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 |
|---|---|---|
| 82785 | HCPCS | Covered |
| 86003 | HCPCS | Covered |
| 86005 | HCPCS | Covered |
| 86008 | HCPCS | Covered |
| 95004 | HCPCS | Covered |
| 95017 | HCPCS | Covered |
| 95018 | HCPCS | Covered |
| 95024 | HCPCS | Covered |
| 95027 | HCPCS | Covered |
| 95028 | HCPCS | Covered |
| 95044 | HCPCS | Covered |
| 95052 | HCPCS | Covered |
| 95056 | HCPCS | Covered |
| 95060 | HCPCS | Covered |
| 95065 | HCPCS | Covered |
| 95070 | HCPCS | Covered |
| 95076 | HCPCS | Covered |
| 95079 | HCPCS | Covered |
| B44.81 | ICD10CM | Covered |
| E80.0 | ICD10CM | Covered |
| E80.1 | ICD10CM | Covered |
| E80.21 | ICD10CM | Covered |
| E80.29 | ICD10CM | Covered |
| H01.111 | ICD10CM | Covered |
| H01.112 | ICD10CM | Covered |
| H01.114 | ICD10CM | Covered |
| H01.115 | ICD10CM | Covered |
| H01.131 | ICD10CM | Covered |
| H01.132 | ICD10CM | Covered |
| H01.134 | ICD10CM | Covered |
| H01.135 | ICD10CM | Covered |
| H10.411 | ICD10CM | Covered |
| H10.412 | ICD10CM | Covered |
| H10.413 | ICD10CM | Covered |
| H10.44 | ICD10CM | Covered |
| H10.45 | ICD10CM | Covered |
| H16.261 | ICD10CM | Covered |
| H16.262 | ICD10CM | Covered |
| H16.263 | ICD10CM | Covered |
| H65.04 | ICD10CM | Covered |
| H65.05 | ICD10CM | Covered |
| H65.06 | ICD10CM | Covered |
| H65.111 | ICD10CM | Covered |
| H65.112 | ICD10CM | Covered |
| H65.113 | ICD10CM | Covered |
| H65.114 | ICD10CM | Covered |
| H65.115 | ICD10CM | Covered |
| H65.116 | ICD10CM | Covered |
| H65.21 | ICD10CM | Covered |
| H65.22 | ICD10CM | Covered |
| H65.23 | ICD10CM | Covered |
| H65.411 | ICD10CM | Covered |
| H65.412 | ICD10CM | Covered |
| H65.413 | ICD10CM | Covered |
| H65.491 | ICD10CM | Covered |
| H65.492 | ICD10CM | Covered |
| H65.493 | ICD10CM | Covered |
| H68.012 | ICD10CM | Covered |
| H68.022 | ICD10CM | Covered |
| H68.023 | ICD10CM | Covered |
| J01.01 | ICD10CM | Covered |
| J01.11 | ICD10CM | Covered |
| J01.21 | ICD10CM | Covered |
| J01.31 | ICD10CM | Covered |
| J01.41 | ICD10CM | Covered |
| J01.81 | ICD10CM | Covered |
| J30.0 | ICD10CM | Covered |
| J30.1 | ICD10CM | Covered |
| J30.2 | ICD10CM | Covered |
| J30.5 | ICD10CM | Covered |
| J30.81 | ICD10CM | Covered |
| J30.89 | ICD10CM | Covered |
| J31.0 | ICD10CM | Covered |
| J31.1 | ICD10CM | Covered |
| J32.0 | ICD10CM | Covered |
| J32.1 | ICD10CM | Covered |
| J32.2 | ICD10CM | Covered |
| J32.3 | ICD10CM | Covered |
| J33.0 | ICD10CM | Covered |
| J33.8 | ICD10CM | Covered |
| J45.20 | ICD10CM | Covered |
| J45.21 | ICD10CM | Covered |
| J45.22 | ICD10CM | Covered |
| J45.30 | ICD10CM | Covered |
| J45.31 | ICD10CM | Covered |
| J45.32 | ICD10CM | Covered |
| J45.40 | ICD10CM | Covered |
