covered |
| I66.03 | ICD10CM | Covered |
| I66.11 | ICD10CM | Covered |
| I66.12 | ICD10CM | Covered |
| I66.13 | ICD10CM | Covered |
| I66.21 | ICD10CM | Covered |
| I66.22 | ICD10CM | Covered |
| I66.23 | ICD10CM | Covered |
| I66.3 | ICD10CM | Covered |
| I66.8 | ICD10CM | Covered |
| I67.0 | ICD10CM | Covered |
| I67.1 | ICD10CM | Covered |
| I67.5 | ICD10CM | Covered |
| I67.841 | ICD10CM | Covered |
| I67.848 | ICD10CM | Covered |
| I71.010 | ICD10CM | Covered |
| I71.011 | ICD10CM | Covered |
| I71.012 | ICD10CM | Covered |
| I71.019 | ICD10CM | Covered |
| I71.02 | ICD10CM | Covered |
| I71.03 | ICD10CM | Covered |
| I71.10 | ICD10CM | Covered |
| I71.11 | ICD10CM | Covered |
| I71.12 | ICD10CM | Covered |
| I71.13 | ICD10CM | Covered |
| I71.20 | ICD10CM | Covered |
| I71.21 | ICD10CM | Covered |
| I71.22 | ICD10CM | Covered |
| I71.23 | ICD10CM | Covered |
| I71.30 | ICD10CM | Covered |
| I71.31 | ICD10CM | Covered |
| I71.32 | ICD10CM | Covered |
| I71.33 | ICD10CM | Covered |
| I71.40 | ICD10CM | Covered |
| I71.41 | ICD10CM | Covered |
| I71.42 | ICD10CM | Covered |
| I71.43 | ICD10CM | Covered |
| I71.50 | ICD10CM | Covered |
| I71.51 | ICD10CM | Covered |
| I71.52 | ICD10CM | Covered |
| I71.60 | ICD10CM | Covered |
| I71.61 | ICD10CM | Covered |
| I71.62 | ICD10CM | Covered |
| I71.8 | ICD10CM | Covered |
| I77.71 | ICD10CM | Covered |
| I77.74 | ICD10CM | Covered |
| I77.79 | ICD10CM | Covered |
| I79.0 | ICD10CM | Covered |
| M40.03 | ICD10CM | Covered |
| M40.04 | ICD10CM | Covered |
| M40.05 | ICD10CM | Covered |
| M40.12 | ICD10CM | Covered |
| M40.13 | ICD10CM | Covered |
| M40.14 | ICD10CM | Covered |
| M40.15 | ICD10CM | Covered |
| M40.202 | ICD10CM | Covered |
| M40.203 | ICD10CM | Covered |
| M40.204 | ICD10CM | Covered |
| M40.205 | ICD10CM | Covered |
| M40.292 | ICD10CM | Covered |
| M40.293 | ICD10CM | Covered |
| M40.294 | ICD10CM | Covered |
| M40.295 | ICD10CM | Covered |
| M40.35 | ICD10CM | Covered |
| M40.36 | ICD10CM | Covered |
| M40.37 | ICD10CM | Covered |
| M40.45 | ICD10CM | Covered |
| M40.46 | ICD10CM | Covered |
| M40.47 | ICD10CM | Covered |
| M40.55 | ICD10CM | Covered |
| M40.56 | ICD10CM | Covered |
| M40.57 | ICD10CM | Covered |
| M41.02 | ICD10CM | Covered |
| M41.03 | ICD10CM | Covered |
| M41.04 | ICD10CM | Covered |
| M41.05 | ICD10CM | Covered |
| M41.06 | ICD10CM | Covered |
| M41.07 | ICD10CM | Covered |
| M41.08 | ICD10CM | Covered |
| M41.112 | ICD10CM | Covered |
| M41.113 | ICD10CM | Covered |
| M41.114 | ICD10CM | Covered |
| M41.115 | ICD10CM | Covered |
| M41.116 | ICD10CM | Covered |
| M41.117 | ICD10CM | Covered |
| M41.122 | ICD10CM | Covered |
| M41.123 | ICD10CM | Covered |
| M41.124 | ICD10CM | Covered |
| M41.125 | ICD10CM | Covered |
| M41.126 | ICD10CM | Covered |
| M41.127 | ICD10CM | Covered |
| M41.22 | ICD10CM | Covered |
| M41.23 | ICD10CM | Covered |
| M41.24 | ICD10CM | Covered |
| M41.25 | ICD10CM | Covered |
| M41.26 | ICD10CM | Covered |
| M41.27 | ICD10CM | Covered |
| M41.34 | ICD10CM | Covered |
| M41.35 | ICD10CM | Covered |
| M41.41 | ICD10CM | Covered |
| M41.42 | ICD10CM | Covered |
| M41.43 | ICD10CM | Covered |
