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 |
|---|---|---|
| 0032U | HCPCS | Covered |
| 0070U | HCPCS | Covered |
| 0071U | HCPCS | Covered |
| 0072U | HCPCS | Covered |
| 0073U | HCPCS | Covered |
| 0074U | HCPCS | Covered |
| 0075U | HCPCS | Covered |
| 0076U | HCPCS | Covered |
| 0117U | HCPCS | Covered |
| 0173U | HCPCS | Covered |
| 0175U | HCPCS | Covered |
| 0193U | HCPCS | Covered |
| 0286U | HCPCS | Covered |
| 0349U | HCPCS | Covered |
| 0392U | HCPCS | Covered |
| 81220 | HCPCS | Covered |
| 81225 | HCPCS | Covered |
| 81226 | HCPCS | Covered |
| 81227 | HCPCS | Covered |
| 81230 | HCPCS | Covered |
| 81231 | HCPCS | Covered |
| 81232 | HCPCS | Covered |
| 81247 | HCPCS | Covered |
| 81283 | HCPCS | Covered |
| 81306 | HCPCS | Covered |
| 81328 | HCPCS | Covered |
| 81335 | HCPCS | Covered |
| 81346 | HCPCS | Covered |
| 81350 | HCPCS | Covered |
| 81355 | HCPCS | Covered |
| 81374 | HCPCS | Covered |
| 81377 | HCPCS | Covered |
| 81381 | HCPCS | Covered |
| 81383 | HCPCS | Covered |
| 81401 | HCPCS | Covered |
| 81406 | HCPCS | Covered |
| 81407 | HCPCS | Covered |
| 81408 | HCPCS | Covered |
| 81418 | HCPCS | Covered |
| 81479 | HCPCS | Covered |
| A03.8 | ICD10CM | Covered |
| A03.9 | ICD10CM | Covered |
| A04.4 | ICD10CM | Covered |
| A15.9 | ICD10CM | Covered |
| A17.9 | ICD10CM | Covered |
| A18.01 | ICD10CM | Covered |
| A18.02 | ICD10CM | Covered |
| A18.03 | ICD10CM | Covered |
| A18.09 | ICD10CM | Covered |
| A18.10 | ICD10CM | Covered |
| A18.11 | ICD10CM | Covered |
| A18.12 | ICD10CM | Covered |
| A18.13 | ICD10CM | Covered |
| A18.14 | ICD10CM | Covered |
| A18.15 | ICD10CM | Covered |
| A18.16 | ICD10CM | Covered |
| A18.17 | ICD10CM | Covered |
| A18.18 | ICD10CM | Covered |
| A18.2 | ICD10CM | Covered |
| A18.31 | ICD10CM | Covered |
| A18.32 | ICD10CM | Covered |
| A18.39 | ICD10CM | Covered |
| A18.4 | ICD10CM | Covered |
| A18.50 | ICD10CM | Covered |
| A18.51 | ICD10CM | Covered |
| A18.52 | ICD10CM | Covered |
| A18.53 | ICD10CM | Covered |
| A18.54 | ICD10CM | Covered |
| A18.59 | ICD10CM | Covered |
| A18.6 | ICD10CM | Covered |
| A18.7 | ICD10CM | Covered |
| A18.81 | ICD10CM | Covered |
| A18.82 | ICD10CM | Covered |
| A18.83 | ICD10CM | Covered |
| A18.84 | ICD10CM | Covered |
| A18.85 | ICD10CM | Covered |
| A18.89 | ICD10CM | Covered |
| A19.8 | ICD10CM | Covered |
| A19.9 | ICD10CM | Covered |
| B18.0 | ICD10CM | Covered |
| B18.1 | ICD10CM | Covered |
| B18.2 | ICD10CM | Covered |
| B20 | ICD10CM | Covered |
| B37.81 | ICD10CM | Covered |
| B37.89 | ICD10CM | Covered |
