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 |
|---|---|---|
| 92132 | HCPCS | Covered |
| 92133 | HCPCS | Covered |
| 92134 | HCPCS | Covered |
| 92137 | HCPCS | Covered |
| A18.53 | ICD10CM | Covered |
| B39.4 | ICD10CM | Covered |
| C69.01 | ICD10CM | Covered |
| C69.02 | ICD10CM | Covered |
| C69.11 | ICD10CM | Covered |
| C69.12 | ICD10CM | Covered |
| C69.21 | ICD10CM | Covered |
| C69.22 | ICD10CM | Covered |
| C69.31 | ICD10CM | Covered |
| C69.32 | ICD10CM | Covered |
| C69.41 | ICD10CM | Covered |
| C69.42 | ICD10CM | Covered |
| D31.31 | ICD10CM | Covered |
| D31.32 | 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 |
| E08.37X1 | ICD10CM | Covered |
| E08.37X2 | ICD10CM | Covered |
| E08.37X3 | 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 |
| E09.37X1 | ICD10CM | Covered |
| E09.37X2 | ICD10CM | Covered |
| E09.37X3 | 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 |
| E10.37X1 | ICD10CM | Covered |
| E10.37X2 | ICD10CM | Covered |
| E10.37X3 | 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 |
| E11.37X1 | ICD10CM | Covered |
| E11.37X2 | ICD10CM | Covered |
| E11.37X3 | 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 |
| E13.37X1 | ICD10CM | Covered |
| E13.37X2 | ICD10CM | Covered |
| E13.37X3 | ICD10CM | Covered |
| G45.3 | ICD10CM | Covered |
| H17.01 | ICD10CM | Covered |
| H17.02 | ICD10CM | Covered |
| H17.03 | ICD10CM | Covered |
| H17.11 | ICD10CM | Covered |
| H17.12 | ICD10CM | Covered |
| H17.13 | ICD10CM | Covered |
| H17.811 | ICD10CM | Covered |
| H17.812 | ICD10CM | Covered |
| H17.813 | ICD10CM | Covered |
| H17.821 | ICD10CM | Covered |
| H17.822 | ICD10CM | Covered |
| H17.823 | ICD10CM | Covered |
| H17.89 | ICD10CM | Covered |
| H18.20 | ICD10CM | Covered |
| H18.211 | ICD10CM | Covered |
| H18.212 | ICD10CM | Covered |
| H18.213 | ICD10CM | Covered |
| H18.221 | ICD10CM | Covered |
| H18.222 | ICD10CM | Covered |
| H18.223 | ICD10CM | Covered |
| H18.231 | ICD10CM | Covered |
| H18.232 | ICD10CM | Covered |
| H18.233 | ICD10CM | Covered |
| H21.221 | ICD10CM | Covered |
| H21.222 | ICD10CM | Covered |
| H21.223 | ICD10CM | Covered |
| H21.231 | ICD10CM | Covered |
| H21.232 | ICD10CM | Covered |
| H21.233 | ICD10CM | Covered |
| H21.271 | ICD10CM | Covered |
| H21.272 | ICD10CM | Covered |
| H21.273 | ICD10CM | Covered |
| H21.301 | ICD10CM | Covered |
| H21.302 | ICD10CM | Covered |
| H21.303 | ICD10CM | Covered |
| H21.311 | ICD10CM | Covered |
| H21.312 | ICD10CM | Covered |
| H21.313 | ICD10CM | Covered |
| H21.321 | ICD10CM | Covered |
| H21.322 | ICD10CM | Covered |
| H21.323 | ICD10CM | Covered |
| H21.89 | ICD10CM | Covered |
| H30.011 | ICD10CM | Covered |
| H30.012 | ICD10CM | Covered |
| H30.013 | ICD10CM | Covered |
| H30.021 | ICD10CM | Covered |
| H30.022 | ICD10CM | Covered |
| H30.023 | ICD10CM | Covered |
| H30.031 | ICD10CM | Covered |
| H30.032 | ICD10CM | Covered |
| H30.033 | ICD10CM | Covered |
| H30.041 | ICD10CM | Covered |
