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 |
|---|---|---|
| 0068U | HCPCS | Covered |
| 0096U | HCPCS | Covered |
| 0109U | HCPCS | Covered |
| 0115U | HCPCS | Covered |
| 0140U | HCPCS | Covered |
| 0141U | HCPCS | Covered |
| 0142U | HCPCS | Covered |
| 0202U | HCPCS | Covered |
| 0223U | HCPCS | Covered |
| 0225U | HCPCS | Covered |
| 0301U | HCPCS | Covered |
| 0302U | HCPCS | Covered |
| 0402U | HCPCS | Covered |
| 0429U | HCPCS | Covered |
| 0455U | HCPCS | Covered |
| 0483U | HCPCS | Covered |
| 0484U | HCPCS | Covered |
| 0502U | HCPCS | Covered |
| 0527U | HCPCS | Covered |
| 0528U | HCPCS | Covered |
| 0563U | HCPCS | Covered |
| 0564U | HCPCS | Covered |
| 0595U | HCPCS | Covered |
| 0629U | HCPCS | Covered |
| 81513 | HCPCS | Covered |
| 81514 | HCPCS | Covered |
| 81515 | HCPCS | Covered |
| 87149 | HCPCS | Covered |
| 87150 | HCPCS | Covered |
| 87153 | HCPCS | Covered |
| 87154 | HCPCS | Covered |
| 87468 | HCPCS | Covered |
| 87469 | HCPCS | Covered |
| 87471 | HCPCS | Covered |
| 87472 | HCPCS | Covered |
| 87475 | HCPCS | Covered |
| 87476 | HCPCS | Covered |
| 87478 | HCPCS | Covered |
| 87480 | HCPCS | Covered |
| 87481 | HCPCS | Covered |
| 87482 | HCPCS | Covered |
| 87483 | HCPCS | Covered |
| 87484 | HCPCS | Covered |
| 87485 | HCPCS | Covered |
| 87486 | HCPCS | Covered |
| 87487 | HCPCS | Covered |
| 87490 | HCPCS | Covered |
| 87491 | HCPCS | Covered |
| 87492 | HCPCS | Covered |
| 87493 | HCPCS | Covered |
| 87494 | HCPCS | Covered |
| 87495 | HCPCS | Covered |
| 87496 | HCPCS | Covered |
| 87497 | HCPCS | Covered |
| 87498 | HCPCS | Covered |
| 87501 | HCPCS | Covered |
| 87502 | HCPCS | Covered |
| 87503 | HCPCS | Covered |
| 87505 | HCPCS | Covered |
| 87506 | HCPCS | Covered |
| 87507 | HCPCS | Covered |
| 87510 | HCPCS | Covered |
| 87511 | HCPCS | Covered |
| 87512 | HCPCS | Covered |
| 87513 | HCPCS | Covered |
| 87516 | HCPCS | Covered |
| 87517 | HCPCS | Covered |
| 87520 | HCPCS | Covered |
| 87521 | HCPCS | Covered |
| 87522 | HCPCS | Covered |
| 87523 | HCPCS | Covered |
| 87525 | HCPCS | Covered |
| 87526 | HCPCS | Covered |
| 87527 | HCPCS | Covered |
| 87528 | HCPCS | Covered |
| 87529 | HCPCS | Covered |
| 87530 | HCPCS | Covered |
| 87531 | HCPCS | Covered |
| 87532 | HCPCS | Covered |
| 87533 | HCPCS | Covered |
| 87534 | HCPCS | Covered |
| 87535 | HCPCS | Covered |
| 87536 | HCPCS | Covered |
| 87537 | HCPCS | Covered |
| 87538 | HCPCS | Covered |
| 87539 | HCPCS | Covered |
| 87540 | HCPCS | Covered |
| 87541 | HCPCS | Covered |
| 87542 | HCPCS | Covered |
| 87550 | HCPCS | Covered |
| 87551 | HCPCS | Covered |
| 87552 | HCPCS | Covered |
| 87555 | HCPCS | Covered |
| 87556 | HCPCS | Covered |
| 87557 | HCPCS | Covered |
| 87560 | HCPCS | Covered |
| 87561 | HCPCS | Covered |
| 87562 | HCPCS | Covered |
| 87563 | HCPCS | Covered |
| 87564 | HCPCS | Covered |
| 87580 | HCPCS | Covered |
| 87581 | HCPCS | Covered |
| 87582 | HCPCS | Covered |
| 87590 | HCPCS | Covered |
| 87591 | HCPCS | Covered |
| 87592 | HCPCS | Covered |
| 87593 | HCPCS | Covered |
| 87594 | HCPCS | Covered |
| 87623 | HCPCS | Covered |
| 87624 | HCPCS | Covered |
| 87625 | HCPCS | Covered |
| 87626 | HCPCS | Covered |
| 87627 | HCPCS | Covered |
| 87631 | HCPCS | Covered |
| 87632 | HCPCS | Covered |
| 87633 | HCPCS | Covered |
| 87634 | HCPCS | Covered |
| 87635 | HCPCS | Covered |
| 87636 | HCPCS | Covered |
| 87637 | HCPCS | Covered |
| 87640 | HCPCS | Covered |
| 87641 | HCPCS | Covered |
| 87650 | HCPCS | Covered |
| 87651 | HCPCS | Covered |
| 87652 | HCPCS | Covered |
| 87653 | HCPCS | Covered |
| 87660 | HCPCS | Covered |
| 87661 | HCPCS | Covered |
| 87662 | HCPCS | Covered |
| 87797 | HCPCS | Covered |
| 87798 | HCPCS | Covered |
