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 1,277 codes. The source has the full list.
| Code | Code system | Status in this policy |
|---|---|---|
| 11000 | HCPCS | Covered |
| 11001 | HCPCS | Covered |
| 11004 | HCPCS | Covered |
| 11005 | HCPCS | Covered |
| 11006 | HCPCS | Covered |
| 11008 | HCPCS | Covered |
| 11010 | HCPCS | Covered |
| 11011 | HCPCS | Covered |
| 11012 | HCPCS | Covered |
| 11042 | HCPCS | Covered |
| 11043 | HCPCS | Covered |
| 11044 | HCPCS | Covered |
| 11045 | HCPCS | Covered |
| 11046 | HCPCS | Covered |
| 11047 | HCPCS | Covered |
| 11055 | HCPCS | Covered |
| 11056 | HCPCS | Covered |
| 11057 | HCPCS | Covered |
| 29445 | HCPCS | Covered |
| 29580 | HCPCS | Covered |
| 29581 | HCPCS | Covered |
| 97597 | HCPCS | Covered |
| 97598 | HCPCS | Covered |
| 97602 | HCPCS | Covered |
| 97605 | HCPCS | Covered |
| 97606 | HCPCS | Covered |
| 97607 | HCPCS | Covered |
| 97608 | HCPCS | Covered |
| 97610 | HCPCS | Covered |
| E10.620 | ICD10CM | Covered |
| E10.621 | ICD10CM | Covered |
| E10.622 | ICD10CM | Covered |
| E10.628 | ICD10CM | Covered |
| E10.65 | ICD10CM | Covered |
| E10.69 | ICD10CM | Covered |
| E11.620 | ICD10CM | Covered |
| E11.621 | ICD10CM | Covered |
| E11.622 | ICD10CM | Covered |
| E11.628 | ICD10CM | Covered |
| E11.65 | ICD10CM | Covered |
| E11.69 | ICD10CM | Covered |
| E75.21 | ICD10CM | Covered |
| G60.0 | ICD10CM | Covered |
| G60.1 | ICD10CM | Covered |
| G60.2 | ICD10CM | Covered |
| G60.3 | ICD10CM | Covered |
| G60.8 | ICD10CM | Covered |
| I70.231 | ICD10CM | Covered |
| I70.232 | ICD10CM | Covered |
| I70.233 | ICD10CM | Covered |
| I70.234 | ICD10CM | Covered |
| I70.235 | ICD10CM | Covered |
| I70.238 | ICD10CM | Covered |
| I70.239 | ICD10CM | Covered |
| I70.241 | ICD10CM | Covered |
| I70.242 | ICD10CM | Covered |
| I70.243 | ICD10CM | Covered |
| I70.244 | ICD10CM | Covered |
| I70.245 | ICD10CM | Covered |
| I70.248 | ICD10CM | Covered |
| I70.249 | ICD10CM | Covered |
| I70.25 | ICD10CM | Covered |
| I70.261 | ICD10CM | Covered |
| I70.262 | ICD10CM | Covered |
| I70.263 | ICD10CM | Covered |
| I70.268 | ICD10CM | Covered |
| I70.269 | ICD10CM | Covered |
| I83.011 | ICD10CM | Covered |
| I83.012 | ICD10CM | Covered |
| I83.013 | ICD10CM | Covered |
| I83.014 | ICD10CM | Covered |
| I83.015 | ICD10CM | Covered |
| I83.018 | ICD10CM | Covered |
| I83.021 | ICD10CM | Covered |
| I83.022 | ICD10CM | Covered |
| I83.023 | ICD10CM | Covered |
| I83.024 | ICD10CM | Covered |
| I83.025 | ICD10CM | Covered |
| I83.028 | ICD10CM | Covered |
| I83.211 | ICD10CM | Covered |
| I83.212 | ICD10CM | Covered |
| I83.213 | ICD10CM | Covered |
| I83.214 | ICD10CM | Covered |
| I83.215 | ICD10CM | Covered |
| I83.218 | ICD10CM | Covered |
| I83.221 | ICD10CM | Covered |
| I83.222 | ICD10CM | Covered |
| I83.223 | ICD10CM | Covered |
| I83.224 | ICD10CM | Covered |
| I83.225 | ICD10CM | Covered |
| I83.228 | ICD10CM | Covered |
| I87.011 | ICD10CM | Covered |
| I87.012 | ICD10CM | Covered |
| I87.013 | ICD10CM | Covered |
| I87.031 | ICD10CM | Covered |
| I87.032 | ICD10CM | Covered |
| I87.033 | ICD10CM | Covered |
| I87.311 | ICD10CM | Covered |
| I87.312 | ICD10CM | Covered |
| I87.313 | ICD10CM | Covered |
| I87.331 | ICD10CM | Covered |
| I87.332 | ICD10CM | Covered |
| I87.333 | ICD10CM | Covered |
| I96 | ICD10CM | Covered |
| K12.2 | ICD10CM | Covered |
| K62.6 | ICD10CM | Covered |
| L03.011 | ICD10CM | Covered |
| L03.012 | ICD10CM | Covered |
| L03.031 | ICD10CM | Covered |
| L03.032 | ICD10CM | Covered |
| L03.111 | ICD10CM | Covered |
| L03.112 | ICD10CM | Covered |
| L03.113 | ICD10CM | Covered |
| L03.114 | ICD10CM | Covered |
| L03.115 | ICD10CM | Covered |
| L03.116 | ICD10CM | Covered |
| L03.211 | ICD10CM | Covered |
| L03.221 | ICD10CM | Covered |
| L03.222 | ICD10CM | Covered |
| L03.311 | ICD10CM | Covered |
| L03.312 | ICD10CM | Covered |
| L03.313 | ICD10CM | Covered |
| L03.314 | ICD10CM | Covered |
| L03.315 | ICD10CM | Covered |
| L03.316 | ICD10CM | Covered |
| L03.317 | ICD10CM | Covered |
| L03.811 | ICD10CM | Covered |