| H30.042 | ICD10CM | Covered |
| H30.043 | ICD10CM | Covered |
| H30.111 | ICD10CM | Covered |
| H30.112 | ICD10CM | Covered |
| H30.113 | ICD10CM | Covered |
| H30.121 | ICD10CM | Covered |
| H30.122 | ICD10CM | Covered |
| H30.123 | ICD10CM | Covered |
| H30.131 | ICD10CM | Covered |
| H30.132 | ICD10CM | Covered |
| H30.133 | ICD10CM | Covered |
| H30.141 | ICD10CM | Covered |
| H30.142 | ICD10CM | Covered |
| H30.143 | ICD10CM | Covered |
| H30.21 | ICD10CM | Covered |
| H30.22 | ICD10CM | Covered |
| H30.23 | ICD10CM | Covered |
| H30.811 | ICD10CM | Covered |
| H30.812 | ICD10CM | Covered |
| H30.813 | ICD10CM | Covered |
| H30.891 | ICD10CM | Covered |
| H30.892 | ICD10CM | Covered |
| H30.893 | ICD10CM | Covered |
| H31.021 | ICD10CM | Covered |
| H31.022 | ICD10CM | Covered |
| H31.023 | ICD10CM | Covered |
| H31.101 | ICD10CM | Covered |
| H31.102 | ICD10CM | Covered |
| H31.103 | ICD10CM | Covered |
| H31.111 | ICD10CM | Covered |
| H31.112 | ICD10CM | Covered |
| H31.113 | ICD10CM | Covered |
| H31.121 | ICD10CM | Covered |
| H31.122 | ICD10CM | Covered |
| H31.123 | ICD10CM | Covered |
| H31.21 | ICD10CM | Covered |
| H31.22 | ICD10CM | Covered |
| H31.23 | ICD10CM | Covered |
| H31.29 | ICD10CM | Covered |
| H31.411 | ICD10CM | Covered |
| H31.412 | ICD10CM | Covered |
| H31.413 | ICD10CM | Covered |
| H31.421 | ICD10CM | Covered |
| H31.422 | ICD10CM | Covered |
| H31.423 | ICD10CM | Covered |
| H32 | ICD10CM | Covered |
| H33.011 | ICD10CM | Covered |
| H33.012 | ICD10CM | Covered |
| H33.013 | ICD10CM | Covered |
| H33.021 | ICD10CM | Covered |
| H33.022 | ICD10CM | Covered |
| H33.023 | ICD10CM | Covered |
| H33.031 | ICD10CM | Covered |
| H33.032 | ICD10CM | Covered |
| H33.033 | ICD10CM | Covered |
| H33.041 | ICD10CM | Covered |
| H33.042 | ICD10CM | Covered |
| H33.043 | ICD10CM | Covered |
| H33.051 | ICD10CM | Covered |
| H33.052 | ICD10CM | Covered |
| H33.053 | ICD10CM | Covered |
| H33.111 | ICD10CM | Covered |
| H33.112 | ICD10CM | Covered |
| H33.113 | ICD10CM | Covered |
| H33.191 | ICD10CM | Covered |
| H33.192 | ICD10CM | Covered |
| H33.193 | ICD10CM | Covered |
| H33.21 | ICD10CM | Covered |
| H33.22 | ICD10CM | Covered |
| H33.23 | ICD10CM | Covered |
| H33.311 | ICD10CM | Covered |
| H33.312 | ICD10CM | Covered |
| H33.313 | ICD10CM | Covered |
| H33.321 | ICD10CM | Covered |
| H33.322 | ICD10CM | Covered |
| H33.323 | ICD10CM | Covered |
| H33.331 | ICD10CM | Covered |
| H33.332 | ICD10CM | Covered |
| H33.333 | ICD10CM | Covered |
| H33.41 | ICD10CM | Covered |
| H33.42 | ICD10CM | Covered |
| H33.43 | ICD10CM | Covered |
| H33.8 | ICD10CM | Covered |
| H34.01 | ICD10CM | Covered |
| H34.02 | ICD10CM | Covered |
| H34.03 | ICD10CM | Covered |
| H34.11 | ICD10CM | Covered |
| H34.12 | ICD10CM | Covered |
| H34.13 | ICD10CM | Covered |
| H34.211 | ICD10CM | Covered |
| H34.212 | ICD10CM | Covered |
| H34.213 | ICD10CM | Covered |
| H34.231 | ICD10CM | Covered |
| H34.232 | ICD10CM | Covered |