| 87799 | HCPCS | Covered |
| 87800 | HCPCS | Covered |
| 87801 | HCPCS | Covered |
| 87999 | HCPCS | Covered |
| U0001 | HCPCS | Covered |
| U0002 | HCPCS | Covered |
| A00.0 | ICD10CM | Covered |
| A00.1 | ICD10CM | Covered |
| A00.9 | ICD10CM | Covered |
| A01.00 | ICD10CM | Covered |
| A01.01 | ICD10CM | Covered |
| A01.02 | ICD10CM | Covered |
| A01.03 | ICD10CM | Covered |
| A01.04 | ICD10CM | Covered |
| A01.05 | ICD10CM | Covered |
| A01.09 | ICD10CM | Covered |
| A01.1 | ICD10CM | Covered |
| A01.2 | ICD10CM | Covered |
| A01.3 | ICD10CM | Covered |
| A02.0 | ICD10CM | Covered |
| A02.1 | ICD10CM | Covered |
| A02.23 | ICD10CM | Covered |
| A02.8 | ICD10CM | Covered |
| A03.0 | ICD10CM | Covered |
| A03.1 | ICD10CM | Covered |
| A03.2 | ICD10CM | Covered |
| A03.3 | ICD10CM | Covered |
| A03.8 | ICD10CM | Covered |
| A04.0 | ICD10CM | Covered |
| A04.1 | ICD10CM | Covered |
| A04.2 | ICD10CM | Covered |
| A04.3 | ICD10CM | Covered |
| A04.5 | ICD10CM | Covered |
| A04.6 | ICD10CM | Covered |
| A04.71 | ICD10CM | Covered |
| A04.72 | ICD10CM | Covered |
| A04.8 | ICD10CM | Covered |
| A04.9 | ICD10CM | Covered |
| A05.0 | ICD10CM | Covered |
| A05.1 | ICD10CM | Covered |
| A05.2 | ICD10CM | Covered |
| A05.3 | ICD10CM | Covered |
| A05.4 | ICD10CM | Covered |
| A05.5 | ICD10CM | Covered |
| A06.0 | ICD10CM | Covered |
| A06.1 | ICD10CM | Covered |
| A06.2 | ICD10CM | Covered |
| A07.1 | ICD10CM | Covered |
| A07.2 | ICD10CM | Covered |
| A07.4 | ICD10CM | Covered |
| A08.0 | ICD10CM | Covered |
| A08.11 | ICD10CM | Covered |
| A08.19 | ICD10CM | Covered |
| A08.2 | ICD10CM | Covered |
| A08.31 | ICD10CM | Covered |
| A08.32 | ICD10CM | Covered |
| A08.39 | ICD10CM | Covered |
| A08.8 | ICD10CM | Covered |
| A09 | ICD10CM | Covered |
| A32.11 | ICD10CM | Covered |
| A32.12 | ICD10CM | Covered |
| A32.7 | 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 |
| A37.90 | ICD10CM | Covered |
| A37.91 | ICD10CM | Covered |
| A39.0 | ICD10CM | Covered |
| A39.81 | ICD10CM | Covered |
| A39.9 | ICD10CM | Covered |
| A40.0 | ICD10CM | Covered |
| A40.1 | ICD10CM | Covered |
| A40.3 | ICD10CM | Covered |
| A40.8 | ICD10CM | Covered |
| A40.9 | ICD10CM | Covered |
| A41.01 | ICD10CM | Covered |
| A41.02 | ICD10CM | Covered |
| A41.1 | ICD10CM | Covered |
| A41.2 | ICD10CM | Covered |
| A41.3 | ICD10CM | Covered |
| A41.4 | ICD10CM | Covered |
| A41.50 | ICD10CM | Covered |
| A41.51 | ICD10CM | Covered |
| A41.52 | ICD10CM | Covered |
| A41.53 | ICD10CM | Covered |
| A41.54 | ICD10CM | Covered |
| A41.59 | ICD10CM | Covered |
| A41.81 | ICD10CM | Covered |
| A41.89 | ICD10CM | Covered |
| A41.9 | ICD10CM | Covered |
| A48.1 | ICD10CM | Covered |
| A48.2 | ICD10CM | Covered |
| A51.0 | ICD10CM | Covered |
| A51.1 | ICD10CM | Covered |
| A51.31 | ICD10CM | Covered |
| A52.76 | ICD10CM | Covered |
| A54.00 | ICD10CM | Covered |
| A54.01 | ICD10CM | Covered |
| A54.02 | ICD10CM | Covered |
| A54.03 | ICD10CM | Covered |
| A54.09 | ICD10CM | Covered |
| A54.1 | ICD10CM | Covered |
| A54.21 | ICD10CM | Covered |
| A54.22 | ICD10CM | Covered |
| A54.23 | ICD10CM | Covered |
| A54.24 | ICD10CM | Covered |
| A54.29 | ICD10CM | Covered |
| A54.42 | ICD10CM | Covered |
| A54.6 | ICD10CM | Covered |
| A54.81 | ICD10CM | Covered |
| A54.86 | ICD10CM | Covered |
| A56.00 | ICD10CM | Covered |
| A56.01 | ICD10CM | Covered |
| A56.02 | ICD10CM | Covered |
| A56.09 | ICD10CM | Covered |
| A56.11 | ICD10CM | Covered |
| A56.19 | ICD10CM | Covered |
| A56.2 | ICD10CM | Covered |
| A56.3 | ICD10CM | Covered |
| A59.00 | ICD10CM | Covered |
| A59.01 | ICD10CM | Covered |
| A59.02 | ICD10CM | Covered |
| A59.03 | ICD10CM | Covered |
| A59.09 | ICD10CM | Covered |
| A60.00 | ICD10CM | Covered |