| L05.01 | ICD10CM | Covered |
| L08.0 | ICD10CM | Covered |
| L08.89 | ICD10CM | Covered |
| L11.0 | ICD10CM | Covered |
| L12.0 | ICD10CM | Covered |
| L59.8 | ICD10CM | Covered |
| L73.8 | ICD10CM | Covered |
| L84 | ICD10CM | Covered |
| L85.0 | ICD10CM | Covered |
| L85.1 | ICD10CM | Covered |
| L85.2 | ICD10CM | Covered |
| L85.8 | ICD10CM | Covered |
| L86 | ICD10CM | Covered |
| L87.0 | ICD10CM | Covered |
| L87.2 | ICD10CM | Covered |
| L89.012 | ICD10CM | Covered |
| L89.013 | ICD10CM | Covered |
| L89.014 | ICD10CM | Covered |
| L89.016 | ICD10CM | Covered |
| L89.022 | ICD10CM | Covered |
| L89.023 | ICD10CM | Covered |
| L89.024 | ICD10CM | Covered |
| L89.026 | ICD10CM | Covered |
| L89.112 | ICD10CM | Covered |
| L89.113 | ICD10CM | Covered |
| L89.114 | ICD10CM | Covered |
| L89.116 | ICD10CM | Covered |
| L89.122 | ICD10CM | Covered |
| L89.123 | ICD10CM | Covered |
| L89.124 | ICD10CM | Covered |
| L89.126 | ICD10CM | Covered |
| L89.132 | ICD10CM | Covered |
| L89.133 | ICD10CM | Covered |
| L89.134 | ICD10CM | Covered |
| L89.136 | ICD10CM | Covered |
| L89.142 | ICD10CM | Covered |
| L89.143 | ICD10CM | Covered |
| L89.144 | ICD10CM | Covered |
| L89.146 | ICD10CM | Covered |
| L89.152 | ICD10CM | Covered |
| L89.153 | ICD10CM | Covered |
| L89.154 | ICD10CM | Covered |
| L89.156 | ICD10CM | Covered |
| L89.212 | ICD10CM | Covered |
| L89.213 | ICD10CM | Covered |
| L89.214 | ICD10CM | Covered |
| L89.216 | ICD10CM | Covered |
| L89.222 | ICD10CM | Covered |
| L89.223 | ICD10CM | Covered |
| L89.224 | ICD10CM | Covered |
| L89.226 | ICD10CM | Covered |
| L89.312 | ICD10CM | Covered |
| L89.313 | ICD10CM | Covered |
| L89.314 | ICD10CM | Covered |
| L89.316 | ICD10CM | Covered |
| L89.322 | ICD10CM | Covered |
| L89.323 | ICD10CM | Covered |
| L89.324 | ICD10CM | Covered |
| L89.326 | ICD10CM | Covered |
| L89.42 | ICD10CM | Covered |
| L89.43 | ICD10CM | Covered |
| L89.44 | ICD10CM | Covered |
| L89.46 | ICD10CM | Covered |
| L89.512 | ICD10CM | Covered |
| L89.513 | ICD10CM | Covered |
| L89.514 | ICD10CM | Covered |
| L89.516 | ICD10CM | Covered |
| L89.522 | ICD10CM | Covered |
| L89.523 | ICD10CM | Covered |
| L89.524 | ICD10CM | Covered |
| L89.526 | ICD10CM | Covered |
| L89.612 | ICD10CM | Covered |
| L89.613 | ICD10CM | Covered |
| L89.614 | ICD10CM | Covered |
| L89.616 | ICD10CM | Covered |
| L89.622 | ICD10CM | Covered |
| L89.623 | ICD10CM | Covered |
| L89.624 | ICD10CM | Covered |
| L89.626 | ICD10CM | Covered |
| L89.812 | ICD10CM | Covered |
| L89.813 | ICD10CM | Covered |
| L89.814 | ICD10CM | Covered |
| L89.816 | ICD10CM | Covered |
| L89.892 | ICD10CM | Covered |
| L89.893 | ICD10CM | Covered |
| L89.894 | ICD10CM | Covered |
| L89.896 | ICD10CM | Covered |
| L97.111 | ICD10CM | Covered |
| L97.112 | ICD10CM | Covered |
| L97.113 | ICD10CM | Covered |
| L97.114 | ICD10CM | Covered |
| L97.115 | ICD10CM | Covered |
| L97.116 | ICD10CM | Covered |
| L97.118 | ICD10CM | Covered |
| L97.121 | ICD10CM | Covered |
| L97.122 | ICD10CM | Covered |
| L97.123 | ICD10CM | Covered |
| L97.124 | ICD10CM | Covered |
| L97.125 | ICD10CM | Covered |
| L97.126 | ICD10CM | Covered |
| L97.128 | ICD10CM | Covered |
| L97.211 | ICD10CM | Covered |
| L97.212 | ICD10CM | Covered |
| L97.213 | ICD10CM | Covered |
| L97.214 | ICD10CM | Covered |
| L97.215 | ICD10CM | Covered |
| L97.216 | ICD10CM | Covered |
| L97.218 | ICD10CM | Covered |
| L97.221 | ICD10CM | Covered |
| L97.222 | ICD10CM | Covered |
| L97.223 | ICD10CM | Covered |
| L97.224 | ICD10CM | Covered |
| L97.225 | ICD10CM | Covered |
| L97.226 | ICD10CM | Covered |
| L97.228 | ICD10CM | Covered |
| L97.311 | ICD10CM | Covered |
| L97.312 | ICD10CM | Covered |
| L97.313 | ICD10CM | Covered |
| L97.314 | ICD10CM | Covered |
| L97.315 | ICD10CM | Covered |
| L97.316 | ICD10CM | Covered |
| L97.318 | ICD10CM | Covered |
| L97.321 | ICD10CM | Covered |
| L97.322 | ICD10CM | Covered |
| L97.323 | ICD10CM | Covered |
| L97.324 | ICD10CM | Covered |
| L97.325 | ICD10CM | Covered |
| L97.326 | ICD10CM | Covered |
| L97.328 | ICD10CM | Covered |