| H34.233 | ICD10CM | Covered |
| H34.8110 | ICD10CM | Covered |
| H34.8111 | ICD10CM | Covered |
| H34.8112 | ICD10CM | Covered |
| H34.8120 | ICD10CM | Covered |
| H34.8121 | ICD10CM | Covered |
| H34.8122 | ICD10CM | Covered |
| H34.8130 | ICD10CM | Covered |
| H34.8131 | ICD10CM | Covered |
| H34.8132 | ICD10CM | Covered |
| H34.821 | ICD10CM | Covered |
| H34.822 | ICD10CM | Covered |
| H34.823 | ICD10CM | Covered |
| H34.8310 | ICD10CM | Covered |
| H34.8311 | ICD10CM | Covered |
| H34.8312 | ICD10CM | Covered |
| H34.8320 | ICD10CM | Covered |
| H34.8321 | ICD10CM | Covered |
| H34.8322 | ICD10CM | Covered |
| H34.8330 | ICD10CM | Covered |
| H34.8331 | ICD10CM | Covered |
| H34.8332 | ICD10CM | Covered |
| H35.011 | ICD10CM | Covered |
| H35.012 | ICD10CM | Covered |
| H35.013 | ICD10CM | Covered |
| H35.021 | ICD10CM | Covered |
| H35.022 | ICD10CM | Covered |
| H35.023 | ICD10CM | Covered |
| H35.031 | ICD10CM | Covered |
| H35.032 | ICD10CM | Covered |
| H35.033 | ICD10CM | Covered |
| H35.041 | ICD10CM | Covered |
| H35.042 | ICD10CM | Covered |
| H35.043 | ICD10CM | Covered |
| H35.051 | ICD10CM | Covered |
| H35.052 | ICD10CM | Covered |
| H35.053 | ICD10CM | Covered |
| H35.061 | ICD10CM | Covered |
| H35.062 | ICD10CM | Covered |
| H35.063 | ICD10CM | Covered |
| H35.071 | ICD10CM | Covered |
| H35.072 | ICD10CM | Covered |
| H35.073 | ICD10CM | Covered |
| H35.09 | ICD10CM | Covered |
| H35.171 | ICD10CM | Covered |
| H35.172 | ICD10CM | Covered |
| H35.173 | ICD10CM | Covered |
| H35.21 | ICD10CM | Covered |
| H35.22 | ICD10CM | Covered |
| H35.23 | ICD10CM | Covered |
| H35.3110 | ICD10CM | Covered |
| H35.3111 | ICD10CM | Covered |
| H35.3112 | ICD10CM | Covered |
| H35.3113 | ICD10CM | Covered |
| H35.3114 | ICD10CM | Covered |
| H35.3120 | ICD10CM | Covered |
| H35.3121 | ICD10CM | Covered |
| H35.3122 | ICD10CM | Covered |
| H35.3123 | ICD10CM | Covered |
| H35.3124 | ICD10CM | Covered |
| H35.3130 | ICD10CM | Covered |
| H35.3131 | ICD10CM | Covered |
| H35.3132 | ICD10CM | Covered |
| H35.3133 | ICD10CM | Covered |
| H35.3134 | ICD10CM | Covered |
| H35.3210 | ICD10CM | Covered |
| H35.3211 | ICD10CM | Covered |
| H35.3212 | ICD10CM | Covered |
| H35.3213 | ICD10CM | Covered |
| H35.3220 | ICD10CM | Covered |
| H35.3221 | ICD10CM | Covered |
| H35.3222 | ICD10CM | Covered |
| H35.3223 | ICD10CM | Covered |
| H35.3230 | ICD10CM | Covered |
| H35.3231 | ICD10CM | Covered |
| H35.3232 | ICD10CM | Covered |
| H35.3233 | ICD10CM | Covered |
| H35.33 | ICD10CM | Covered |
| H35.341 | ICD10CM | Covered |
| H35.342 | ICD10CM | Covered |
| H35.343 | ICD10CM | Covered |
| H35.351 | ICD10CM | Covered |
| H35.352 | ICD10CM | Covered |
| H35.353 | ICD10CM | Covered |
| H35.361 | ICD10CM | Covered |
| H35.362 | ICD10CM | Covered |
| H35.363 | ICD10CM | Covered |
| H35.371 | ICD10CM | Covered |
| H35.372 | ICD10CM | Covered |
| H35.373 | ICD10CM | Covered |
| H35.381 | ICD10CM | Covered |
| H35.382 | ICD10CM | Covered |