| J45.41 | ICD10CM | Covered |
| J45.42 | ICD10CM | Covered |
| J45.50 | ICD10CM | Covered |
| J45.51 | ICD10CM | Covered |
| J45.52 | ICD10CM | Covered |
| J45.901 | ICD10CM | Covered |
| J45.902 | ICD10CM | Covered |
| J45.909 | ICD10CM | Covered |
| J45.991 | ICD10CM | Covered |
| J45.998 | ICD10CM | Covered |
| J47.9 | ICD10CM | Covered |
| K20.0 | ICD10CM | Covered |
| L20.0 | ICD10CM | Covered |
| L20.81 | ICD10CM | Covered |
| L20.82 | ICD10CM | Covered |
| L20.84 | ICD10CM | Covered |
| L20.89 | ICD10CM | Covered |
| L20.9 | ICD10CM | Covered |
| L23.0 | ICD10CM | Covered |
| L23.1 | ICD10CM | Covered |
| L23.2 | ICD10CM | Covered |
| L23.3 | ICD10CM | Covered |
| L23.4 | ICD10CM | Covered |
| L23.5 | ICD10CM | Covered |
| L23.6 | ICD10CM | Covered |
| L23.7 | ICD10CM | Covered |
| L23.81 | ICD10CM | Covered |
| L23.89 | ICD10CM | Covered |
| L23.9 | ICD10CM | Covered |
| L24.0 | ICD10CM | Covered |
| L24.1 | ICD10CM | Covered |
| L24.2 | ICD10CM | Covered |
| L24.3 | ICD10CM | Covered |
| L24.4 | ICD10CM | Covered |
| L24.5 | ICD10CM | Covered |
| L24.6 | ICD10CM | Covered |
| L24.7 | ICD10CM | Covered |
| L24.81 | ICD10CM | Covered |
| L24.89 | ICD10CM | Covered |
| L24.9 | ICD10CM | Covered |
| L25.0 | ICD10CM | Covered |
| L25.1 | ICD10CM | Covered |
| L25.2 | ICD10CM | Covered |
| L25.3 | ICD10CM | Covered |
| L25.4 | ICD10CM | Covered |
| L25.5 | ICD10CM | Covered |
| L25.8 | ICD10CM | Covered |
| L25.9 | ICD10CM | Covered |
| L27.0 | ICD10CM | Covered |
| L27.1 | ICD10CM | Covered |
| L27.2 | ICD10CM | Covered |
| L27.8 | ICD10CM | Covered |
| L27.9 | ICD10CM | Covered |
| L28.0 | ICD10CM | Covered |
| L29.89 | ICD10CM | Covered |
| L29.9 | ICD10CM | Covered |
| L30.0 | ICD10CM | Covered |
| L30.8 | ICD10CM | Covered |
| L30.9 | ICD10CM | Covered |
| L50.0 | ICD10CM | Covered |
| L50.1 | ICD10CM | Covered |
| L50.3 | ICD10CM | Covered |
| L50.6 | ICD10CM | Covered |
| L50.8 | ICD10CM | Covered |
| L56.0 | ICD10CM | Covered |
| L56.1 | ICD10CM | Covered |
| L56.2 | ICD10CM | Covered |
| L56.3 | ICD10CM | Covered |
| L56.4 | ICD10CM | Covered |
| L56.8 | ICD10CM | Covered |
| L57.1 | ICD10CM | Covered |
| L57.5 | ICD10CM | Covered |
| L95.1 | ICD10CM | Covered |
| R05.3 | ICD10CM | Covered |
| R06.02 | ICD10CM | Covered |
| R06.09 | ICD10CM | Covered |
| R06.2 | ICD10CM | Covered |
| R09.81 | ICD10CM | Covered |
| R21 | ICD10CM | Covered |
| T36.0X5A | ICD10CM | Covered |
| T36.0X5D | ICD10CM | Covered |
| T36.0X5S | ICD10CM | Covered |
| T36.1X5A | ICD10CM | Covered |
| T36.1X5D | ICD10CM | Covered |
| T36.1X5S | ICD10CM | Covered |
| T36.2X5A | ICD10CM | Covered |
| T36.2X5D | ICD10CM | Covered |
| T36.2X5S | ICD10CM | Covered |
| T36.3X5A | ICD10CM | Covered |