| B44.0 | ICD10CM | Covered |
| B48.8 | ICD10CM | Covered |
| B51.0 | ICD10CM | Covered |
| B51.8 | ICD10CM | Covered |
| B51.9 | ICD10CM | Covered |
| B59 | ICD10CM | Covered |
| B96.20 | ICD10CM | Covered |
| C15.3 | ICD10CM | Covered |
| C15.4 | ICD10CM | Covered |
| C15.5 | ICD10CM | Covered |
| C15.8 | ICD10CM | Covered |
| C15.9 | ICD10CM | Covered |
| C16.0 | ICD10CM | Covered |
| C16.1 | ICD10CM | Covered |
| C16.2 | ICD10CM | Covered |
| C16.3 | ICD10CM | Covered |
| C16.4 | ICD10CM | Covered |
| C16.5 | ICD10CM | Covered |
| C16.6 | ICD10CM | Covered |
| C16.8 | ICD10CM | Covered |
| C16.9 | ICD10CM | Covered |
| C18.9 | ICD10CM | Covered |
| C19 | ICD10CM | Covered |
| C20 | ICD10CM | Covered |
| C25.0 | ICD10CM | Covered |
| C25.1 | ICD10CM | Covered |
| C25.2 | ICD10CM | Covered |
| C25.3 | ICD10CM | Covered |
| C25.4 | ICD10CM | Covered |
| C25.7 | ICD10CM | Covered |
| C25.8 | ICD10CM | Covered |
| C25.9 | ICD10CM | Covered |
| C34.90 | ICD10CM | Covered |
| C43.0 | ICD10CM | Covered |
| C43.111 | ICD10CM | Covered |
| C43.112 | ICD10CM | Covered |
| C43.121 | ICD10CM | Covered |
| C43.122 | ICD10CM | Covered |
| C43.21 | ICD10CM | Covered |
| C43.22 | ICD10CM | Covered |
| C43.31 | ICD10CM | Covered |
| C43.39 | ICD10CM | Covered |
| C43.4 | ICD10CM | Covered |
| C43.51 | ICD10CM | Covered |
| C43.52 | ICD10CM | Covered |
| C43.59 | ICD10CM | Covered |
| C43.61 | ICD10CM | Covered |
| C43.62 | ICD10CM | Covered |
| C43.71 | ICD10CM | Covered |
| C43.72 | ICD10CM | Covered |
| C43.8 | ICD10CM | Covered |
| C43.9 | ICD10CM | Covered |
| C49.9 | ICD10CM | Covered |
| C50.011 | ICD10CM | Covered |
| C50.012 | ICD10CM | Covered |
| C50.019 | ICD10CM | Covered |
| C50.021 | ICD10CM | Covered |
| C50.022 | ICD10CM | Covered |
| C50.029 | ICD10CM | Covered |
| C50.111 | ICD10CM | Covered |
| C50.112 | ICD10CM | Covered |
| C50.119 | ICD10CM | Covered |
| C50.121 | ICD10CM | Covered |
| C50.122 | ICD10CM | Covered |
| C50.129 | ICD10CM | Covered |
| C50.211 | ICD10CM | Covered |
| C50.212 | ICD10CM | Covered |
| C50.219 | ICD10CM | Covered |
| C50.221 | ICD10CM | Covered |
| C50.222 | ICD10CM | Covered |
| C50.229 | ICD10CM | Covered |
| C50.311 | ICD10CM | Covered |
| C50.312 | ICD10CM | Covered |
| C50.319 | ICD10CM | Covered |
| C50.321 | ICD10CM | Covered |
| C50.322 | ICD10CM | Covered |
| C50.329 | ICD10CM | Covered |
| C50.411 | ICD10CM | Covered |
| C50.412 | ICD10CM | Covered |
| C50.419 | ICD10CM | Covered |
| C50.421 | ICD10CM | Covered |
| C50.422 | ICD10CM | Covered |
| C50.429 | ICD10CM | Covered |