| A60.01 | ICD10CM | Covered |
| A60.02 | ICD10CM | Covered |
| A60.03 | ICD10CM | Covered |
| A60.04 | ICD10CM | Covered |
| A60.09 | ICD10CM | Covered |
| A60.1 | ICD10CM | Covered |
| A60.9 | ICD10CM | Covered |
| A63.0 | ICD10CM | Covered |
| A77.40 | ICD10CM | Covered |
| A77.41 | ICD10CM | Covered |
| A77.49 | ICD10CM | Covered |
| A79.82 | ICD10CM | Covered |
| A79.9 | ICD10CM | Covered |
| A80.0 | ICD10CM | Covered |
| A80.1 | ICD10CM | Covered |
| A80.2 | ICD10CM | Covered |
| A80.30 | ICD10CM | Covered |
| A80.39 | ICD10CM | Covered |
| A80.4 | ICD10CM | Covered |
| A80.9 | ICD10CM | Covered |
| A84.89 | ICD10CM | Covered |
| A84.9 | ICD10CM | Covered |
| A85.0 | ICD10CM | Covered |
| A85.1 | ICD10CM | Covered |
| A85.2 | ICD10CM | Covered |
| A85.8 | ICD10CM | Covered |
| A86 | ICD10CM | Covered |
| A87.0 | ICD10CM | Covered |
| A87.8 | ICD10CM | Covered |
| A87.9 | ICD10CM | Covered |
| A93.8 | ICD10CM | Covered |
| A94 | ICD10CM | Covered |
| B00.0 | ICD10CM | Covered |
| B00.1 | ICD10CM | Covered |
| B00.2 | ICD10CM | Covered |
| B00.3 | ICD10CM | Covered |
| B00.4 | ICD10CM | Covered |
| B00.59 | ICD10CM | Covered |
| B01.0 | ICD10CM | Covered |
| B01.11 | ICD10CM | Covered |
| B01.81 | ICD10CM | Covered |
| B01.9 | ICD10CM | Covered |
| B02.1 | ICD10CM | Covered |
| B02.30 | ICD10CM | Covered |
| B02.31 | ICD10CM | Covered |
| B02.32 | ICD10CM | Covered |
| B02.33 | ICD10CM | Covered |
| B02.34 | ICD10CM | Covered |
| B02.39 | ICD10CM | Covered |
| B02.7 | ICD10CM | Covered |
| B02.8 | ICD10CM | Covered |
| B10.01 | ICD10CM | Covered |
| B20 | ICD10CM | Covered |
| B25.0 | ICD10CM | Covered |
| B25.1 | ICD10CM | Covered |
| B25.2 | ICD10CM | Covered |
| B27.02 | ICD10CM | Covered |
| B27.12 | ICD10CM | Covered |
| B27.82 | ICD10CM | Covered |
| B33.23 | ICD10CM | Covered |
| B33.24 | ICD10CM | Covered |
| B35.1 | ICD10CM | Covered |
| B37.31 | ICD10CM | Covered |
| B37.32 | ICD10CM | Covered |
| B37.41 | ICD10CM | Covered |
| B37.42 | ICD10CM | Covered |
| B37.49 | ICD10CM | Covered |
| B37.5 | ICD10CM | Covered |
| B37.7 | ICD10CM | Covered |
| B37.89 | ICD10CM | Covered |
| B45.1 | ICD10CM | Covered |
| B59 | ICD10CM | Covered |
| B60.00 | ICD10CM | Covered |
| B60.01 | ICD10CM | Covered |
| B60.02 | ICD10CM | Covered |
| B60.03 | ICD10CM | Covered |
| B60.09 | ICD10CM | Covered |
| B60.2 | ICD10CM | Covered |
| B96.83 | ICD10CM | Covered |
| B97.21 | ICD10CM | Covered |
| B97.29 | ICD10CM | Covered |
| B97.35 | ICD10CM | Covered |
| B99.9 | ICD10CM | Covered |
| C46.0 | ICD10CM | Covered |
| C46.1 | ICD10CM | Covered |
| C46.2 | ICD10CM | Covered |
| C46.3 | ICD10CM | Covered |
| C46.4 | ICD10CM | Covered |
| C46.50 | ICD10CM | Covered |
| C46.51 | ICD10CM | Covered |
| C46.52 | ICD10CM | Covered |
| C46.7 | ICD10CM | Covered |
| D26.0 | ICD10CM | Covered |
| D57.01 | ICD10CM | Covered |
| D59.30 | ICD10CM | Covered |
| D59.31 | ICD10CM | Covered |
| D61.03 | ICD10CM | Covered |
| D61.09 | ICD10CM | Covered |
| D61.1 | ICD10CM | Covered |
| D61.2 | ICD10CM | Covered |
| D61.3 | ICD10CM | Covered |
| D61.810 | ICD10CM | Covered |
| D61.811 | ICD10CM | Covered |
| D61.818 | ICD10CM | Covered |
| D61.82 | ICD10CM | Covered |
| D61.89 | ICD10CM | Covered |
| D61.9 | ICD10CM | Covered |
| D64.81 | ICD10CM | Covered |
| D64.89 | ICD10CM | Covered |
| D70.0 | ICD10CM | Covered |
| D70.1 | ICD10CM | Covered |
| D70.2 | ICD10CM | Covered |
| D70.3 | ICD10CM | Covered |
| D70.4 | ICD10CM | Covered |
| D70.9 | ICD10CM | Covered |
| D71.1 | ICD10CM | Covered |
| D71.8 | ICD10CM | Covered |
| D71.9 | ICD10CM | Covered |
| D80.0 | ICD10CM | Covered |
| D80.1 | ICD10CM | Covered |
| D80.2 | ICD10CM | Covered |
| D80.3 | ICD10CM | Covered |
| D80.4 | ICD10CM | Covered |