| L97.411 | ICD10CM | Covered |
| L97.412 | ICD10CM | Covered |
| L97.413 | ICD10CM | Covered |
| L97.414 | ICD10CM | Covered |
| L97.415 | ICD10CM | Covered |
| L97.416 | ICD10CM | Covered |
| L97.418 | ICD10CM | Covered |
| L97.421 | ICD10CM | Covered |
| L97.422 | ICD10CM | Covered |
| L97.423 | ICD10CM | Covered |
| L97.424 | ICD10CM | Covered |
| L97.425 | ICD10CM | Covered |
| L97.426 | ICD10CM | Covered |
| L97.428 | ICD10CM | Covered |
| L97.511 | ICD10CM | Covered |
| L97.512 | ICD10CM | Covered |
| L97.513 | ICD10CM | Covered |
| L97.514 | ICD10CM | Covered |
| L97.515 | ICD10CM | Covered |
| L97.516 | ICD10CM | Covered |
| L97.518 | ICD10CM | Covered |
| L97.521 | ICD10CM | Covered |
| L97.522 | ICD10CM | Covered |
| L97.523 | ICD10CM | Covered |
| L97.524 | ICD10CM | Covered |
| L97.525 | ICD10CM | Covered |
| L97.526 | ICD10CM | Covered |
| L97.528 | ICD10CM | Covered |
| L97.811 | ICD10CM | Covered |
| L97.812 | ICD10CM | Covered |
| L97.813 | ICD10CM | Covered |
| L97.814 | ICD10CM | Covered |
| L97.815 | ICD10CM | Covered |
| L97.816 | ICD10CM | Covered |
| L97.818 | ICD10CM | Covered |
| L97.821 | ICD10CM | Covered |
| L97.822 | ICD10CM | Covered |
| L97.823 | ICD10CM | Covered |
| L97.824 | ICD10CM | Covered |
| L97.825 | ICD10CM | Covered |
| L97.826 | ICD10CM | Covered |
| L97.828 | ICD10CM | Covered |
| L97.911 | ICD10CM | Covered |
| L97.912 | ICD10CM | Covered |
| L97.913 | ICD10CM | Covered |
| L97.914 | ICD10CM | Covered |
| L97.915 | ICD10CM | Covered |
| L97.916 | ICD10CM | Covered |
| L97.918 | ICD10CM | Covered |
| L97.921 | ICD10CM | Covered |
| L97.922 | ICD10CM | Covered |
| L97.923 | ICD10CM | Covered |
| L97.924 | ICD10CM | Covered |
| L97.925 | ICD10CM | Covered |
| L97.926 | ICD10CM | Covered |
| L97.928 | ICD10CM | Covered |
| L98.411 | ICD10CM | Covered |
| L98.412 | ICD10CM | Covered |
| L98.413 | ICD10CM | Covered |
| L98.414 | ICD10CM | Covered |
| L98.415 | ICD10CM | Covered |
| L98.416 | ICD10CM | Covered |
| L98.418 | ICD10CM | Covered |
| L98.421 | ICD10CM | Covered |
| L98.422 | ICD10CM | Covered |
| L98.423 | ICD10CM | Covered |
| L98.424 | ICD10CM | Covered |
| L98.425 | ICD10CM | Covered |
| L98.426 | ICD10CM | Covered |
| L98.428 | ICD10CM | Covered |
| L98.431 | ICD10CM | Covered |
| L98.432 | ICD10CM | Covered |
| L98.471 | ICD10CM | Covered |
| L98.472 | ICD10CM | Covered |
| L98.473 | ICD10CM | Covered |
| L98.491 | ICD10CM | Covered |
| L98.492 | ICD10CM | Covered |
| L98.493 | ICD10CM | Covered |
| L98.494 | ICD10CM | Covered |
| L98.495 | ICD10CM | Covered |
| L98.496 | ICD10CM | Covered |
| L98.498 | ICD10CM | Covered |
| L98.A111 | ICD10CM | Covered |
| L98.A112 | ICD10CM | Covered |
| L98.A113 | ICD10CM | Covered |
| L98.A114 | ICD10CM | Covered |
| L98.A115 | ICD10CM | Covered |
| L98.A116 | ICD10CM | Covered |
| L98.A118 | ICD10CM | Covered |
| L98.A121 | ICD10CM | Covered |
| L98.A122 | ICD10CM | Covered |
| L98.A123 | ICD10CM | Covered |
| L98.A124 | ICD10CM | Covered |
| L98.A125 | ICD10CM | Covered |
| L98.A126 | ICD10CM | Covered |
| L98.A128 | ICD10CM | Covered |
| L98.A211 | ICD10CM | Covered |
| L98.A212 | ICD10CM | Covered |
| L98.A213 | ICD10CM | Covered |
| L98.A214 | ICD10CM | Covered |
| L98.A215 | ICD10CM | Covered |
| L98.A216 | ICD10CM | Covered |
| L98.A218 | ICD10CM | Covered |
| L98.A221 | ICD10CM | Covered |
| L98.A222 | ICD10CM | Covered |
| L98.A223 | ICD10CM | Covered |
| L98.A224 | ICD10CM | Covered |
| L98.A225 | ICD10CM | Covered |
| L98.A226 | ICD10CM | Covered |
| L98.A228 | ICD10CM | Covered |
| M79.671 | ICD10CM | Covered |
| M79.672 | ICD10CM | Covered |
| M79.674 | ICD10CM | Covered |
| M79.675 | ICD10CM | Covered |
| Q81.9 | ICD10CM | Covered |
| Q82.8 | ICD10CM | Covered |
| S01.00XA | ICD10CM | Covered |
| S01.00XD | ICD10CM | Covered |
| S01.00XS | ICD10CM | Covered |
| S01.01XA | ICD10CM | Covered |
| S01.01XD | ICD10CM | Covered |
| S01.01XS | ICD10CM | Covered |
| S01.20XA | ICD10CM | Covered |
| S01.20XD | ICD10CM | Covered |
| S01.20XS | ICD10CM | Covered |
| S01.21XA | ICD10CM | Covered |