| H35.383 | ICD10CM | Covered |
| H35.40 | ICD10CM | Covered |
| H35.411 | ICD10CM | Covered |
| H35.412 | ICD10CM | Covered |
| H35.413 | ICD10CM | Covered |
| H35.421 | ICD10CM | Covered |
| H35.422 | ICD10CM | Covered |
| H35.423 | ICD10CM | Covered |
| H35.431 | ICD10CM | Covered |
| H35.432 | ICD10CM | Covered |
| H35.433 | ICD10CM | Covered |
| H35.441 | ICD10CM | Covered |
| H35.442 | ICD10CM | Covered |
| H35.443 | ICD10CM | Covered |
| H35.451 | ICD10CM | Covered |
| H35.452 | ICD10CM | Covered |
| H35.453 | ICD10CM | Covered |
| H35.461 | ICD10CM | Covered |
| H35.462 | ICD10CM | Covered |
| H35.463 | ICD10CM | Covered |
| H35.50 | ICD10CM | Covered |
| H35.51 | ICD10CM | Covered |
| H35.52 | ICD10CM | Covered |
| H35.53 | ICD10CM | Covered |
| H35.54 | ICD10CM | Covered |
| H35.61 | ICD10CM | Covered |
| H35.62 | ICD10CM | Covered |
| H35.63 | ICD10CM | Covered |
| H35.70 | ICD10CM | Covered |
| H35.711 | ICD10CM | Covered |
| H35.712 | ICD10CM | Covered |
| H35.713 | ICD10CM | Covered |
| H35.721 | ICD10CM | Covered |
| H35.722 | ICD10CM | Covered |
| H35.723 | ICD10CM | Covered |
| H35.731 | ICD10CM | Covered |
| H35.732 | ICD10CM | Covered |
| H35.733 | ICD10CM | Covered |
| H35.81 | ICD10CM | Covered |
| H35.82 | ICD10CM | Covered |
| H35.89 | ICD10CM | Covered |
| H40.011 | ICD10CM | Covered |
| H40.012 | ICD10CM | Covered |
| H40.013 | ICD10CM | Covered |
| H40.021 | ICD10CM | Covered |
| H40.022 | ICD10CM | Covered |
| H40.023 | ICD10CM | Covered |
| H40.031 | ICD10CM | Covered |
| H40.032 | ICD10CM | Covered |
| H40.033 | ICD10CM | Covered |
| H40.041 | ICD10CM | Covered |
| H40.042 | ICD10CM | Covered |
| H40.043 | ICD10CM | Covered |
| H40.051 | ICD10CM | Covered |
| H40.052 | ICD10CM | Covered |
| H40.053 | ICD10CM | Covered |
| H40.061 | ICD10CM | Covered |
| H40.062 | ICD10CM | Covered |
| H40.063 | ICD10CM | Covered |
| H40.1111 | ICD10CM | Covered |
| H40.1112 | ICD10CM | Covered |
| H40.1113 | ICD10CM | Covered |
| H40.1114 | ICD10CM | Covered |
| H40.1121 | ICD10CM | Covered |
| H40.1122 | ICD10CM | Covered |
| H40.1123 | ICD10CM | Covered |
| H40.1124 | ICD10CM | Covered |
| H40.1131 | ICD10CM | Covered |
| H40.1132 | ICD10CM | Covered |
| H40.1133 | ICD10CM | Covered |
| H40.1134 | ICD10CM | Covered |
| H40.1211 | ICD10CM | Covered |
| H40.1212 | ICD10CM | Covered |
| H40.1213 | ICD10CM | Covered |
| H40.1214 | ICD10CM | Covered |
| H40.1221 | ICD10CM | Covered |
| H40.1222 | ICD10CM | Covered |
| H40.1223 | ICD10CM | Covered |
| H40.1224 | ICD10CM | Covered |
| H40.1231 | ICD10CM | Covered |
| H40.1232 | ICD10CM | Covered |
| H40.1233 | ICD10CM | Covered |
| H40.1234 | ICD10CM | Covered |
| H40.1311 | ICD10CM | Covered |
| H40.1312 | ICD10CM | Covered |
| H40.1313 | ICD10CM | Covered |
| H40.1314 | ICD10CM | Covered |
| H40.1321 | ICD10CM | Covered |
| H40.1322 | ICD10CM | Covered |
| H40.1323 | ICD10CM | Covered |
| H40.1324 | ICD10CM | Covered |
| H40.1331 | ICD10CM | Covered |
| H40.1332 | ICD10CM | Covered |