| D80.5 | ICD10CM | Covered |
| D80.6 | ICD10CM | Covered |
| D80.8 | ICD10CM | Covered |
| D80.9 | ICD10CM | Covered |
| D81.0 | ICD10CM | Covered |
| D81.1 | ICD10CM | Covered |
| D81.2 | ICD10CM | Covered |
| D81.30 | ICD10CM | Covered |
| D81.31 | ICD10CM | Covered |
| D81.32 | ICD10CM | Covered |
| D81.39 | ICD10CM | Covered |
| D81.4 | ICD10CM | Covered |
| D81.5 | ICD10CM | Covered |
| D81.6 | ICD10CM | Covered |
| D81.7 | ICD10CM | Covered |
| D81.810 | ICD10CM | Covered |
| D81.818 | ICD10CM | Covered |
| D81.82 | ICD10CM | Covered |
| D81.89 | ICD10CM | Covered |
| D81.9 | ICD10CM | Covered |
| D82.0 | ICD10CM | Covered |
| D82.1 | ICD10CM | Covered |
| D82.2 | ICD10CM | Covered |
| D82.3 | ICD10CM | Covered |
| D82.4 | ICD10CM | Covered |
| D82.8 | ICD10CM | Covered |
| D83.0 | ICD10CM | Covered |
| D83.1 | ICD10CM | Covered |
| D83.2 | ICD10CM | Covered |
| D83.8 | ICD10CM | Covered |
| D83.9 | ICD10CM | Covered |
| D84.0 | ICD10CM | Covered |
| D84.1 | ICD10CM | Covered |
| D84.821 | ICD10CM | Covered |
| D84.822 | ICD10CM | Covered |
| D84.89 | ICD10CM | Covered |
| D84.9 | ICD10CM | Covered |
| D89.0 | ICD10CM | Covered |
| D89.1 | ICD10CM | Covered |
| D89.3 | ICD10CM | Covered |
| D89.41 | ICD10CM | Covered |
| D89.42 | ICD10CM | Covered |
| D89.43 | ICD10CM | Covered |
| D89.44 | ICD10CM | Covered |
| D89.49 | ICD10CM | Covered |
| D89.810 | ICD10CM | Covered |
| D89.811 | ICD10CM | Covered |
| D89.812 | ICD10CM | Covered |
| D89.813 | ICD10CM | Covered |
| D89.82 | ICD10CM | Covered |
| D89.89 | ICD10CM | Covered |
| E08.43 | ICD10CM | Covered |
| E08.52 | ICD10CM | Covered |
| E10.43 | ICD10CM | Covered |
| E10.52 | ICD10CM | Covered |
| E11.43 | ICD10CM | Covered |
| E11.52 | ICD10CM | Covered |
| E13.43 | ICD10CM | Covered |
| E84.0 | ICD10CM | Covered |
| G00.0 | ICD10CM | Covered |
| G00.1 | ICD10CM | Covered |
| G00.2 | ICD10CM | Covered |
| G00.8 | ICD10CM | Covered |
| G00.9 | ICD10CM | Covered |
| G03.0 | ICD10CM | Covered |
| G03.9 | ICD10CM | Covered |
| G04.01 | ICD10CM | Covered |
| G04.02 | ICD10CM | Covered |
| G04.30 | ICD10CM | Covered |
| G04.31 | ICD10CM | Covered |
| G04.32 | ICD10CM | Covered |
| G04.39 | ICD10CM | Covered |
| G04.81 | ICD10CM | Covered |
| G04.82 | ICD10CM | Covered |
| G04.89 | ICD10CM | Covered |
| G04.90 | ICD10CM | Covered |
| G04.91 | ICD10CM | Covered |
| G05.3 | ICD10CM | Covered |
| G05.4 | ICD10CM | Covered |
| I33.0 | ICD10CM | Covered |
| J05.0 | ICD10CM | Covered |
| J06.9 | 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 |
| J10.2 | ICD10CM | Covered |
| J10.81 | ICD10CM | Covered |
| J10.82 | ICD10CM | Covered |
| J10.83 | ICD10CM | Covered |
| J10.89 | ICD10CM | Covered |
| J11.08 | ICD10CM | Covered |
| J11.1 | ICD10CM | Covered |
| J11.2 | ICD10CM | Covered |
| J11.81 | ICD10CM | Covered |
| J11.82 | ICD10CM | Covered |
| J11.83 | ICD10CM | Covered |
| J11.89 | ICD10CM | Covered |
| J12.0 | ICD10CM | Covered |
| J12.1 | ICD10CM | Covered |
| J12.2 | ICD10CM | Covered |
| J12.3 | ICD10CM | Covered |
| J12.81 | ICD10CM | Covered |
| J12.82 | ICD10CM | Covered |
| J12.89 | ICD10CM | Covered |
| J12.9 | ICD10CM | Covered |
| J13 | ICD10CM | Covered |
| J15.0 | ICD10CM | Covered |
| J15.1 | ICD10CM | Covered |
| J15.20 | ICD10CM | Covered |
| J15.211 | ICD10CM | Covered |
| J15.212 | ICD10CM | Covered |
| J15.29 | ICD10CM | Covered |
| J15.3 | ICD10CM | Covered |
| J15.4 | ICD10CM | Covered |
| J15.61 | ICD10CM | Covered |
| J15.69 | ICD10CM | Covered |
| J15.7 | ICD10CM | Covered |
| J15.8 | ICD10CM | Covered |
| J15.9 | ICD10CM | Covered |
| J16.0 | ICD10CM | Covered |
| J16.8 | ICD10CM | Covered |
| J18.0 | ICD10CM | Covered |
| J18.1 | ICD10CM | Covered |
| J18.2 | ICD10CM | Covered |
| J18.8 | ICD10CM | Covered |