| M41.44 | ICD10CM | Covered |
| M41.45 | ICD10CM | Covered |
| M41.46 | ICD10CM | Covered |
| M41.47 | ICD10CM | Covered |
| M41.52 | ICD10CM | Covered |
| M41.53 | ICD10CM | Covered |
| M41.54 | ICD10CM | Covered |
| M41.55 | ICD10CM | Covered |
| M41.56 | ICD10CM | Covered |
| M41.57 | ICD10CM | Covered |
| M41.82 | ICD10CM | Covered |
| M41.83 | ICD10CM | Covered |
| M41.84 | ICD10CM | Covered |
| M41.85 | ICD10CM | Covered |
| M41.86 | ICD10CM | Covered |
| M41.87 | ICD10CM | Covered |
| M43.8X1 | ICD10CM | Covered |
| M43.8X2 | ICD10CM | Covered |
| M43.8X3 | ICD10CM | Covered |
| M43.8X4 | ICD10CM | Covered |
| M43.8X5 | ICD10CM | Covered |
| M43.8X6 | ICD10CM | Covered |
| M43.8X7 | ICD10CM | Covered |
| M43.8X8 | ICD10CM | Covered |
| M43.9 | ICD10CM | Covered |
| M47.011 | ICD10CM | Covered |
| M47.012 | ICD10CM | Covered |
| M47.013 | ICD10CM | Covered |
| M47.014 | ICD10CM | Covered |
| M47.015 | ICD10CM | Covered |
| M47.016 | ICD10CM | Covered |
| M47.021 | ICD10CM | Covered |
| M47.022 | ICD10CM | Covered |
| M47.11 | ICD10CM | Covered |
| M47.12 | ICD10CM | Covered |
| M47.13 | ICD10CM | Covered |
| M47.14 | ICD10CM | Covered |
| M47.15 | ICD10CM | Covered |
| M47.16 | ICD10CM | Covered |
| M47.24 | ICD10CM | Covered |
| M47.25 | ICD10CM | Covered |
| M47.26 | ICD10CM | Covered |
| M47.27 | ICD10CM | Covered |
| M47.28 | ICD10CM | Covered |
| M47.814 | ICD10CM | Covered |
| M47.815 | ICD10CM | Covered |
| M47.816 | ICD10CM | Covered |
| M47.817 | ICD10CM | Covered |
| M47.818 | ICD10CM | Covered |
| M47.894 | ICD10CM | Covered |
| M47.895 | ICD10CM | Covered |
| M47.896 | ICD10CM | Covered |
| M47.897 | ICD10CM | Covered |
| M47.898 | ICD10CM | Covered |
| M48.01 | ICD10CM | Covered |
| M48.02 | ICD10CM | Covered |
| M48.03 | ICD10CM | Covered |
| M48.04 | ICD10CM | Covered |
| M48.05 | ICD10CM | Covered |
| M48.061 | ICD10CM | Covered |
| M48.062 | ICD10CM | Covered |
| M48.07 | ICD10CM | Covered |
| M50.01 | ICD10CM | Covered |
| M50.021 | ICD10CM | Covered |
| M50.022 | ICD10CM | Covered |
| M50.023 | ICD10CM | Covered |
| M50.03 | ICD10CM | Covered |
| M51.04 | ICD10CM | Covered |
| M51.05 | ICD10CM | Covered |
| M51.06 | ICD10CM | Covered |
| M96.2 | ICD10CM | Covered |
| M96.3 | ICD10CM | Covered |
| M96.4 | ICD10CM | Covered |
| M96.5 | ICD10CM | Covered |
| M99.20 | ICD10CM | Covered |
| M99.21 | ICD10CM | Covered |
| M99.22 | ICD10CM | Covered |
| M99.23 | ICD10CM | Covered |
| M99.30 | ICD10CM | Covered |
| M99.31 | ICD10CM | Covered |
| M99.32 | ICD10CM | Covered |
| M99.33 | ICD10CM | Covered |
| M99.40 | ICD10CM | Covered |
| M99.41 | ICD10CM | Covered |
| M99.42 | ICD10CM | Covered |
| M99.43 | ICD10CM | Covered |
| M99.50 | ICD10CM | Covered |
| M99.51 | ICD10CM | Covered |
| M99.52 | ICD10CM | Covered |
| M99.53 | ICD10CM | Covered |
| M99.60 | ICD10CM | Covered |
| M99.61 | ICD10CM | Covered |
| M99.62 | ICD10CM | Covered |
| M99.63 | ICD10CM | Covered |
| M99.70 | ICD10CM | Covered |
| M99.71 | ICD10CM | Covered |
| M99.72 | ICD10CM | Covered |
| M99.73 | ICD10CM | Covered |
| P11.3 | ICD10CM | Covered |
| P11.4 | ICD10CM | Covered |
| P11.5 | ICD10CM | Covered |
| P14.0 | ICD10CM | Covered |