| S01.21XD | ICD10CM | Covered |
| S01.21XS | ICD10CM | Covered |
| S01.22XA | ICD10CM | Covered |
| S01.22XD | ICD10CM | Covered |
| S01.22XS | ICD10CM | Covered |
| S01.23XA | ICD10CM | Covered |
| S01.23XD | ICD10CM | Covered |
| S01.23XS | ICD10CM | Covered |
| S01.24XA | ICD10CM | Covered |
| S01.24XD | ICD10CM | Covered |
| S01.24XS | ICD10CM | Covered |
| S01.25XA | ICD10CM | Covered |
| S01.25XD | ICD10CM | Covered |
| S01.25XS | ICD10CM | Covered |
| S01.301A | ICD10CM | Covered |
| S01.301D | ICD10CM | Covered |
| S01.301S | ICD10CM | Covered |
| S01.302A | ICD10CM | Covered |
| S01.302D | ICD10CM | Covered |
| S01.302S | ICD10CM | Covered |
| S01.311A | ICD10CM | Covered |
| S01.311D | ICD10CM | Covered |
| S01.311S | ICD10CM | Covered |
| S01.312A | ICD10CM | Covered |
| S01.312D | ICD10CM | Covered |
| S01.312S | ICD10CM | Covered |
| S01.321A | ICD10CM | Covered |
| S01.321D | ICD10CM | Covered |
| S01.321S | ICD10CM | Covered |
| S01.322A | ICD10CM | Covered |
| S01.322D | ICD10CM | Covered |
| S01.322S | ICD10CM | Covered |
| S01.351A | ICD10CM | Covered |
| S01.351D | ICD10CM | Covered |
| S01.351S | ICD10CM | Covered |
| S01.352A | ICD10CM | Covered |
| S01.352D | ICD10CM | Covered |
| S01.352S | ICD10CM | Covered |
| S01.411A | ICD10CM | Covered |
| S01.411D | ICD10CM | Covered |
| S01.411S | ICD10CM | Covered |
| S01.412A | ICD10CM | Covered |
| S01.412D | ICD10CM | Covered |
| S01.412S | ICD10CM | Covered |
| S01.451A | ICD10CM | Covered |
| S01.451D | ICD10CM | Covered |
| S01.451S | ICD10CM | Covered |
| S01.452A | ICD10CM | Covered |
| S01.452D | ICD10CM | Covered |
| S01.452S | ICD10CM | Covered |
| S01.501A | ICD10CM | Covered |
| S01.501D | ICD10CM | Covered |
| S01.501S | ICD10CM | Covered |
| S01.502A | ICD10CM | Covered |
| S01.502D | ICD10CM | Covered |
| S01.502S | ICD10CM | Covered |
| S01.80XA | ICD10CM | Covered |
| S01.80XD | ICD10CM | Covered |
| S01.80XS | ICD10CM | Covered |
| S01.81XA | ICD10CM | Covered |
| S01.81XD | ICD10CM | Covered |
| S01.81XS | ICD10CM | Covered |
| S01.82XA | ICD10CM | Covered |
| S01.82XD | ICD10CM | Covered |
| S01.82XS | ICD10CM | Covered |
| S01.83XA | ICD10CM | Covered |
| S01.83XD | ICD10CM | Covered |
| S01.83XS | ICD10CM | Covered |
| S01.84XA | ICD10CM | Covered |
| S01.84XD | ICD10CM | Covered |
| S01.84XS | ICD10CM | Covered |
| S01.85XA | ICD10CM | Covered |
| S01.85XD | ICD10CM | Covered |
| S01.85XS | ICD10CM | Covered |
| S21.001A | ICD10CM | Covered |
| S21.001D | ICD10CM | Covered |
| S21.001S | ICD10CM | Covered |
| S21.002A | ICD10CM | Covered |
| S21.002D | ICD10CM | Covered |
| S21.002S | ICD10CM | Covered |
| S21.011A | ICD10CM | Covered |
| S21.011D | ICD10CM | Covered |
| S21.011S | ICD10CM | Covered |
| S21.012A | ICD10CM | Covered |
| S21.012D | ICD10CM | Covered |
| S21.012S | ICD10CM | Covered |
| S21.021A | ICD10CM | Covered |
| S21.021D | ICD10CM | Covered |
| S21.021S | ICD10CM | Covered |
| S21.022A | ICD10CM | Covered |
| S21.022D | ICD10CM | Covered |
| S21.022S | ICD10CM | Covered |
| S21.051A | ICD10CM | Covered |
| S21.051D | ICD10CM | Covered |
| S21.051S | ICD10CM | Covered |
| S21.052A | ICD10CM | Covered |
| S21.052D | ICD10CM | Covered |
| S21.052S | ICD10CM | Covered |
| S21.101A | ICD10CM | Covered |
| S21.101D | ICD10CM | Covered |
| S21.101S | ICD10CM | Covered |
| S21.102A | ICD10CM | Covered |
| S21.102D | ICD10CM | Covered |
| S21.102S | ICD10CM | Covered |
| S21.111A | ICD10CM | Covered |
| S21.111D | ICD10CM | Covered |
| S21.111S | ICD10CM | Covered |
| S21.112A | ICD10CM | Covered |
| S21.112D | ICD10CM | Covered |
| S21.112S | ICD10CM | Covered |
| S21.121A | ICD10CM | Covered |
| S21.121D | ICD10CM | Covered |
| S21.121S | ICD10CM | Covered |
| S21.122A | ICD10CM | Covered |
| S21.122D | ICD10CM | Covered |
| S21.122S | ICD10CM | Covered |
| S21.151A | ICD10CM | Covered |
| S21.151D | ICD10CM | Covered |
| S21.151S | ICD10CM | Covered |
| S21.152A | ICD10CM | Covered |
| S21.152D | ICD10CM | Covered |
| S21.152S | ICD10CM | Covered |
| S21.201A | ICD10CM | Covered |
| S21.201D | ICD10CM | Covered |