| T36.3X5D | ICD10CM | Covered |
| T36.3X5S | ICD10CM | Covered |
| T36.4X5A | ICD10CM | Covered |
| T36.4X5D | ICD10CM | Covered |
| T36.4X5S | ICD10CM | Covered |
| T36.5X5A | ICD10CM | Covered |
| T36.5X5D | ICD10CM | Covered |
| T36.5X5S | ICD10CM | Covered |
| T36.6X5A | ICD10CM | Covered |
| T36.6X5D | ICD10CM | Covered |
| T36.6X5S | ICD10CM | Covered |
| T36.7X5A | ICD10CM | Covered |
| T36.7X5D | ICD10CM | Covered |
| T36.7X5S | ICD10CM | Covered |
| T36.8X5A | ICD10CM | Covered |
| T36.8X5D | ICD10CM | Covered |
| T36.8X5S | ICD10CM | Covered |
| T37.0X5A | ICD10CM | Covered |
| T37.0X5D | ICD10CM | Covered |
| T37.0X5S | ICD10CM | Covered |
| T37.1X5A | ICD10CM | Covered |
| T37.1X5D | ICD10CM | Covered |
| T37.1X5S | ICD10CM | Covered |
| T37.2X5A | ICD10CM | Covered |
| T37.2X5D | ICD10CM | Covered |
| T37.2X5S | ICD10CM | Covered |
| T37.3X5A | ICD10CM | Covered |
| T37.3X5D | ICD10CM | Covered |
| T37.3X5S | ICD10CM | Covered |
| T37.4X5A | ICD10CM | Covered |
| T37.4X5D | ICD10CM | Covered |
| T37.4X5S | ICD10CM | Covered |
| T37.5X5A | ICD10CM | Covered |
| T37.5X5D | ICD10CM | Covered |
| T37.5X5S | ICD10CM | Covered |
| T38.0X5A | ICD10CM | Covered |
| T38.0X5D | ICD10CM | Covered |
| T38.0X5S | ICD10CM | Covered |
| T38.1X5A | ICD10CM | Covered |
| T38.1X5D | ICD10CM | Covered |
| T38.1X5S | ICD10CM | Covered |
| T38.2X5A | ICD10CM | Covered |
| T38.2X5D | ICD10CM | Covered |
| T38.2X5S | ICD10CM | Covered |
| T38.3X5A | ICD10CM | Covered |
| T38.3X5D | ICD10CM | Covered |
| T38.3X5S | ICD10CM | Covered |
| T38.4X5A | ICD10CM | Covered |
| T38.4X5D | ICD10CM | Covered |
| T38.4X5S | ICD10CM | Covered |
| T38.5X5A | ICD10CM | Covered |
| T38.5X5D | ICD10CM | Covered |
| T38.5X5S | ICD10CM | Covered |
| T38.6X5A | ICD10CM | Covered |
| T38.6X5D | ICD10CM | Covered |
| T38.6X5S | ICD10CM | Covered |
| T38.7X5A | ICD10CM | Covered |
| T38.7X5D | ICD10CM | Covered |
| T38.7X5S | ICD10CM | Covered |
| T38.815A | ICD10CM | Covered |
| T38.815D | ICD10CM | Covered |
| T38.815S | ICD10CM | Covered |
| T38.895A | ICD10CM | Covered |
| T38.895D | ICD10CM | Covered |
| T38.895S | ICD10CM | Covered |
| T38.995A | ICD10CM | Covered |
| T38.995D | ICD10CM | Covered |
| T38.995S | ICD10CM | Covered |
| T39.015A | ICD10CM | Covered |
| T39.015D | ICD10CM | Covered |
| T39.015S | ICD10CM | Covered |
| T39.095A | ICD10CM | Covered |
| T39.095D | ICD10CM | Covered |
| T39.095S | ICD10CM | Covered |
| T39.1X5A | ICD10CM | Covered |
| T39.1X5D | ICD10CM | Covered |
| T39.1X5S | ICD10CM | Covered |
| T39.2X5A | ICD10CM | Covered |
| T39.2X5D | ICD10CM | Covered |
| T39.2X5S | ICD10CM | Covered |
| T39.315A | ICD10CM | Covered |
| T39.315D | ICD10CM | Covered |
| T39.315S | ICD10CM | Covered |