| P14.1 | ICD10CM | Covered |
| P14.2 | ICD10CM | Covered |
| P14.3 | ICD10CM | Covered |
| P14.8 | ICD10CM | Covered |
| P14.9 | ICD10CM | Covered |
| Q05.0 | ICD10CM | Covered |
| Q05.1 | ICD10CM | Covered |
| Q05.2 | ICD10CM | Covered |
| Q05.3 | ICD10CM | Covered |
| Q05.4 | ICD10CM | Covered |
| Q05.5 | ICD10CM | Covered |
| Q05.6 | ICD10CM | Covered |
| Q05.7 | ICD10CM | Covered |
| Q05.8 | ICD10CM | Covered |
| Q07.00 | ICD10CM | Covered |
| Q07.01 | ICD10CM | Covered |
| Q07.02 | ICD10CM | Covered |
| Q07.03 | ICD10CM | Covered |
| Q27.9 | ICD10CM | Covered |
| Q28.2 | ICD10CM | Covered |
| Q28.3 | ICD10CM | Covered |
| Q85.01 | ICD10CM | Covered |
| Q85.02 | ICD10CM | Covered |
| Q85.03 | ICD10CM | Covered |
| Q85.09 | ICD10CM | Covered |
| R20.0 | ICD10CM | Covered |
| R20.1 | ICD10CM | Covered |
| R20.2 | ICD10CM | Covered |
| R20.3 | ICD10CM | Covered |
| R20.8 | ICD10CM | Covered |
| R40.2110 | ICD10CM | Covered |
| R40.2112 | ICD10CM | Covered |
| R40.2113 | ICD10CM | Covered |
| R40.2114 | ICD10CM | Covered |
| R40.2120 | ICD10CM | Covered |
| R40.2122 | ICD10CM | Covered |
| R40.2123 | ICD10CM | Covered |
| R40.2124 | ICD10CM | Covered |
| R40.2210 | ICD10CM | Covered |
| R40.2212 | ICD10CM | Covered |
| R40.2213 | ICD10CM | Covered |
| R40.2214 | ICD10CM | Covered |
| R40.2220 | ICD10CM | Covered |
| R40.2222 | ICD10CM | Covered |
| R40.2223 | ICD10CM | Covered |
| R40.2224 | ICD10CM | Covered |
| R40.2310 | ICD10CM | Covered |
| R40.2312 | ICD10CM | Covered |
| R40.2313 | ICD10CM | Covered |
| R40.2314 | ICD10CM | Covered |
| R40.2320 | ICD10CM | Covered |
| R40.2322 | ICD10CM | Covered |
| R40.2323 | ICD10CM | Covered |
| R40.2324 | ICD10CM | Covered |
| R40.2340 | ICD10CM | Covered |
| R40.2342 | ICD10CM | Covered |
| R40.2343 | ICD10CM | Covered |
| R40.2344 | ICD10CM | Covered |
| R40.2A | ICD10CM | Covered |
| S12.000A | ICD10CM | Covered |
| S12.001A | ICD10CM | Covered |
| S12.100A | ICD10CM | Covered |
| S12.101A | ICD10CM | Covered |
| S12.200A | ICD10CM | Covered |
| S12.201A | ICD10CM | Covered |
| S12.300A | ICD10CM | Covered |
| S12.301A | ICD10CM | Covered |
| S12.400A | ICD10CM | Covered |
| S12.401A | ICD10CM | Covered |
| S12.500A | ICD10CM | Covered |
| S12.501A | ICD10CM | Covered |
| S12.600A | ICD10CM | Covered |
| S12.601A | 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 |
| S14.2XXA | ICD10CM | Covered |
| S14.3XXA | ICD10CM | Covered |
| S22.019A | ICD10CM | Covered |
| S22.029A | ICD10CM | Covered |
| S22.039A | ICD10CM | Covered |
| S22.049A | ICD10CM | Covered |
| S22.059A | ICD10CM | Covered |
| S22.069A | ICD10CM | Covered |
| S22.079A | ICD10CM | Covered |
| S22.089A | 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 |
| S24.2XXA | ICD10CM | Covered |
| S32.019A | ICD10CM | Covered |
| S32.029A | ICD10CM | Covered |
| S32.039A | ICD10CM | Covered |
| S32.049A | ICD10CM | Covered |
| S32.059A | ICD10CM | Covered |
| S32.10XA | ICD10CM | Covered |
| S32.2XXA | ICD10CM | Covered |
| S34.101A | ICD10CM | Covered |
| S34.102A | ICD10CM | Covered |
| S34.103A | ICD10CM | Covered |
| S34.104A | ICD10CM | Covered |
| S34.105A | ICD10CM | Covered |
| S34.111A | ICD10CM | Covered |