| S21.201S | ICD10CM | Covered |
| S21.202A | ICD10CM | Covered |
| S21.202D | ICD10CM | Covered |
| S21.202S | ICD10CM | Covered |
| S21.211A | ICD10CM | Covered |
| S21.211D | ICD10CM | Covered |
| S21.211S | ICD10CM | Covered |
| S21.212A | ICD10CM | Covered |
| S21.212D | ICD10CM | Covered |
| S21.212S | ICD10CM | Covered |
| S21.221A | ICD10CM | Covered |
| S21.221D | ICD10CM | Covered |
| S21.221S | ICD10CM | Covered |
| S21.222A | ICD10CM | Covered |
| S21.222D | ICD10CM | Covered |
| S21.222S | ICD10CM | Covered |
| S21.241A | ICD10CM | Covered |
| S21.241D | ICD10CM | Covered |
| S21.241S | ICD10CM | Covered |
| S21.242A | ICD10CM | Covered |
| S21.242D | ICD10CM | Covered |
| S21.242S | ICD10CM | Covered |
| S30.85AA | ICD10CM | Covered |
| S30.85AD | ICD10CM | Covered |
| S30.85AS | ICD10CM | Covered |
| S31.000A | ICD10CM | Covered |
| S31.000D | ICD10CM | Covered |
| S31.000S | ICD10CM | Covered |
| S31.010A | ICD10CM | Covered |
| S31.010D | ICD10CM | Covered |
| S31.010S | ICD10CM | Covered |
| S31.011A | ICD10CM | Covered |
| S31.011D | ICD10CM | Covered |
| S31.011S | ICD10CM | Covered |
| S31.020A | ICD10CM | Covered |
| S31.020D | ICD10CM | Covered |
| S31.020S | ICD10CM | Covered |
| S31.050A | ICD10CM | Covered |
| S31.050D | ICD10CM | Covered |
| S31.050S | ICD10CM | Covered |
| S31.100A | ICD10CM | Covered |
| S31.100D | ICD10CM | Covered |
| S31.100S | ICD10CM | Covered |
| S31.101A | ICD10CM | Covered |
| S31.101D | ICD10CM | Covered |
| S31.101S | ICD10CM | Covered |
| S31.102A | ICD10CM | Covered |
| S31.102D | ICD10CM | Covered |
| S31.102S | ICD10CM | Covered |
| S31.103A | ICD10CM | Covered |
| S31.103D | ICD10CM | Covered |
| S31.103S | ICD10CM | Covered |
| S31.104A | ICD10CM | Covered |
| S31.104D | ICD10CM | Covered |
| S31.104S | ICD10CM | Covered |
| S31.105A | ICD10CM | Covered |
| S31.105D | ICD10CM | Covered |
| S31.105S | ICD10CM | Covered |
| S31.110A | ICD10CM | Covered |
| S31.110D | ICD10CM | Covered |
| S31.110S | ICD10CM | Covered |
| S31.111A | ICD10CM | Covered |
| S31.111D | ICD10CM | Covered |
| S31.111S | ICD10CM | Covered |
| S31.112A | ICD10CM | Covered |
| S31.112D | ICD10CM | Covered |
| S31.112S | ICD10CM | Covered |
| S31.113A | ICD10CM | Covered |
| S31.113D | ICD10CM | Covered |
| S31.113S | ICD10CM | Covered |
| S31.114A | ICD10CM | Covered |
| S31.114D | ICD10CM | Covered |
| S31.114S | ICD10CM | Covered |
| S31.115A | ICD10CM | Covered |
| S31.115D | ICD10CM | Covered |
| S31.115S | ICD10CM | Covered |
| S31.116A | ICD10CM | Covered |
| S31.116D | ICD10CM | Covered |
| S31.116S | ICD10CM | Covered |
| S31.117A | ICD10CM | Covered |
| S31.117D | ICD10CM | Covered |
| S31.117S | ICD10CM | Covered |
| S31.11AA | ICD10CM | Covered |
| S31.11AD | ICD10CM | Covered |
| S31.11AS | ICD10CM | Covered |
| S31.120A | ICD10CM | Covered |
| S31.120D | ICD10CM | Covered |
| S31.120S | ICD10CM | Covered |
| S31.121A | ICD10CM | Covered |
| S31.121D | ICD10CM | Covered |
| S31.121S | ICD10CM | Covered |
| S31.122A | ICD10CM | Covered |
| S31.122D | ICD10CM | Covered |
| S31.122S | ICD10CM | Covered |
| S31.123A | ICD10CM | Covered |
| S31.123D | ICD10CM | Covered |
| S31.123S | ICD10CM | Covered |
| S31.124A | ICD10CM | Covered |
| S31.124D | ICD10CM | Covered |
| S31.124S | ICD10CM | Covered |
| S31.125A | ICD10CM | Covered |
| S31.125D | ICD10CM | Covered |
| S31.125S | ICD10CM | Covered |
| S31.126A | ICD10CM | Covered |
| S31.126D | ICD10CM | Covered |
| S31.126S | ICD10CM | Covered |
| S31.127A | ICD10CM | Covered |
| S31.127D | ICD10CM | Covered |
| S31.127S | ICD10CM | Covered |
| S31.129A | ICD10CM | Covered |
| S31.129D | ICD10CM | Covered |
| S31.129S | ICD10CM | Covered |
| S31.12AA | ICD10CM | Covered |
| S31.12AD | ICD10CM | Covered |
| S31.12AS | ICD10CM | Covered |
| S31.150A | ICD10CM | Covered |
| S31.150D | ICD10CM | Covered |
| S31.150S | ICD10CM | Covered |
| S31.151A | ICD10CM | Covered |
| S31.151D | ICD10CM | Covered |
| S31.151S | ICD10CM | Covered |
| S31.152A | ICD10CM | Covered |
| S31.152D | ICD10CM | Covered |