| T39.395A | ICD10CM | Covered |
| T39.395D | ICD10CM | Covered |
| T39.395S | ICD10CM | Covered |
| T39.4X5A | ICD10CM | Covered |
| T39.4X5D | ICD10CM | Covered |
| T39.4X5S | ICD10CM | Covered |
| T39.8X5A | ICD10CM | Covered |
| T39.8X5D | ICD10CM | Covered |
| T39.8X5S | ICD10CM | Covered |
| T40.0X5A | ICD10CM | Covered |
| T40.0X5D | ICD10CM | Covered |
| T40.0X5S | ICD10CM | Covered |
| T40.2X5A | ICD10CM | Covered |
| T40.2X5D | ICD10CM | Covered |
| T40.2X5S | ICD10CM | Covered |
| T40.3X5A | ICD10CM | Covered |
| T40.3X5D | ICD10CM | Covered |
| T40.3X5S | ICD10CM | Covered |
| T40.415A | ICD10CM | Covered |
| T40.415D | ICD10CM | Covered |
| T40.415S | ICD10CM | Covered |
| T40.425A | ICD10CM | Covered |
| T40.425D | ICD10CM | Covered |
| T40.425S | ICD10CM | Covered |
| T40.495A | ICD10CM | Covered |
| T40.495D | ICD10CM | Covered |
| T40.495S | ICD10CM | Covered |
| T40.5X5A | ICD10CM | Covered |
| T40.5X5D | ICD10CM | Covered |
| T40.5X5S | ICD10CM | Covered |
| T40.695A | ICD10CM | Covered |
| T40.695D | ICD10CM | Covered |
| T40.695S | ICD10CM | Covered |
| T40.715A | ICD10CM | Covered |
| T40.715D | ICD10CM | Covered |
| T40.715S | ICD10CM | Covered |
| T40.725A | ICD10CM | Covered |
| T40.725D | ICD10CM | Covered |
| T40.725S | ICD10CM | Covered |
| T40.995A | ICD10CM | Covered |
| T40.995D | ICD10CM | Covered |
| T40.995S | ICD10CM | Covered |
| T41.0X5A | ICD10CM | Covered |
| T41.0X5D | ICD10CM | Covered |
| T41.0X5S | ICD10CM | Covered |
| T41.1X5A | ICD10CM | Covered |
| T41.1X5D | ICD10CM | Covered |
| T41.1X5S | ICD10CM | Covered |
| T41.295A | ICD10CM | Covered |
| T41.295D | ICD10CM | Covered |
| T41.295S | ICD10CM | Covered |
| T41.3X5A | ICD10CM | Covered |
| T41.3X5D | ICD10CM | Covered |
| T41.3X5S | ICD10CM | Covered |
| T41.5X5A | ICD10CM | Covered |
| T41.5X5D | ICD10CM | Covered |
| T41.5X5S | ICD10CM | Covered |
| T42.0X5A | ICD10CM | Covered |
| T42.0X5D | ICD10CM | Covered |
| T42.0X5S | ICD10CM | Covered |
| T42.1X5A | ICD10CM | Covered |
| T42.1X5D | ICD10CM | Covered |
| T42.1X5S | ICD10CM | Covered |
| T42.2X5A | ICD10CM | Covered |
| T42.2X5D | ICD10CM | Covered |
| T42.2X5S | ICD10CM | Covered |
| T42.3X5A | ICD10CM | Covered |
| T42.3X5D | ICD10CM | Covered |
| T42.3X5S | ICD10CM | Covered |
| T42.4X5A | ICD10CM | Covered |
| T42.4X5D | ICD10CM | Covered |
| T42.4X5S | ICD10CM | Covered |
| T42.5X5A | ICD10CM | Covered |
| T42.5X5D | ICD10CM | Covered |
| T42.5X5S | ICD10CM | Covered |
| T42.6X5A | ICD10CM | Covered |
| T42.6X5D | ICD10CM | Covered |
| T42.6X5S | ICD10CM | Covered |
| T42.8X5A | ICD10CM | Covered |
| T42.8X5D | ICD10CM | Covered |
| T42.8X5S | ICD10CM | Covered |
| T43.015A | ICD10CM | Covered |
| T43.015D | ICD10CM | Covered |