| C50.511 | ICD10CM | Covered |
| C50.512 | ICD10CM | Covered |
| C50.519 | ICD10CM | Covered |
| C50.521 | ICD10CM | Covered |
| C50.522 | ICD10CM | Covered |
| C50.529 | ICD10CM | Covered |
| C50.611 | ICD10CM | Covered |
| C50.612 | ICD10CM | Covered |
| C50.619 | ICD10CM | Covered |
| C50.621 | ICD10CM | Covered |
| C50.622 | ICD10CM | Covered |
| C50.629 | ICD10CM | Covered |
| C50.811 | ICD10CM | Covered |
| C50.812 | ICD10CM | Covered |
| C50.819 | ICD10CM | Covered |
| C50.821 | ICD10CM | Covered |
| C50.822 | ICD10CM | Covered |
| C50.829 | ICD10CM | Covered |
| C50.911 | ICD10CM | Covered |
| C50.912 | ICD10CM | Covered |
| C50.919 | ICD10CM | Covered |
| C50.921 | ICD10CM | Covered |
| C50.922 | ICD10CM | Covered |
| C50.929 | ICD10CM | Covered |
| C50.A0 | ICD10CM | Covered |
| C50.A1 | ICD10CM | Covered |
| C50.A2 | ICD10CM | Covered |
| C64.1 | ICD10CM | Covered |
| C64.2 | ICD10CM | Covered |
| C64.9 | ICD10CM | Covered |
| C65.1 | ICD10CM | Covered |
| C65.2 | ICD10CM | Covered |
| C66.1 | ICD10CM | Covered |
| C66.2 | ICD10CM | Covered |
| C67.0 | ICD10CM | Covered |
| C67.1 | ICD10CM | Covered |
| C67.2 | ICD10CM | Covered |
| C67.3 | ICD10CM | Covered |
| C67.4 | ICD10CM | Covered |
| C67.5 | ICD10CM | Covered |
| C67.6 | ICD10CM | Covered |
| C67.7 | ICD10CM | Covered |
| C67.8 | ICD10CM | Covered |
| C67.9 | ICD10CM | Covered |
| C68.0 | ICD10CM | Covered |
| C68.1 | ICD10CM | Covered |
| C68.8 | ICD10CM | Covered |
| C7A.093 | ICD10CM | Covered |
| C84.40 | ICD10CM | Covered |
| C84.48 | ICD10CM | Covered |
| C91.00 | ICD10CM | Covered |
| C91.01 | ICD10CM | Covered |
| C91.02 | ICD10CM | Covered |
| C92.00 | ICD10CM | Covered |
| C92.01 | ICD10CM | Covered |
| C92.02 | ICD10CM | Covered |
| C92.10 | ICD10CM | Covered |
| C92.12 | ICD10CM | Covered |
| D13.7 | ICD10CM | Covered |
| D18.02 | 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 |
| D74.8 | ICD10CM | Covered |
| D84.89 | ICD10CM | Covered |
| D84.9 | ICD10CM | Covered |
| E11.8 | ICD10CM | Covered |
| E11.9 | ICD10CM | Covered |
| E16.4 | ICD10CM | Covered |
| E31.20 | ICD10CM | Covered |
| E31.8 | ICD10CM | Covered |
| E46 | ICD10CM | Covered |
| E75.22 | ICD10CM | Covered |
| E78.00 | ICD10CM | Covered |
| E78.010 | ICD10CM | Covered |
| E78.011 | ICD10CM | Covered |
| E78.019 | ICD10CM | Covered |
| E78.1 | ICD10CM | Covered |
| E78.2 | ICD10CM | Covered |
| E78.49 | ICD10CM | Covered |
| E79.9 | ICD10CM | Covered |
| E84.8 | ICD10CM | Covered |
| F11.23 | ICD10CM | Covered |
| F20.0 | ICD10CM | Covered |