| S31.152S | ICD10CM | Covered |
| S31.153A | ICD10CM | Covered |
| S31.153D | ICD10CM | Covered |
| S31.153S | ICD10CM | Covered |
| S31.154A | ICD10CM | Covered |
| S31.154D | ICD10CM | Covered |
| S31.154S | ICD10CM | Covered |
| S31.155A | ICD10CM | Covered |
| S31.155D | ICD10CM | Covered |
| S31.155S | ICD10CM | Covered |
| S31.20XA | ICD10CM | Covered |
| S31.20XD | ICD10CM | Covered |
| S31.20XS | ICD10CM | Covered |
| S31.21XA | ICD10CM | Covered |
| S31.21XD | ICD10CM | Covered |
| S31.21XS | ICD10CM | Covered |
| S31.22XA | ICD10CM | Covered |
| S31.22XD | ICD10CM | Covered |
| S31.22XS | ICD10CM | Covered |
| S31.25XA | ICD10CM | Covered |
| S31.25XD | ICD10CM | Covered |
| S31.25XS | ICD10CM | Covered |
| S31.31XA | ICD10CM | Covered |
| S31.31XD | ICD10CM | Covered |
| S31.31XS | ICD10CM | Covered |
| S31.32XA | ICD10CM | Covered |
| S31.32XD | ICD10CM | Covered |
| S31.32XS | ICD10CM | Covered |
| S31.35XA | ICD10CM | Covered |
| S31.35XD | ICD10CM | Covered |
| S31.35XS | ICD10CM | Covered |
| S31.40XA | ICD10CM | Covered |
| S31.40XD | ICD10CM | Covered |
| S31.40XS | ICD10CM | Covered |
| S31.41XA | ICD10CM | Covered |
| S31.41XD | ICD10CM | Covered |
| S31.41XS | ICD10CM | Covered |
| S31.42XA | ICD10CM | Covered |
| S31.42XD | ICD10CM | Covered |
| S31.42XS | ICD10CM | Covered |
| S31.45XA | ICD10CM | Covered |
| S31.45XD | ICD10CM | Covered |
| S31.45XS | ICD10CM | Covered |
| S31.811A | ICD10CM | Covered |
| S31.811D | ICD10CM | Covered |
| S31.811S | ICD10CM | Covered |
| S31.812A | ICD10CM | Covered |
| S31.812D | ICD10CM | Covered |
| S31.812S | ICD10CM | Covered |
| S31.815A | ICD10CM | Covered |
| S31.815D | ICD10CM | Covered |
| S31.815S | ICD10CM | Covered |
| S31.819A | ICD10CM | Covered |
| S31.819D | ICD10CM | Covered |
| S31.819S | ICD10CM | Covered |
| S31.821A | ICD10CM | Covered |
| S31.821D | ICD10CM | Covered |
| S31.821S | ICD10CM | Covered |
| S31.822A | ICD10CM | Covered |
| S31.822D | ICD10CM | Covered |
| S31.822S | ICD10CM | Covered |
| S31.825A | ICD10CM | Covered |
| S31.825D | ICD10CM | Covered |
| S31.825S | ICD10CM | Covered |
| S31.829A | ICD10CM | Covered |
| S31.829D | ICD10CM | Covered |
| S31.829S | ICD10CM | Covered |
| S41.001A | ICD10CM | Covered |
| S41.001D | ICD10CM | Covered |
| S41.001S | ICD10CM | Covered |
| S41.002A | ICD10CM | Covered |
| S41.002D | ICD10CM | Covered |
| S41.002S | ICD10CM | Covered |
| S41.011A | ICD10CM | Covered |
| S41.011D | ICD10CM | Covered |
| S41.011S | ICD10CM | Covered |
| S41.012A | ICD10CM | Covered |
| S41.012D | ICD10CM | Covered |
| S41.012S | ICD10CM | Covered |
| S41.021A | ICD10CM | Covered |
| S41.021D | ICD10CM | Covered |
| S41.021S | ICD10CM | Covered |
| S41.022A | ICD10CM | Covered |
| S41.022D | ICD10CM | Covered |
| S41.022S | ICD10CM | Covered |
| S41.051A | ICD10CM | Covered |
| S41.051D | ICD10CM | Covered |
| S41.051S | ICD10CM | Covered |
| S41.052A | ICD10CM | Covered |
| S41.052D | ICD10CM | Covered |
| S41.052S | ICD10CM | Covered |
| S41.101A | ICD10CM | Covered |
| S41.101D | ICD10CM | Covered |
| S41.101S | ICD10CM | Covered |
| S41.102A | ICD10CM | Covered |
| S41.102D | ICD10CM | Covered |
| S41.102S | ICD10CM | Covered |
| S41.111A | ICD10CM | Covered |
| S41.111D | ICD10CM | Covered |
| S41.111S | ICD10CM | Covered |
| S41.112A | ICD10CM | Covered |
| S41.112D | ICD10CM | Covered |
| S41.112S | ICD10CM | Covered |
| S41.121A | ICD10CM | Covered |
| S41.121D | ICD10CM | Covered |
| S41.121S | ICD10CM | Covered |
| S41.122A | ICD10CM | Covered |
| S41.122D | ICD10CM | Covered |
| S41.122S | ICD10CM | Covered |
| S41.151A | ICD10CM | Covered |
| S41.151D | ICD10CM | Covered |
| S41.151S | ICD10CM | Covered |
| S41.152A | ICD10CM | Covered |
| S41.152D | ICD10CM | Covered |
| S41.152S | ICD10CM | Covered |
| S51.001A | ICD10CM | Covered |
| S51.001D | ICD10CM | Covered |
| S51.001S | ICD10CM | Covered |
| S51.002A | ICD10CM | Covered |
| S51.002D | ICD10CM | Covered |
| S51.002S | ICD10CM | Covered |
| S51.011A | ICD10CM | Covered |
| S51.011D | ICD10CM | Covered |
| S51.011S | ICD10CM | Covered |