| T43.015S | ICD10CM | Covered |
| T43.025A | ICD10CM | Covered |
| T43.025D | ICD10CM | Covered |
| T43.025S | ICD10CM | Covered |
| T43.1X5A | ICD10CM | Covered |
| T43.1X5D | ICD10CM | Covered |
| T43.1X5S | ICD10CM | Covered |
| T43.215A | ICD10CM | Covered |
| T43.215D | ICD10CM | Covered |
| T43.215S | ICD10CM | Covered |
| T43.225A | ICD10CM | Covered |
| T43.225D | ICD10CM | Covered |
| T43.225S | ICD10CM | Covered |
| T43.295A | ICD10CM | Covered |
| T43.295D | ICD10CM | Covered |
| T43.295S | ICD10CM | Covered |
| T43.3X5A | ICD10CM | Covered |
| T43.3X5D | ICD10CM | Covered |
| T43.3X5S | ICD10CM | Covered |
| T43.4X5A | ICD10CM | Covered |
| T43.4X5D | ICD10CM | Covered |
| T43.4X5S | ICD10CM | Covered |
| T43.595A | ICD10CM | Covered |
| T43.595D | ICD10CM | Covered |
| T43.595S | ICD10CM | Covered |
| T43.615A | ICD10CM | Covered |
| T43.615D | ICD10CM | Covered |
| T43.615S | ICD10CM | Covered |
| T43.625A | ICD10CM | Covered |
| T43.625D | ICD10CM | Covered |
| T43.625S | ICD10CM | Covered |
| T43.635A | ICD10CM | Covered |
| T43.635D | ICD10CM | Covered |
| T43.635S | ICD10CM | Covered |
| T43.655A | ICD10CM | Covered |
| T43.655D | ICD10CM | Covered |
| T43.655S | ICD10CM | Covered |
| T43.695A | ICD10CM | Covered |
| T43.695D | ICD10CM | Covered |
| T43.695S | ICD10CM | Covered |
| T43.8X5A | ICD10CM | Covered |
| T43.8X5D | ICD10CM | Covered |
| T43.8X5S | ICD10CM | Covered |
| T44.0X5A | ICD10CM | Covered |
| T44.0X5D | ICD10CM | Covered |
| T44.0X5S | ICD10CM | Covered |
| T44.1X5A | ICD10CM | Covered |
| T44.1X5D | ICD10CM | Covered |
| T44.1X5S | ICD10CM | Covered |
| T44.2X5A | ICD10CM | Covered |
| T44.2X5D | ICD10CM | Covered |
| T44.2X5S | ICD10CM | Covered |
| T44.3X5A | ICD10CM | Covered |
| T44.3X5D | ICD10CM | Covered |
| T44.3X5S | ICD10CM | Covered |
| T44.4X5A | ICD10CM | Covered |
| T44.4X5D | ICD10CM | Covered |
| T44.4X5S | ICD10CM | Covered |
| T44.5X5A | ICD10CM | Covered |
| T44.5X5D | ICD10CM | Covered |
| T44.5X5S | ICD10CM | Covered |
| T44.6X5A | ICD10CM | Covered |
| T44.6X5D | ICD10CM | Covered |
| T44.6X5S | ICD10CM | Covered |
| T44.7X5A | ICD10CM | Covered |
| T44.7X5D | ICD10CM | Covered |
| T44.7X5S | ICD10CM | Covered |
| T44.8X5A | ICD10CM | Covered |
| T44.8X5D | ICD10CM | Covered |
| T44.8X5S | ICD10CM | Covered |
| T44.995A | ICD10CM | Covered |
| T44.995D | ICD10CM | Covered |
| T44.995S | ICD10CM | Covered |
| T45.0X5A | ICD10CM | Covered |
| T45.0X5D | ICD10CM | Covered |
| T45.0X5S | ICD10CM | Covered |
| T45.1X5A | ICD10CM | Covered |
| T45.1X5D | ICD10CM | Covered |
| T45.1X5S | ICD10CM | Covered |
| T45.2X5A | ICD10CM | Covered |
| T45.2X5D | ICD10CM | Covered |
| T45.2X5S | ICD10CM | Covered |
| T45.3X5A | ICD10CM | Covered |