| J18.9 | ICD10CM | Covered |
| J20.0 | ICD10CM | Covered |
| J20.1 | ICD10CM | Covered |
| J20.2 | ICD10CM | Covered |
| J20.3 | ICD10CM | Covered |
| J20.4 | ICD10CM | Covered |
| J20.5 | ICD10CM | Covered |
| J20.6 | ICD10CM | Covered |
| J20.8 | ICD10CM | Covered |
| J20.9 | ICD10CM | Covered |
| J21.9 | ICD10CM | Covered |
| J22 | ICD10CM | Covered |
| J44.0 | ICD10CM | Covered |
| J44.1 | ICD10CM | Covered |
| J44.81 | ICD10CM | Covered |
| J44.89 | ICD10CM | Covered |
| J44.9 | ICD10CM | Covered |
| J45.31 | ICD10CM | Covered |
| J45.32 | ICD10CM | Covered |
| J45.41 | ICD10CM | Covered |
| J45.42 | ICD10CM | Covered |
| J45.51 | ICD10CM | Covered |
| J45.52 | ICD10CM | Covered |
| J45.901 | ICD10CM | Covered |
| J45.902 | ICD10CM | Covered |
| J45.991 | ICD10CM | Covered |
| J70.1 | ICD10CM | Covered |
| J84.01 | ICD10CM | Covered |
| J84.02 | ICD10CM | Covered |
| J84.03 | ICD10CM | Covered |
| J84.10 | ICD10CM | Covered |
| J84.112 | ICD10CM | Covered |
| J84.114 | 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 |
| J84.89 | ICD10CM | Covered |
| J85.0 | ICD10CM | Covered |
| J85.1 | ICD10CM | Covered |
| J85.2 | ICD10CM | Covered |
| J85.3 | ICD10CM | Covered |
| K35.200 | ICD10CM | Covered |
| K35.201 | ICD10CM | Covered |
| K35.209 | ICD10CM | Covered |
| K35.210 | ICD10CM | Covered |
| K35.211 | ICD10CM | Covered |
| K35.219 | ICD10CM | Covered |
| K50.011 | ICD10CM | Covered |
| K50.012 | ICD10CM | Covered |
| K50.013 | ICD10CM | Covered |
| K50.014 | ICD10CM | Covered |
| K50.018 | ICD10CM | Covered |
| K50.111 | ICD10CM | Covered |
| K50.112 | ICD10CM | Covered |
| K50.113 | ICD10CM | Covered |
| K50.114 | ICD10CM | Covered |
| K50.118 | ICD10CM | Covered |
| K50.812 | ICD10CM | Covered |
| K50.813 | ICD10CM | Covered |
| K50.814 | ICD10CM | Covered |
| K50.818 | ICD10CM | Covered |
| K50.911 | ICD10CM | Covered |
| K50.912 | ICD10CM | Covered |
| K50.913 | ICD10CM | Covered |
| K50.914 | ICD10CM | Covered |
| K50.918 | ICD10CM | Covered |
| K51.011 | ICD10CM | Covered |
| K51.012 | ICD10CM | Covered |
| K51.013 | ICD10CM | Covered |
| K51.014 | ICD10CM | Covered |
| K51.018 | ICD10CM | Covered |
| K51.019 | ICD10CM | Covered |
| K51.211 | ICD10CM | Covered |
| K51.212 | ICD10CM | Covered |
| K51.213 | ICD10CM | Covered |
| K51.214 | ICD10CM | Covered |
| K51.218 | ICD10CM | Covered |
| K51.219 | ICD10CM | Covered |
| K51.311 | ICD10CM | Covered |
| K51.312 | ICD10CM | Covered |
| K51.313 | ICD10CM | Covered |
| K51.314 | ICD10CM | Covered |
| K51.318 | ICD10CM | Covered |
| K51.319 | ICD10CM | Covered |
| K51.411 | ICD10CM | Covered |
| K51.412 | ICD10CM | Covered |
| K51.413 | ICD10CM | Covered |
| K51.414 | ICD10CM | Covered |
| K51.418 | ICD10CM | Covered |
| K51.419 | ICD10CM | Covered |
| K51.511 | ICD10CM | Covered |
| K51.512 | ICD10CM | Covered |
| K51.513 | ICD10CM | Covered |
| K51.514 | ICD10CM | Covered |
| K51.518 | ICD10CM | Covered |
| K51.519 | ICD10CM | Covered |
| K51.811 | ICD10CM | Covered |
| K51.812 | ICD10CM | Covered |
| K51.813 | ICD10CM | Covered |
| K51.814 | ICD10CM | Covered |
| K51.818 | ICD10CM | Covered |
| K51.911 | ICD10CM | Covered |
| K51.912 | ICD10CM | Covered |
| K51.913 | ICD10CM | Covered |
| K51.914 | ICD10CM | Covered |
| K51.918 | ICD10CM | Covered |
| K52.0 | ICD10CM | Covered |
| K52.1 | ICD10CM | Covered |
| K56.0 | ICD10CM | Covered |
| K56.3 | ICD10CM | Covered |
| K62.7 | ICD10CM | Covered |
| K63.8211 | ICD10CM | Covered |
| K63.8212 | ICD10CM | Covered |
| K63.8219 | ICD10CM | Covered |
| K63.822 | ICD10CM | Covered |
| K63.829 | ICD10CM | Covered |
| K92.1 | ICD10CM | Covered |
| L29.2 | ICD10CM | Covered |
| L29.3 | ICD10CM | Covered |
| M00.00 | ICD10CM | Covered |
| M00.011 | ICD10CM | Covered |