| S51.012A | ICD10CM | Covered |
| S51.012D | ICD10CM | Covered |
| S51.012S | ICD10CM | Covered |
| S51.021A | ICD10CM | Covered |
| S51.021D | ICD10CM | Covered |
| S51.021S | ICD10CM | Covered |
| S51.022A | ICD10CM | Covered |
| S51.022D | ICD10CM | Covered |
| S51.022S | ICD10CM | Covered |
| S51.051A | ICD10CM | Covered |
| S51.051D | ICD10CM | Covered |
| S51.051S | ICD10CM | Covered |
| S51.052A | ICD10CM | Covered |
| S51.052D | ICD10CM | Covered |
| S51.052S | ICD10CM | Covered |
| S51.801A | ICD10CM | Covered |
| S51.801D | ICD10CM | Covered |
| S51.801S | ICD10CM | Covered |
| S51.802A | ICD10CM | Covered |
| S51.802D | ICD10CM | Covered |
| S51.802S | ICD10CM | Covered |
| S51.811A | ICD10CM | Covered |
| S51.811D | ICD10CM | Covered |
| S51.811S | ICD10CM | Covered |
| S51.812A | ICD10CM | Covered |
| S51.812D | ICD10CM | Covered |
| S51.812S | ICD10CM | Covered |
| S51.821A | ICD10CM | Covered |
| S51.821D | ICD10CM | Covered |
| S51.821S | ICD10CM | Covered |
| S51.822A | ICD10CM | Covered |
| S51.822D | ICD10CM | Covered |
| S51.822S | ICD10CM | Covered |
| S51.851A | ICD10CM | Covered |
| S51.851D | ICD10CM | Covered |
| S51.851S | ICD10CM | Covered |
| S51.852A | ICD10CM | Covered |
| S51.852D | ICD10CM | Covered |
| S51.852S | ICD10CM | Covered |
| S58.011A | ICD10CM | Covered |
| S58.011D | ICD10CM | Covered |
| S58.011S | ICD10CM | Covered |
| S58.012A | ICD10CM | Covered |
| S58.012D | ICD10CM | Covered |
| S58.012S | ICD10CM | Covered |
| S58.021A | ICD10CM | Covered |
| S58.021D | ICD10CM | Covered |
| S58.021S | ICD10CM | Covered |
| S58.022A | ICD10CM | Covered |
| S58.022D | ICD10CM | Covered |
| S58.022S | ICD10CM | Covered |
| S58.111A | ICD10CM | Covered |
| S58.111D | ICD10CM | Covered |
| S58.111S | ICD10CM | Covered |
| S58.112A | ICD10CM | Covered |
| S58.112D | ICD10CM | Covered |
| S58.112S | ICD10CM | Covered |
| S58.121A | ICD10CM | Covered |
| S58.121D | ICD10CM | Covered |
| S58.121S | ICD10CM | Covered |
| S58.122A | ICD10CM | Covered |
| S58.122D | ICD10CM | Covered |
| S58.122S | ICD10CM | Covered |
| S61.001A | ICD10CM | Covered |
| S61.001D | ICD10CM | Covered |
| S61.001S | ICD10CM | Covered |
| S61.002A | ICD10CM | Covered |
| S61.002D | ICD10CM | Covered |
| S61.002S | ICD10CM | Covered |
| S61.011A | ICD10CM | Covered |
| S61.011D | ICD10CM | Covered |
| S61.011S | ICD10CM | Covered |
| S61.012A | ICD10CM | Covered |
| S61.012D | ICD10CM | Covered |
| S61.012S | ICD10CM | Covered |
| S61.051A | ICD10CM | Covered |
| S61.051D | ICD10CM | Covered |
| S61.051S | ICD10CM | Covered |
| S61.052A | ICD10CM | Covered |
| S61.052D | ICD10CM | Covered |
| S61.052S | ICD10CM | Covered |
| S61.200A | ICD10CM | Covered |
| S61.200D | ICD10CM | Covered |
| S61.200S | ICD10CM | Covered |
| S61.201A | ICD10CM | Covered |
| S61.201D | ICD10CM | Covered |
| S61.201S | ICD10CM | Covered |
| S61.202A | ICD10CM | Covered |
| S61.202D | ICD10CM | Covered |
| S61.202S | ICD10CM | Covered |
| S61.203A | ICD10CM | Covered |
| S61.203D | ICD10CM | Covered |
| S61.203S | ICD10CM | Covered |
| S61.204A | ICD10CM | Covered |
| S61.204D | ICD10CM | Covered |
| S61.204S | ICD10CM | Covered |
| S61.205A | ICD10CM | Covered |
| S61.205D | ICD10CM | Covered |
| S61.205S | ICD10CM | Covered |
| S61.206A | ICD10CM | Covered |
| S61.206D | ICD10CM | Covered |
| S61.206S | ICD10CM | Covered |
| S61.207A | ICD10CM | Covered |
| S61.207D | ICD10CM | Covered |
| S61.207S | ICD10CM | Covered |
| S61.210A | ICD10CM | Covered |
| S61.210D | ICD10CM | Covered |
| S61.210S | ICD10CM | Covered |
| S61.211A | ICD10CM | Covered |
| S61.211D | ICD10CM | Covered |
| S61.211S | ICD10CM | Covered |
| S61.212A | ICD10CM | Covered |
| S61.212D | ICD10CM | Covered |
| S61.212S | ICD10CM | Covered |
| S61.213A | ICD10CM | Covered |
| S61.213D | ICD10CM | Covered |
| S61.213S | ICD10CM | Covered |
| S61.214A | ICD10CM | Covered |
| S61.214D | ICD10CM | Covered |
| S61.214S | ICD10CM | Covered |
| S61.215A | ICD10CM | Covered |
| S61.215D | ICD10CM | Covered |
| S61.215S | ICD10CM | Covered |