| F20.1 | ICD10CM | Covered |
| F20.2 | ICD10CM | Covered |
| F20.3 | ICD10CM | Covered |
| F20.5 | ICD10CM | Covered |
| F20.81 | ICD10CM | Covered |
| F20.89 | ICD10CM | Covered |
| F31.0 | ICD10CM | Covered |
| F31.11 | ICD10CM | Covered |
| F31.12 | ICD10CM | Covered |
| F31.13 | ICD10CM | Covered |
| F31.2 | ICD10CM | Covered |
| F31.31 | ICD10CM | Covered |
| F31.32 | ICD10CM | Covered |
| F31.4 | ICD10CM | Covered |
| F31.5 | ICD10CM | Covered |
| F31.61 | ICD10CM | Covered |
| F31.62 | ICD10CM | Covered |
| F31.63 | ICD10CM | Covered |
| F31.64 | ICD10CM | Covered |
| F31.71 | ICD10CM | Covered |
| F31.73 | ICD10CM | Covered |
| F31.75 | ICD10CM | Covered |
| F31.77 | ICD10CM | Covered |
| F32.1 | ICD10CM | Covered |
| F32.2 | ICD10CM | Covered |
| F32.3 | ICD10CM | Covered |
| F32.4 | ICD10CM | Covered |
| F32.81 | ICD10CM | Covered |
| F32.9 | ICD10CM | Covered |
| F33.1 | ICD10CM | Covered |
| F33.2 | ICD10CM | Covered |
| F33.3 | ICD10CM | Covered |
| F33.41 | ICD10CM | Covered |
| F33.9 | ICD10CM | Covered |
| F40.01 | ICD10CM | Covered |
| F40.11 | ICD10CM | Covered |
| F41.0 | ICD10CM | Covered |
| F41.1 | ICD10CM | Covered |
| F43.11 | ICD10CM | Covered |
| F43.12 | ICD10CM | Covered |
| F52.0 | ICD10CM | Covered |
| F60.5 | ICD10CM | Covered |
| F84.0 | ICD10CM | Covered |
| F90.1 | ICD10CM | Covered |
| F90.2 | ICD10CM | Covered |
| F90.8 | ICD10CM | Covered |
| F95.2 | ICD10CM | Covered |
| G10 | ICD10CM | Covered |
| G24.01 | ICD10CM | Covered |
| G40.101 | ICD10CM | Covered |
| G40.109 | ICD10CM | Covered |
| G40.111 | ICD10CM | Covered |
| G40.119 | ICD10CM | Covered |
| G40.201 | ICD10CM | Covered |
| G40.209 | ICD10CM | Covered |
| G40.211 | ICD10CM | Covered |
| G40.219 | ICD10CM | Covered |
| G40.301 | ICD10CM | Covered |
| G40.309 | ICD10CM | Covered |
| G40.311 | ICD10CM | Covered |
| G40.319 | ICD10CM | Covered |
| G40.401 | ICD10CM | Covered |
| G40.409 | ICD10CM | Covered |
| G40.411 | ICD10CM | Covered |
| G40.419 | ICD10CM | Covered |
| G40.801 | ICD10CM | Covered |
| G40.802 | ICD10CM | Covered |
| G40.803 | ICD10CM | Covered |
| G40.804 | ICD10CM | Covered |
| G40.811 | ICD10CM | Covered |
| G40.812 | ICD10CM | Covered |
| G40.813 | ICD10CM | Covered |
| G40.814 | ICD10CM | Covered |
| G47.09 | ICD10CM | Covered |
| G47.411 | ICD10CM | Covered |
| G47.419 | ICD10CM | Covered |
| G50.0 | ICD10CM | Covered |
| G70.80 | ICD10CM | Covered |
| G70.81 | ICD10CM | Covered |
| G89.11 | ICD10CM | Covered |
| G89.18 | ICD10CM | Covered |
| G89.29 | ICD10CM | Covered |
| H66.90 | ICD10CM | Covered |