| M00.012 | ICD10CM | Covered |
| M00.019 | ICD10CM | Covered |
| M00.021 | ICD10CM | Covered |
| M00.022 | ICD10CM | Covered |
| M00.029 | ICD10CM | Covered |
| M00.031 | ICD10CM | Covered |
| M00.032 | ICD10CM | Covered |
| M00.039 | ICD10CM | Covered |
| M00.041 | ICD10CM | Covered |
| M00.042 | ICD10CM | Covered |
| M00.049 | ICD10CM | Covered |
| M00.051 | ICD10CM | Covered |
| M00.052 | ICD10CM | Covered |
| M00.059 | ICD10CM | Covered |
| M00.061 | ICD10CM | Covered |
| M00.062 | ICD10CM | Covered |
| M00.069 | ICD10CM | Covered |
| M00.071 | ICD10CM | Covered |
| M00.072 | ICD10CM | Covered |
| M00.079 | ICD10CM | Covered |
| M00.08 | ICD10CM | Covered |
| M00.09 | ICD10CM | Covered |
| M00.10 | ICD10CM | Covered |
| M00.111 | ICD10CM | Covered |
| M00.112 | ICD10CM | Covered |
| M00.119 | ICD10CM | Covered |
| M00.121 | ICD10CM | Covered |
| M00.122 | ICD10CM | Covered |
| M00.129 | ICD10CM | Covered |
| M00.131 | ICD10CM | Covered |
| M00.132 | ICD10CM | Covered |
| M00.139 | ICD10CM | Covered |
| M00.141 | ICD10CM | Covered |
| M00.142 | ICD10CM | Covered |
| M00.149 | ICD10CM | Covered |
| M00.151 | ICD10CM | Covered |
| M00.152 | ICD10CM | Covered |
| M00.159 | ICD10CM | Covered |
| M00.161 | ICD10CM | Covered |
| M00.162 | ICD10CM | Covered |
| M00.169 | ICD10CM | Covered |
| M00.171 | ICD10CM | Covered |
| M00.172 | ICD10CM | Covered |
| M00.179 | ICD10CM | Covered |
| M00.18 | ICD10CM | Covered |
| M00.211 | ICD10CM | Covered |
| M00.212 | ICD10CM | Covered |
| M00.219 | ICD10CM | Covered |
| M00.221 | ICD10CM | Covered |
| M00.222 | ICD10CM | Covered |
| M00.229 | ICD10CM | Covered |
| M00.231 | ICD10CM | Covered |
| M00.232 | ICD10CM | Covered |
| M00.239 | ICD10CM | Covered |
| M00.241 | ICD10CM | Covered |
| M00.242 | ICD10CM | Covered |
| M00.249 | ICD10CM | Covered |
| M00.251 | ICD10CM | Covered |
| M00.252 | ICD10CM | Covered |
| M00.259 | ICD10CM | Covered |
| M00.261 | ICD10CM | Covered |
| M00.262 | ICD10CM | Covered |
| M00.269 | ICD10CM | Covered |
| M00.271 | ICD10CM | Covered |
| M00.272 | ICD10CM | Covered |
| M00.279 | ICD10CM | Covered |
| M00.28 | ICD10CM | Covered |
| M00.29 | ICD10CM | Covered |
| M00.80 | ICD10CM | Covered |
| M00.811 | ICD10CM | Covered |
| M00.812 | ICD10CM | Covered |
| M00.819 | ICD10CM | Covered |
| M00.821 | ICD10CM | Covered |
| M00.822 | ICD10CM | Covered |
| M00.829 | ICD10CM | Covered |
| M00.831 | ICD10CM | Covered |
| M00.832 | ICD10CM | Covered |
| M00.839 | ICD10CM | Covered |
| M00.841 | ICD10CM | Covered |
| M00.842 | ICD10CM | Covered |
| M00.849 | ICD10CM | Covered |
| M00.851 | ICD10CM | Covered |
| M00.852 | ICD10CM | Covered |
| M00.859 | ICD10CM | Covered |
| M00.861 | ICD10CM | Covered |
| M00.862 | ICD10CM | Covered |
| M00.869 | ICD10CM | Covered |
| M00.871 | ICD10CM | Covered |
| M00.872 | ICD10CM | Covered |
| M00.879 | ICD10CM | Covered |
| M00.88 | ICD10CM | Covered |
| M00.89 | ICD10CM | Covered |
| M00.9 | ICD10CM | Covered |
| M01.X0 | ICD10CM | Covered |
| M01.X11 | ICD10CM | Covered |
| M01.X12 | ICD10CM | Covered |
| M01.X19 | ICD10CM | Covered |
| M01.X21 | ICD10CM | Covered |
| M01.X22 | ICD10CM | Covered |
| M01.X29 | ICD10CM | Covered |
| M01.X31 | ICD10CM | Covered |
| M01.X32 | ICD10CM | Covered |
| M01.X39 | ICD10CM | Covered |
| M01.X41 | ICD10CM | Covered |
| M01.X42 | ICD10CM | Covered |
| M01.X49 | ICD10CM | Covered |
| M01.X51 | ICD10CM | Covered |
| M01.X52 | ICD10CM | Covered |
| M01.X59 | ICD10CM | Covered |
| M01.X61 | ICD10CM | Covered |
| M01.X62 | ICD10CM | Covered |
| M01.X69 | ICD10CM | Covered |
| M01.X71 | ICD10CM | Covered |
| M01.X72 | ICD10CM | Covered |
| M01.X79 | ICD10CM | Covered |
| M01.X8 | ICD10CM | Covered |
| M01.X9 | ICD10CM | Covered |