| H40.1333 | ICD10CM | Covered |
| H40.1334 | ICD10CM | Covered |
| H40.1411 | ICD10CM | Covered |
| H40.1412 | ICD10CM | Covered |
| H40.1413 | ICD10CM | Covered |
| H40.1414 | ICD10CM | Covered |
| H40.1421 | ICD10CM | Covered |
| H40.1422 | ICD10CM | Covered |
| H40.1423 | ICD10CM | Covered |
| H40.1424 | ICD10CM | Covered |
| H40.1431 | ICD10CM | Covered |
| H40.1432 | ICD10CM | Covered |
| H40.1433 | ICD10CM | Covered |
| H40.1434 | ICD10CM | Covered |
| H40.211 | ICD10CM | Covered |
| H40.212 | ICD10CM | Covered |
| H40.213 | ICD10CM | Covered |
| H40.2211 | ICD10CM | Covered |
| H40.2212 | ICD10CM | Covered |
| H40.2213 | ICD10CM | Covered |
| H40.2214 | ICD10CM | Covered |
| H40.2221 | ICD10CM | Covered |
| H40.2222 | ICD10CM | Covered |
| H40.2223 | ICD10CM | Covered |
| H40.2224 | ICD10CM | Covered |
| H40.2231 | ICD10CM | Covered |
| H40.2232 | ICD10CM | Covered |
| H40.2233 | ICD10CM | Covered |
| H40.2234 | ICD10CM | Covered |
| H40.231 | ICD10CM | Covered |
| H40.232 | ICD10CM | Covered |
| H40.233 | ICD10CM | Covered |
| H40.241 | ICD10CM | Covered |
| H40.242 | ICD10CM | Covered |
| H40.243 | ICD10CM | Covered |
| H40.31X1 | ICD10CM | Covered |
| H40.31X2 | ICD10CM | Covered |
| H40.31X3 | ICD10CM | Covered |
| H40.31X4 | ICD10CM | Covered |
| H40.32X1 | ICD10CM | Covered |
| H40.32X2 | ICD10CM | Covered |
| H40.32X3 | ICD10CM | Covered |
| H40.32X4 | ICD10CM | Covered |
| H40.33X1 | ICD10CM | Covered |
| H40.33X2 | ICD10CM | Covered |
| H40.33X3 | ICD10CM | Covered |
| H40.33X4 | ICD10CM | Covered |
| H40.41X1 | ICD10CM | Covered |
| H40.41X2 | ICD10CM | Covered |
| H40.41X3 | ICD10CM | Covered |
| H40.41X4 | ICD10CM | Covered |
| H40.42X1 | ICD10CM | Covered |
| H40.42X2 | ICD10CM | Covered |
| H40.42X3 | ICD10CM | Covered |
| H40.42X4 | ICD10CM | Covered |
| H40.43X1 | ICD10CM | Covered |
| H40.43X2 | ICD10CM | Covered |
| H40.43X3 | ICD10CM | Covered |
| H40.43X4 | ICD10CM | Covered |
| H40.51X1 | ICD10CM | Covered |
| H40.51X2 | ICD10CM | Covered |
| H40.51X3 | ICD10CM | Covered |
| H40.51X4 | ICD10CM | Covered |
| H40.52X1 | ICD10CM | Covered |
| H40.52X2 | ICD10CM | Covered |
| H40.52X3 | ICD10CM | Covered |
| H40.52X4 | ICD10CM | Covered |
| H40.53X1 | ICD10CM | Covered |
| H40.53X2 | ICD10CM | Covered |
| H40.53X3 | ICD10CM | Covered |
| H40.53X4 | ICD10CM | Covered |
| H40.61X1 | ICD10CM | Covered |
| H40.61X2 | ICD10CM | Covered |
| H40.61X3 | ICD10CM | Covered |
| H40.61X4 | ICD10CM | Covered |
| H40.62X1 | ICD10CM | Covered |
| H40.62X2 | ICD10CM | Covered |
| H40.62X3 | ICD10CM | Covered |
| H40.62X4 | ICD10CM | Covered |
| H40.63X1 | ICD10CM | Covered |
| H40.63X2 | ICD10CM | Covered |
| H40.63X3 | ICD10CM | Covered |
| H40.63X4 | ICD10CM | Covered |
| H40.811 | ICD10CM | Covered |
| H40.812 | ICD10CM | Covered |
| H40.813 | ICD10CM | Covered |
| H40.821 | ICD10CM | Covered |
| H40.822 | ICD10CM | Covered |
| H40.823 | ICD10CM | Covered |
| H40.831 | ICD10CM | Covered |
| H40.832 | ICD10CM | Covered |