| H66.93 | ICD10CM | Covered |
| I10 | ICD10CM | Covered |
| I20.0 | ICD10CM | Covered |
| I21.01 | ICD10CM | Covered |
| I21.02 | ICD10CM | Covered |
| I21.09 | ICD10CM | Covered |
| I21.11 | ICD10CM | Covered |
| I21.19 | ICD10CM | Covered |
| I21.21 | ICD10CM | Covered |
| I21.29 | ICD10CM | Covered |
| I21.4 | ICD10CM | Covered |
| I21.9 | ICD10CM | Covered |
| I21.A1 | ICD10CM | Covered |
| I21.A9 | ICD10CM | Covered |
| I21.B | ICD10CM | Covered |
| I22.0 | ICD10CM | Covered |
| I22.1 | ICD10CM | Covered |
| I22.2 | ICD10CM | Covered |
| I22.8 | ICD10CM | Covered |
| I22.9 | ICD10CM | Covered |
| I23.6 | ICD10CM | Covered |
| I25.10 | ICD10CM | Covered |
| I25.2 | ICD10CM | Covered |
| I26.02 | ICD10CM | Covered |
| I26.03 | ICD10CM | Covered |
| I26.04 | ICD10CM | Covered |
| I26.09 | ICD10CM | Covered |
| I26.92 | ICD10CM | Covered |
| I26.93 | ICD10CM | Covered |
| I26.94 | ICD10CM | Covered |
| I26.95 | ICD10CM | Covered |
| I26.96 | ICD10CM | Covered |
| I26.99 | ICD10CM | Covered |
| I42.1 | ICD10CM | Covered |
| I48.0 | ICD10CM | Covered |
| I48.11 | ICD10CM | Covered |
| I48.19 | ICD10CM | Covered |
| I48.20 | ICD10CM | Covered |
| I48.21 | ICD10CM | Covered |
| I50.1 | ICD10CM | Covered |
| I50.20 | ICD10CM | Covered |
| I50.30 | ICD10CM | Covered |
| I50.40 | ICD10CM | Covered |
| I50.89 | ICD10CM | Covered |
| I50.9 | ICD10CM | Covered |
| I51.3 | ICD10CM | Covered |
| I69.30 | ICD10CM | Covered |
| I82.890 | ICD10CM | Covered |
| I82.891 | ICD10CM | Covered |
| J42 | ICD10CM | Covered |
| J62.8 | ICD10CM | Covered |
| K21.00 | ICD10CM | Covered |
| K21.01 | ICD10CM | Covered |
| K21.9 | ICD10CM | Covered |
| K22.10 | ICD10CM | Covered |
| K22.11 | ICD10CM | Covered |
| K25.9 | ICD10CM | Covered |
| K26.6 | ICD10CM | Covered |
| K26.7 | ICD10CM | Covered |
| K26.9 | ICD10CM | Covered |
| K27.4 | ICD10CM | Covered |
| K27.5 | ICD10CM | Covered |
| K27.6 | ICD10CM | Covered |
| K27.7 | ICD10CM | Covered |
| K27.9 | ICD10CM | Covered |
| K31.84 | ICD10CM | Covered |
| K51.90 | ICD10CM | Covered |
| K51.918 | ICD10CM | Covered |
| K51.919 | ICD10CM | Covered |
| K73.9 | ICD10CM | Covered |
| L20.89 | ICD10CM | Covered |
| L70.0 | ICD10CM | Covered |
| M06.89 | ICD10CM | Covered |
| M06.8A | ICD10CM | Covered |
| M10.00 | ICD10CM | Covered |
| M10.09 | ICD10CM | Covered |
| M10.40 | ICD10CM | Covered |
| M10.49 | ICD10CM | Covered |
| M10.9 | ICD10CM | Covered |
| M19.09 | ICD10CM | Covered |
| M19.29 | ICD10CM | Covered |
| M1A.00X0 | ICD10CM | Covered |
| M1A.00X1 | ICD10CM | Covered |