| M31.19 | ICD10CM | Covered |
| N34.1 | ICD10CM | Covered |
| N34.2 | ICD10CM | Covered |
| N41.0 | ICD10CM | Covered |
| N41.3 | ICD10CM | Covered |
| N48.5 | ICD10CM | Covered |
| N76.0 | ICD10CM | Covered |
| N76.1 | ICD10CM | Covered |
| N76.2 | ICD10CM | Covered |
| N76.3 | ICD10CM | Covered |
| N76.5 | ICD10CM | Covered |
| N76.6 | ICD10CM | Covered |
| N76.82 | ICD10CM | Covered |
| N76.89 | ICD10CM | Covered |
| N77.1 | ICD10CM | Covered |
| N89.8 | ICD10CM | Covered |
| N90.89 | ICD10CM | Covered |
| N93.0 | ICD10CM | Covered |
| N93.8 | ICD10CM | Covered |
| O09.90 | ICD10CM | Covered |
| O09.91 | ICD10CM | Covered |
| O09.92 | ICD10CM | Covered |
| O09.93 | ICD10CM | Covered |
| O98.711 | ICD10CM | Covered |
| O98.712 | ICD10CM | Covered |
| O98.713 | ICD10CM | Covered |
| R05.1 | ICD10CM | Covered |
| R05.2 | ICD10CM | Covered |
| R05.3 | ICD10CM | Covered |
| R05.8 | ICD10CM | Covered |
| R06.02 | ICD10CM | Covered |
| R06.03 | ICD10CM | Covered |
| R06.2 | ICD10CM | Covered |
| R10.0 | ICD10CM | Covered |
| R10.11 | ICD10CM | Covered |
| R10.12 | ICD10CM | Covered |
| R10.13 | ICD10CM | Covered |
| R10.20 | ICD10CM | Covered |
| R10.21 | ICD10CM | Covered |
| R10.22 | ICD10CM | Covered |
| R10.23 | ICD10CM | Covered |
| R10.24 | ICD10CM | Covered |
| R10.31 | ICD10CM | Covered |
| R10.32 | ICD10CM | Covered |
| R10.33 | ICD10CM | Covered |
| R10.811 | ICD10CM | Covered |
| R10.812 | ICD10CM | Covered |
| R10.813 | ICD10CM | Covered |
| R10.814 | ICD10CM | Covered |
| R10.815 | ICD10CM | Covered |
| R10.817 | ICD10CM | Covered |
| R10.821 | ICD10CM | Covered |
| R10.822 | ICD10CM | Covered |
| R10.823 | ICD10CM | Covered |
| R10.824 | ICD10CM | Covered |
| R10.825 | ICD10CM | Covered |
| R10.826 | ICD10CM | Covered |
| R10.827 | ICD10CM | Covered |
| R10.829 | ICD10CM | Covered |
| R10.84 | ICD10CM | Covered |
| R10.85 | ICD10CM | Covered |
| R10.8A3 | ICD10CM | Covered |
| R19.5 | ICD10CM | Covered |
| R19.7 | ICD10CM | Covered |
| R30.0 | ICD10CM | Covered |
| R41.82 | ICD10CM | Covered |
| R50.81 | ICD10CM | Covered |
| R50.9 | ICD10CM | Covered |
| R65.20 | ICD10CM | Covered |
| R65.21 | ICD10CM | Covered |
| R78.81 | ICD10CM | Covered |
| T74.21XA | ICD10CM | Covered |
| T74.21XD | ICD10CM | Covered |
| T74.21XS | ICD10CM | Covered |
| T74.51XA | ICD10CM | Covered |
| T74.51XD | ICD10CM | Covered |
| T74.51XS | ICD10CM | Covered |
| T76.21XA | ICD10CM | Covered |
| T76.21XD | ICD10CM | Covered |
| T76.21XS | ICD10CM | Covered |
| T76.51XA | ICD10CM | Covered |
| T76.51XD | ICD10CM | Covered |
| T76.51XS | ICD10CM | Covered |
| T80.211A | ICD10CM | Covered |
| T80.211D | ICD10CM | Covered |
| T80.211S | ICD10CM | Covered |
| T80.218A | ICD10CM | Covered |
| T80.218D | ICD10CM | Covered |
| T80.218S | ICD10CM | Covered |
| T80.219A | ICD10CM | Covered |
| T80.219D | ICD10CM | Covered |
| T80.219S | ICD10CM | Covered |
| T80.22XA | ICD10CM | Covered |
| T80.22XD | ICD10CM | Covered |
| T80.22XS | ICD10CM | Covered |
| T80.29XA | ICD10CM | Covered |
| T80.29XD | ICD10CM | Covered |
| T80.29XS | ICD10CM | Covered |
| T80.82XS | ICD10CM | Covered |
| T82.6XXA | ICD10CM | Covered |
| T82.6XXD | ICD10CM | Covered |
| T82.6XXS | ICD10CM | Covered |
| T82.7XXA | ICD10CM | Covered |
| T82.7XXD | ICD10CM | Covered |
| T82.7XXS | ICD10CM | Covered |
| T84.50XA | ICD10CM | Covered |
| T84.50XD | ICD10CM | Covered |
| T84.50XS | ICD10CM | Covered |
| T84.51XA | ICD10CM | Covered |
| T84.51XD | ICD10CM | Covered |
| T84.51XS | ICD10CM | Covered |
| T84.52XA | ICD10CM | Covered |
| T84.52XD | ICD10CM | Covered |
| T84.52XS | ICD10CM | Covered |
| T84.53XA | ICD10CM | Covered |
| T84.53XD | ICD10CM | Covered |
| T84.53XS | ICD10CM | Covered |
| T84.54XA | ICD10CM | Covered |