| H40.833 | ICD10CM | Covered |
| H40.841 | ICD10CM | Covered |
| H40.842 | ICD10CM | Covered |
| H40.843 | ICD10CM | Covered |
| H40.89 | ICD10CM | Covered |
| H43.811 | ICD10CM | Covered |
| H43.812 | ICD10CM | Covered |
| H43.813 | ICD10CM | Covered |
| H43.821 | ICD10CM | Covered |
| H43.822 | ICD10CM | Covered |
| H43.823 | ICD10CM | Covered |
| H44.2A1 | ICD10CM | Covered |
| H44.2A2 | ICD10CM | Covered |
| H44.2A3 | ICD10CM | Covered |
| H44.2B1 | ICD10CM | Covered |
| H44.2B2 | ICD10CM | Covered |
| H44.2B3 | ICD10CM | Covered |
| H44.2C1 | ICD10CM | Covered |
| H44.2C2 | ICD10CM | Covered |
| H44.2C3 | ICD10CM | Covered |
| H44.2D1 | ICD10CM | Covered |
| H44.2D2 | ICD10CM | Covered |
| H44.2D3 | ICD10CM | Covered |
| H44.2E1 | ICD10CM | Covered |
| H44.2E2 | ICD10CM | Covered |
| H44.2E3 | ICD10CM | Covered |
| H46.01 | ICD10CM | Covered |
| H46.02 | ICD10CM | Covered |
| H46.03 | ICD10CM | Covered |
| H46.11 | ICD10CM | Covered |
| H46.12 | ICD10CM | Covered |
| H46.13 | ICD10CM | Covered |
| H46.8 | ICD10CM | Covered |
| H47.011 | ICD10CM | Covered |
| H47.012 | ICD10CM | Covered |
| H47.013 | ICD10CM | Covered |
| H47.031 | ICD10CM | Covered |
| H47.032 | ICD10CM | Covered |
| H47.033 | ICD10CM | Covered |
| H47.11 | ICD10CM | Covered |
| H47.12 | ICD10CM | Covered |
| H47.13 | ICD10CM | Covered |
| H47.141 | ICD10CM | Covered |
| H47.142 | ICD10CM | Covered |
| H47.143 | ICD10CM | Covered |
| H47.211 | ICD10CM | Covered |
| H47.212 | ICD10CM | Covered |
| H47.213 | ICD10CM | Covered |
| H47.231 | ICD10CM | Covered |
| H47.232 | ICD10CM | Covered |
| H47.233 | ICD10CM | Covered |
| H47.291 | ICD10CM | Covered |
| H47.292 | ICD10CM | Covered |
| H47.293 | ICD10CM | Covered |
| H47.321 | ICD10CM | Covered |
| H47.322 | ICD10CM | Covered |
| H47.323 | ICD10CM | Covered |
| H47.331 | ICD10CM | Covered |
| H47.332 | ICD10CM | Covered |
| H47.333 | ICD10CM | Covered |
| H47.391 | ICD10CM | Covered |
| H47.392 | ICD10CM | Covered |
| H47.393 | ICD10CM | Covered |
| H53.15 | ICD10CM | Covered |
| H53.411 | ICD10CM | Covered |
| H53.412 | ICD10CM | Covered |
| H53.413 | ICD10CM | Covered |
| H53.421 | ICD10CM | Covered |
| H53.422 | ICD10CM | Covered |
| H53.423 | ICD10CM | Covered |
| H53.431 | ICD10CM | Covered |
| H53.432 | ICD10CM | Covered |
| H53.433 | ICD10CM | Covered |
| H53.451 | ICD10CM | Covered |
| H53.452 | ICD10CM | Covered |
| H53.453 | ICD10CM | Covered |
| H53.481 | ICD10CM | Covered |
| H53.482 | ICD10CM | Covered |
| H53.483 | ICD10CM | Covered |
| H59.031 | ICD10CM | Covered |
| H59.032 | ICD10CM | Covered |
| H59.033 | ICD10CM | Covered |
| Q15.0 | ICD10CM | Covered |
| T86.8401 | ICD10CM | Covered |
| T86.8402 | ICD10CM | Covered |
| T86.8403 | ICD10CM | Covered |
| T86.8411 | ICD10CM | Covered |
| T86.8412 | ICD10CM | Covered |
| T86.8413 | ICD10CM | Covered |
| T86.8421 | ICD10CM | Covered |
| T86.8422 | ICD10CM | Covered |
| T86.8423 | ICD10CM | Covered |
| Z79.899 | ICD10CM | Covered |