| M1A.0110 | ICD10CM | Covered |
| M1A.0111 | ICD10CM | Covered |
| M1A.0120 | ICD10CM | Covered |
| M1A.0121 | ICD10CM | Covered |
| M1A.0210 | ICD10CM | Covered |
| M1A.0211 | ICD10CM | Covered |
| M1A.0220 | ICD10CM | Covered |
| M1A.0221 | ICD10CM | Covered |
| M1A.0310 | ICD10CM | Covered |
| M1A.0311 | ICD10CM | Covered |
| M1A.0320 | ICD10CM | Covered |
| M1A.0321 | ICD10CM | Covered |
| M1A.0410 | ICD10CM | Covered |
| M1A.0411 | ICD10CM | Covered |
| M1A.0420 | ICD10CM | Covered |
| M1A.0421 | ICD10CM | Covered |
| M1A.0510 | ICD10CM | Covered |
| M1A.0511 | ICD10CM | Covered |
| M1A.0520 | ICD10CM | Covered |
| M1A.0521 | ICD10CM | Covered |
| M1A.0610 | ICD10CM | Covered |
| M1A.0611 | ICD10CM | Covered |
| M1A.0620 | ICD10CM | Covered |
| M1A.0621 | ICD10CM | Covered |
| M1A.0710 | ICD10CM | Covered |
| M1A.0711 | ICD10CM | Covered |
| M1A.0720 | ICD10CM | Covered |
| M1A.0721 | ICD10CM | Covered |
| M1A.08X0 | ICD10CM | Covered |
| M1A.08X1 | ICD10CM | Covered |
| M1A.09X0 | ICD10CM | Covered |
| M1A.09X1 | ICD10CM | Covered |
| M1A.1110 | ICD10CM | Covered |
| M1A.1111 | ICD10CM | Covered |
| M1A.1120 | ICD10CM | Covered |
| M1A.1121 | ICD10CM | Covered |
| M1A.1210 | ICD10CM | Covered |
| M1A.1211 | ICD10CM | Covered |
| M1A.1220 | ICD10CM | Covered |
| M1A.1221 | ICD10CM | Covered |
| M1A.1310 | ICD10CM | Covered |
| M1A.1311 | ICD10CM | Covered |
| M1A.1320 | ICD10CM | Covered |
| M1A.1321 | ICD10CM | Covered |
| M1A.1410 | ICD10CM | Covered |
| M1A.1411 | ICD10CM | Covered |
| M1A.1420 | ICD10CM | Covered |
| M1A.1421 | ICD10CM | Covered |
| M1A.1510 | ICD10CM | Covered |
| M1A.1511 | ICD10CM | Covered |
| M1A.1520 | ICD10CM | Covered |
| M1A.1521 | ICD10CM | Covered |
| M1A.1610 | ICD10CM | Covered |
| M1A.1611 | ICD10CM | Covered |
| M1A.1620 | ICD10CM | Covered |
| M1A.1621 | ICD10CM | Covered |
| M1A.1710 | ICD10CM | Covered |
| M1A.1711 | ICD10CM | Covered |
| M1A.1720 | ICD10CM | Covered |
| M1A.1721 | ICD10CM | Covered |
| M1A.18X0 | ICD10CM | Covered |
| M1A.18X1 | ICD10CM | Covered |
| M1A.19X0 | ICD10CM | Covered |
| M1A.19X1 | ICD10CM | Covered |
| M1A.2110 | ICD10CM | Covered |
| M1A.2111 | ICD10CM | Covered |
| M1A.2120 | ICD10CM | Covered |
| M1A.2121 | ICD10CM | Covered |
| M1A.2210 | ICD10CM | Covered |
| M1A.2211 | ICD10CM | Covered |
| M1A.2220 | ICD10CM | Covered |
| M1A.2221 | ICD10CM | Covered |
| M1A.2310 | ICD10CM | Covered |
| M1A.2311 | ICD10CM | Covered |
| M1A.2320 | ICD10CM | Covered |
| M1A.2321 | ICD10CM | Covered |
| M1A.2410 | ICD10CM | Covered |
| M1A.2411 | ICD10CM | Covered |