| T84.54XD | ICD10CM | Covered |
| T84.54XS | ICD10CM | Covered |
| T84.59XA | ICD10CM | Covered |
| T84.59XD | ICD10CM | Covered |
| T84.59XS | ICD10CM | Covered |
| T84.60XA | ICD10CM | Covered |
| T84.60XD | ICD10CM | Covered |
| T84.60XS | ICD10CM | Covered |
| T84.610A | ICD10CM | Covered |
| T84.610D | ICD10CM | Covered |
| T84.610S | ICD10CM | Covered |
| T84.611A | ICD10CM | Covered |
| T84.611D | ICD10CM | Covered |
| T84.611S | ICD10CM | Covered |
| T84.612A | ICD10CM | Covered |
| T84.612D | ICD10CM | Covered |
| T84.612S | ICD10CM | Covered |
| T84.613A | ICD10CM | Covered |
| T84.613D | ICD10CM | Covered |
| T84.613S | ICD10CM | Covered |
| T84.614A | ICD10CM | Covered |
| T84.614D | ICD10CM | Covered |
| T84.614S | ICD10CM | Covered |
| T84.615A | ICD10CM | Covered |
| T84.615D | ICD10CM | Covered |
| T84.615S | ICD10CM | Covered |
| T84.619A | ICD10CM | Covered |
| T84.619D | ICD10CM | Covered |
| T84.619S | ICD10CM | Covered |
| T84.620A | ICD10CM | Covered |
| T84.620D | ICD10CM | Covered |
| T84.620S | ICD10CM | Covered |
| T84.621A | ICD10CM | Covered |
| T84.621D | ICD10CM | Covered |
| T84.621S | ICD10CM | Covered |
| T84.622A | ICD10CM | Covered |
| T84.622D | ICD10CM | Covered |
| T84.622S | ICD10CM | Covered |
| T84.623A | ICD10CM | Covered |
| T84.623D | ICD10CM | Covered |
| T84.623S | ICD10CM | Covered |
| T84.624A | ICD10CM | Covered |
| T84.624D | ICD10CM | Covered |
| T84.624S | ICD10CM | Covered |
| T84.625A | ICD10CM | Covered |
| T84.625D | ICD10CM | Covered |
| T84.625S | ICD10CM | Covered |
| T84.629A | ICD10CM | Covered |
| T84.629D | ICD10CM | Covered |
| T84.629S | ICD10CM | Covered |
| T84.63XA | ICD10CM | Covered |
| T84.63XD | ICD10CM | Covered |
| T84.63XS | ICD10CM | Covered |
| T84.69XA | ICD10CM | Covered |
| T84.69XD | ICD10CM | Covered |
| T84.69XS | ICD10CM | Covered |
| T84.7XXA | ICD10CM | Covered |
| T84.7XXD | ICD10CM | Covered |
| T84.7XXS | ICD10CM | Covered |
| T85.71XA | ICD10CM | Covered |
| T85.71XD | ICD10CM | Covered |
| T85.71XS | ICD10CM | Covered |
| T85.72XA | ICD10CM | Covered |
| T85.72XD | ICD10CM | Covered |
| T85.72XS | ICD10CM | Covered |
| T86.03 | ICD10CM | Covered |
| T86.23 | ICD10CM | Covered |
| T86.33 | ICD10CM | Covered |
| T86.5 | ICD10CM | Covered |
| T86.812 | ICD10CM | Covered |
| T86.852 | ICD10CM | Covered |
| U07.1 | ICD10CM | Covered |
| W57.XXXA | ICD10CM | Covered |
| W57.XXXD | ICD10CM | Covered |
| W57.XXXS | ICD10CM | Covered |
| Z03.818 | ICD10CM | Covered |
| Z04.41 | ICD10CM | Covered |
| Z04.71 | ICD10CM | Covered |
| Z04.81 | ICD10CM | Covered |
| Z11.3 | ICD10CM | Covered |
| Z20.2 | ICD10CM | Covered |
| Z20.6 | ICD10CM | Covered |
| Z21 | ICD10CM | Covered |
| Z33.1 | ICD10CM | Covered |
| Z33.3 | ICD10CM | Covered |
| Z34.00 | ICD10CM | Covered |
| Z34.01 | ICD10CM | Covered |
| Z34.02 | ICD10CM | Covered |
| Z34.03 | ICD10CM | Covered |
| Z34.80 | ICD10CM | Covered |
| Z34.81 | ICD10CM | Covered |
| Z34.82 | ICD10CM | Covered |
| Z34.83 | ICD10CM | Covered |
| Z34.90 | ICD10CM | Covered |
| Z34.91 | ICD10CM | Covered |
| Z34.92 | ICD10CM | Covered |
| Z34.93 | ICD10CM | Covered |
| Z51.11 | ICD10CM | Covered |
| Z72.51 | ICD10CM | Covered |
| Z72.52 | ICD10CM | Covered |
| Z72.53 | ICD10CM | Covered |
| Z72.89 | ICD10CM | Covered |
| Z92.850 | ICD10CM | Covered |
| Z92.858 | ICD10CM | Covered |
| Z92.86 | ICD10CM | Covered |
| Z94.0 | ICD10CM | Covered |
| Z94.1 | ICD10CM | Covered |
| Z94.2 | ICD10CM | Covered |
| Z94.3 | ICD10CM | Covered |
| Z94.4 | ICD10CM | Covered |
| Z94.5 | ICD10CM | Covered |
| Z94.6 | ICD10CM | Covered |
| Z94.81 | ICD10CM | Covered |
| Z94.82 | ICD10CM | Covered |
| Z94.83 | ICD10CM | Covered |
| Z94.84 | ICD10CM | Covered |
| Z94.89 | ICD10CM | Covered |