| S61.216A | ICD10CM | Covered |
| S61.216D | ICD10CM | Covered |
| S61.216S | ICD10CM | Covered |
| S61.217A | ICD10CM | Covered |
| S61.217D | ICD10CM | Covered |
| S61.217S | ICD10CM | Covered |
| S61.220A | ICD10CM | Covered |
| S61.220D | ICD10CM | Covered |
| S61.220S | ICD10CM | Covered |
| S61.221A | ICD10CM | Covered |
| S61.221D | ICD10CM | Covered |
| S61.221S | ICD10CM | Covered |
| S61.222A | ICD10CM | Covered |
| S61.222D | ICD10CM | Covered |
| S61.222S | ICD10CM | Covered |
| S61.223A | ICD10CM | Covered |
| S61.223D | ICD10CM | Covered |
| S61.223S | ICD10CM | Covered |
| S61.224A | ICD10CM | Covered |
| S61.224D | ICD10CM | Covered |
| S61.224S | ICD10CM | Covered |
| S61.225A | ICD10CM | Covered |
| S61.225D | ICD10CM | Covered |
| S61.225S | ICD10CM | Covered |
| S61.226A | ICD10CM | Covered |
| S61.226D | ICD10CM | Covered |
| S61.226S | ICD10CM | Covered |
| S61.227A | ICD10CM | Covered |
| S61.227D | ICD10CM | Covered |
| S61.227S | ICD10CM | Covered |
| S61.250A | ICD10CM | Covered |
| S61.250D | ICD10CM | Covered |
| S61.250S | ICD10CM | Covered |
| S61.251A | ICD10CM | Covered |
| S61.251D | ICD10CM | Covered |
| S61.251S | ICD10CM | Covered |
| S61.252A | ICD10CM | Covered |
| S61.252D | ICD10CM | Covered |
| S61.252S | ICD10CM | Covered |
| S61.253A | ICD10CM | Covered |
| S61.253D | ICD10CM | Covered |
| S61.253S | ICD10CM | Covered |
| S61.254A | ICD10CM | Covered |
| S61.254D | ICD10CM | Covered |
| S61.254S | ICD10CM | Covered |
| S61.255A | ICD10CM | Covered |
| S61.255D | ICD10CM | Covered |
| S61.255S | ICD10CM | Covered |
| S61.256A | ICD10CM | Covered |
| S61.256D | ICD10CM | Covered |
| S61.256S | ICD10CM | Covered |
| S61.257A | ICD10CM | Covered |
| S61.257D | ICD10CM | Covered |
| S61.257S | ICD10CM | Covered |
| S61.401A | ICD10CM | Covered |
| S61.401D | ICD10CM | Covered |
| S61.401S | ICD10CM | Covered |
| S61.402A | ICD10CM | Covered |
| S61.402D | ICD10CM | Covered |
| S61.402S | ICD10CM | Covered |
| S61.411A | ICD10CM | Covered |
| S61.411D | ICD10CM | Covered |
| S61.411S | ICD10CM | Covered |
| S61.412A | ICD10CM | Covered |
| S61.412D | ICD10CM | Covered |
| S61.412S | ICD10CM | Covered |
| S61.421A | ICD10CM | Covered |
| S61.421D | ICD10CM | Covered |
| S61.421S | ICD10CM | Covered |
| S61.422A | ICD10CM | Covered |
| S61.422D | ICD10CM | Covered |
| S61.422S | ICD10CM | Covered |
| S61.451A | ICD10CM | Covered |
| S61.451D | ICD10CM | Covered |
| S61.451S | ICD10CM | Covered |
| S61.452A | ICD10CM | Covered |
| S61.452D | ICD10CM | Covered |
| S61.452S | ICD10CM | Covered |
| S61.501A | ICD10CM | Covered |
| S61.501D | ICD10CM | Covered |
| S61.501S | ICD10CM | Covered |
| S61.502A | ICD10CM | Covered |
| S61.502D | ICD10CM | Covered |
| S61.502S | ICD10CM | Covered |
| S61.511A | ICD10CM | Covered |
| S61.511D | ICD10CM | Covered |
| S61.511S | ICD10CM | Covered |
| S61.512A | ICD10CM | Covered |
| S61.512D | ICD10CM | Covered |
| S61.512S | ICD10CM | Covered |
| S61.521A | ICD10CM | Covered |
| S61.521D | ICD10CM | Covered |
| S61.521S | ICD10CM | Covered |
| S61.522A | ICD10CM | Covered |
| S61.522D | ICD10CM | Covered |
| S61.522S | ICD10CM | Covered |
| S61.551A | ICD10CM | Covered |
| S61.551D | ICD10CM | Covered |
| S61.551S | ICD10CM | Covered |
| S61.552A | ICD10CM | Covered |
| S61.552D | ICD10CM | Covered |
| S61.552S | ICD10CM | Covered |
| S68.011A | ICD10CM | Covered |
| S68.011D | ICD10CM | Covered |
| S68.011S | ICD10CM | Covered |
| S68.012A | ICD10CM | Covered |
| S68.012D | ICD10CM | Covered |
| S68.012S | ICD10CM | Covered |
| S68.021A | ICD10CM | Covered |
| S68.021D | ICD10CM | Covered |
| S68.021S | ICD10CM | Covered |
| S68.022A | ICD10CM | Covered |
| S68.022D | ICD10CM | Covered |
| S68.022S | ICD10CM | Covered |
| S68.110A | ICD10CM | Covered |
| S68.110D | ICD10CM | Covered |
| S68.110S | ICD10CM | Covered |
| S68.111A | ICD10CM | Covered |
| S68.111D | ICD10CM | Covered |
| S68.111S | ICD10CM | Covered |
| S68.112A | ICD10CM | Covered |
| S68.112D | ICD10CM | Covered |
| S68.112S | ICD10CM | Covered |
| S68.113A | ICD10CM | Covered |