| M1A.2420 | ICD10CM | Covered |
| M1A.2421 | ICD10CM | Covered |
| M1A.2510 | ICD10CM | Covered |
| M1A.2511 | ICD10CM | Covered |
| M1A.2520 | ICD10CM | Covered |
| M1A.2521 | ICD10CM | Covered |
| M1A.2610 | ICD10CM | Covered |
| M1A.2611 | ICD10CM | Covered |
| M1A.2620 | ICD10CM | Covered |
| M1A.2621 | ICD10CM | Covered |
| M1A.2710 | ICD10CM | Covered |
| M1A.2711 | ICD10CM | Covered |
| M1A.2720 | ICD10CM | Covered |
| M1A.2721 | ICD10CM | Covered |
| M1A.28X0 | ICD10CM | Covered |
| M1A.28X1 | ICD10CM | Covered |
| M1A.29X0 | ICD10CM | Covered |
| M1A.29X1 | ICD10CM | Covered |
| M1A.3110 | ICD10CM | Covered |
| M1A.3111 | ICD10CM | Covered |
| M1A.3120 | ICD10CM | Covered |
| M1A.3121 | ICD10CM | Covered |
| M1A.3210 | ICD10CM | Covered |
| M1A.3211 | ICD10CM | Covered |
| M1A.3220 | ICD10CM | Covered |
| M1A.3221 | ICD10CM | Covered |
| M1A.3310 | ICD10CM | Covered |
| M1A.3311 | ICD10CM | Covered |
| M1A.3320 | ICD10CM | Covered |
| M1A.3321 | ICD10CM | Covered |
| M1A.3410 | ICD10CM | Covered |
| M1A.3411 | ICD10CM | Covered |
| M1A.3420 | ICD10CM | Covered |
| M1A.3421 | ICD10CM | Covered |
| M1A.3510 | ICD10CM | Covered |
| M1A.3511 | ICD10CM | Covered |
| M1A.3520 | ICD10CM | Covered |
| M1A.3521 | ICD10CM | Covered |
| M1A.3610 | ICD10CM | Covered |
| M1A.3611 | ICD10CM | Covered |
| M1A.3620 | ICD10CM | Covered |
| M1A.3621 | ICD10CM | Covered |
| M1A.3710 | ICD10CM | Covered |
| M1A.3711 | ICD10CM | Covered |
| M1A.3720 | ICD10CM | Covered |
| M1A.3721 | ICD10CM | Covered |
| M1A.38X0 | ICD10CM | Covered |
| M1A.38X1 | ICD10CM | Covered |
| M1A.39X0 | ICD10CM | Covered |
| M1A.39X1 | ICD10CM | Covered |
| M1A.40X0 | ICD10CM | Covered |
| M1A.40X1 | ICD10CM | Covered |
| M1A.4110 | ICD10CM | Covered |
| M1A.4111 | ICD10CM | Covered |
| M1A.4120 | ICD10CM | Covered |
| M1A.4121 | ICD10CM | Covered |
| M1A.4210 | ICD10CM | Covered |
| M1A.4211 | ICD10CM | Covered |
| M1A.4220 | ICD10CM | Covered |
| M1A.4221 | ICD10CM | Covered |
| M1A.4310 | ICD10CM | Covered |
| M1A.4311 | ICD10CM | Covered |
| M1A.4320 | ICD10CM | Covered |
| M1A.4321 | ICD10CM | Covered |
| M1A.4410 | ICD10CM | Covered |
| M1A.4411 | ICD10CM | Covered |
| M1A.4420 | ICD10CM | Covered |
| M1A.4421 | ICD10CM | Covered |
| M1A.4510 | ICD10CM | Covered |
| M1A.4511 | ICD10CM | Covered |
| M1A.4520 | ICD10CM | Covered |
| M1A.4521 | ICD10CM | Covered |
| M1A.4610 | ICD10CM | Covered |
| M1A.4611 | ICD10CM | Covered |
| M1A.4620 | ICD10CM | Covered |
| M1A.4621 | ICD10CM | Covered |
| M1A.4710 | ICD10CM | Covered |