| S34.112A | ICD10CM | Covered |
| S34.113A | ICD10CM | Covered |
| S34.114A | ICD10CM | Covered |
| S34.115A | ICD10CM | Covered |
| S34.121A | ICD10CM | Covered |
| S34.122A | ICD10CM | Covered |
| S34.123A | ICD10CM | Covered |
| S34.124A | ICD10CM | Covered |
| S34.125A | ICD10CM | Covered |
| S34.131A | ICD10CM | Covered |
| S34.132A | ICD10CM | Covered |
| S34.139A | ICD10CM | Covered |
| S34.21XA | ICD10CM | Covered |
| S34.22XA | ICD10CM | Covered |
| S34.3XXA | ICD10CM | Covered |
| S34.4XXA | ICD10CM | Covered |
| S44.01XA | ICD10CM | Covered |
| S44.02XA | ICD10CM | Covered |
| S44.11XA | ICD10CM | Covered |
| S44.12XA | ICD10CM | Covered |
| S44.21XA | ICD10CM | Covered |
| S44.22XA | ICD10CM | Covered |
| S44.31XA | ICD10CM | Covered |
| S44.32XA | ICD10CM | Covered |
| S44.41XA | ICD10CM | Covered |
| S44.42XA | ICD10CM | Covered |
| S44.51XA | ICD10CM | Covered |
| S44.52XA | ICD10CM | Covered |
| S44.8X1A | ICD10CM | Covered |
| S44.8X2A | ICD10CM | Covered |
| S44.91XA | ICD10CM | Covered |
| S44.92XA | ICD10CM | Covered |
| S54.01XA | ICD10CM | Covered |
| S54.02XA | ICD10CM | Covered |
| S54.11XA | ICD10CM | Covered |
| S54.12XA | ICD10CM | Covered |
| S54.21XA | ICD10CM | Covered |
| S54.22XA | ICD10CM | Covered |
| S54.31XA | ICD10CM | Covered |
| S54.32XA | ICD10CM | Covered |
| S54.8X1A | ICD10CM | Covered |
| S54.8X2A | ICD10CM | Covered |
| S54.91XA | ICD10CM | Covered |
| S54.92XA | ICD10CM | Covered |
| S64.01XA | ICD10CM | Covered |
| S64.02XA | ICD10CM | Covered |
| S64.11XA | ICD10CM | Covered |
| S64.12XA | ICD10CM | Covered |
| S64.21XA | ICD10CM | Covered |
| S64.22XA | ICD10CM | Covered |
| S64.31XA | ICD10CM | Covered |
| S64.32XA | ICD10CM | Covered |
| S64.490A | ICD10CM | Covered |
| S64.491A | ICD10CM | Covered |
| S64.492A | ICD10CM | Covered |
| S64.493A | ICD10CM | Covered |
| S64.494A | ICD10CM | Covered |
| S64.495A | ICD10CM | Covered |
| S64.496A | ICD10CM | Covered |
| S64.497A | ICD10CM | Covered |
| S64.8X1A | ICD10CM | Covered |
| S64.8X2A | ICD10CM | Covered |
| S64.91XA | ICD10CM | Covered |
| S64.92XA | ICD10CM | Covered |
| S74.01XA | ICD10CM | Covered |
| S74.02XA | ICD10CM | Covered |
| S74.11XA | ICD10CM | Covered |
| S74.12XA | ICD10CM | Covered |
| S74.21XA | ICD10CM | Covered |
| S74.22XA | ICD10CM | Covered |
| S74.8X1A | ICD10CM | Covered |
| S74.8X2A | ICD10CM | Covered |
| S74.91XA | ICD10CM | Covered |
| S74.92XA | ICD10CM | Covered |
| S84.01XA | ICD10CM | Covered |
| S84.02XA | ICD10CM | Covered |
| S84.11XA | ICD10CM | Covered |
| S84.12XA | ICD10CM | Covered |
| S84.21XA | ICD10CM | Covered |
| S84.22XA | ICD10CM | Covered |
| S84.801A | ICD10CM | Covered |
| S84.802A | ICD10CM | Covered |
| S84.91XA | ICD10CM | Covered |
| S84.92XA | ICD10CM | Covered |
| S94.01XA | ICD10CM | Covered |
| S94.02XA | ICD10CM | Covered |
| S94.11XA | ICD10CM | Covered |
| S94.12XA | ICD10CM | Covered |
| S94.21XA | ICD10CM | Covered |
| S94.22XA | ICD10CM | Covered |
| S94.31XA | ICD10CM | Covered |
| S94.32XA | ICD10CM | Covered |
| S94.8X1A | ICD10CM | Covered |
| S94.8X2A | ICD10CM | Covered |
| S94.91XA | ICD10CM | Covered |
| S94.92XA | ICD10CM | Covered |