| M1A.4711 | ICD10CM | Covered |
| M1A.4720 | ICD10CM | Covered |
| M1A.4721 | ICD10CM | Covered |
| M1A.48X0 | ICD10CM | Covered |
| M1A.48X1 | ICD10CM | Covered |
| M1A.49X0 | ICD10CM | Covered |
| M1A.49X1 | ICD10CM | Covered |
| M1A.9XX0 | ICD10CM | Covered |
| M1A.9XX1 | ICD10CM | Covered |
| M35.00 | ICD10CM | Covered |
| N18.6 | ICD10CM | Covered |
| N20.9 | ICD10CM | Covered |
| N30.00 | ICD10CM | Covered |
| N30.01 | ICD10CM | Covered |
| N39.0 | ICD10CM | Covered |
| N39.41 | ICD10CM | Covered |
| N39.46 | ICD10CM | Covered |
| R11.2 | ICD10CM | Covered |
| R45.851 | ICD10CM | Covered |
| R52 | ICD10CM | Covered |
| T36.5X5A | ICD10CM | Covered |
| T38.3X5A | ICD10CM | Covered |
| T41.0X5A | ICD10CM | Covered |
| T41.0X5D | ICD10CM | Covered |
| T41.0X5S | ICD10CM | Covered |
| T41.0X6A | ICD10CM | Covered |
| T41.0X6D | ICD10CM | Covered |
| T41.0X6S | ICD10CM | Covered |
| T41.1X5A | ICD10CM | Covered |
| T41.1X5D | ICD10CM | Covered |
| T41.1X5S | ICD10CM | Covered |
| T41.1X6A | ICD10CM | Covered |
| T41.1X6D | ICD10CM | Covered |
| T41.1X6S | ICD10CM | Covered |
| T75.3XXA | ICD10CM | Covered |
| T75.3XXD | ICD10CM | Covered |
| T75.3XXS | ICD10CM | Covered |
| T82.817A | ICD10CM | Covered |
| T82.817D | ICD10CM | Covered |
| T82.817S | ICD10CM | Covered |
| T82.818A | ICD10CM | Covered |
| T82.818D | ICD10CM | Covered |
| T82.818S | ICD10CM | Covered |
| T82.867A | ICD10CM | Covered |
| T82.867D | ICD10CM | Covered |
| T82.867S | ICD10CM | Covered |
| T82.868A | ICD10CM | Covered |
| T82.868D | ICD10CM | Covered |
| T82.868S | ICD10CM | Covered |
| Z08 | ICD10CM | Covered |
| Z20.1 | ICD10CM | Covered |
| Z20.6 | ICD10CM | Covered |
| Z21 | ICD10CM | Covered |
| Z22.7 | ICD10CM | Covered |
| Z48.811 | ICD10CM | Covered |
| Z79.01 | ICD10CM | Covered |
| Z79.02 | ICD10CM | Covered |
| Z85.030 | ICD10CM | Covered |
| Z85.038 | ICD10CM | Covered |
| Z85.040 | ICD10CM | Covered |
| Z85.6 | ICD10CM | Covered |
| Z85.79 | ICD10CM | Covered |
| Z85.819 | ICD10CM | Covered |
| Z85.9 | ICD10CM | Covered |
| Z86.39 | ICD10CM | Covered |
| Z86.711 | ICD10CM | Covered |
| Z86.718 | ICD10CM | Covered |
| Z86.73 | ICD10CM | Covered |
| Z86.79 | ICD10CM | Covered |
| Z90.3 | ICD10CM | Covered |
| Z92.241 | ICD10CM | Covered |
| Z92.25 | ICD10CM | Covered |
| Z92.3 | ICD10CM | Covered |
| Z94.0 | ICD10CM | Covered |
| Z94.1 | ICD10CM | Covered |
| Z94.4 | ICD10CM | Covered |
| Z95.2 | ICD10CM | Covered |
| Z95.4 | ICD10CM | Covered |
| Z98.61 | ICD10CM | Covered |
| Z98.62 | ICD10CM | Covered |
| Z98.84 | ICD10CM | Covered |