| T45.3X5D | ICD10CM | Covered |
| T45.3X5S | ICD10CM | Covered |
| T45.4X5A | ICD10CM | Covered |
| T45.4X5D | ICD10CM | Covered |
| T45.4X5S | ICD10CM | Covered |
| T45.515A | ICD10CM | Covered |
| T45.515D | ICD10CM | Covered |
| T45.515S | ICD10CM | Covered |
| T45.525A | ICD10CM | Covered |
| T45.525D | ICD10CM | Covered |
| T45.525S | ICD10CM | Covered |
| T45.605A | ICD10CM | Covered |
| T45.605D | ICD10CM | Covered |
| T45.605S | ICD10CM | Covered |
| T45.615A | ICD10CM | Covered |
| T45.615D | ICD10CM | Covered |
| T45.615S | ICD10CM | Covered |
| T45.625A | ICD10CM | Covered |
| T45.625D | ICD10CM | Covered |
| T45.625S | ICD10CM | Covered |
| T45.695A | ICD10CM | Covered |
| T45.695D | ICD10CM | Covered |
| T45.695S | ICD10CM | Covered |
| T45.7X5A | ICD10CM | Covered |
| T45.7X5D | ICD10CM | Covered |
| T45.7X5S | ICD10CM | Covered |
| T45.8X5A | ICD10CM | Covered |
| T45.8X5D | ICD10CM | Covered |
| T45.8X5S | ICD10CM | Covered |
| T45.AX5A | ICD10CM | Covered |
| T45.AX5D | ICD10CM | Covered |
| T45.AX5S | ICD10CM | Covered |
| T46.0X5A | ICD10CM | Covered |
| T46.0X5D | ICD10CM | Covered |
| T46.0X5S | ICD10CM | Covered |
| T46.1X5A | ICD10CM | Covered |
| T46.1X5D | ICD10CM | Covered |
| T46.1X5S | ICD10CM | Covered |
| T46.2X5A | ICD10CM | Covered |
| T46.2X5D | ICD10CM | Covered |
| T46.2X5S | ICD10CM | Covered |
| T46.3X5A | ICD10CM | Covered |
| T46.3X5D | ICD10CM | Covered |
| T46.3X5S | ICD10CM | Covered |
| T46.4X5A | ICD10CM | Covered |
| T46.4X5D | ICD10CM | Covered |
| T46.4X5S | ICD10CM | Covered |
| T46.5X5A | ICD10CM | Covered |
| T46.5X5D | ICD10CM | Covered |
| T46.5X5S | ICD10CM | Covered |
| T46.6X5A | ICD10CM | Covered |
| T46.6X5D | ICD10CM | Covered |
| T46.6X5S | ICD10CM | Covered |
| T46.7X5A | ICD10CM | Covered |
| T46.7X5D | ICD10CM | Covered |
| T46.7X5S | ICD10CM | Covered |
| T46.8X5A | ICD10CM | Covered |
| T46.8X5D | ICD10CM | Covered |
| T46.8X5S | ICD10CM | Covered |
| T46.995A | ICD10CM | Covered |
| T46.995D | ICD10CM | Covered |
| T46.995S | ICD10CM | Covered |
| T47.0X5A | ICD10CM | Covered |
| T47.0X5D | ICD10CM | Covered |
| T47.0X5S | ICD10CM | Covered |
| T47.1X5A | ICD10CM | Covered |
| T47.1X5D | ICD10CM | Covered |
| T47.1X5S | ICD10CM | Covered |
| T47.2X5A | ICD10CM | Covered |
| T47.2X5D | ICD10CM | Covered |
| T47.2X5S | ICD10CM | Covered |
| T47.3X5A | ICD10CM | Covered |
| T47.3X5D | ICD10CM | Covered |
| T47.3X5S | ICD10CM | Covered |
| T47.4X5A | ICD10CM | Covered |
| T47.4X5D | ICD10CM | Covered |
| T47.4X5S | ICD10CM | Covered |
| T47.5X5A | ICD10CM | Covered |
| T47.5X5D | ICD10CM | Covered |
| T47.5X5S | ICD10CM | Covered |
| T47.6X5A | ICD10CM | Covered |
| T47.6X5D | ICD10CM | Covered |
| T47.6X5S | ICD10CM | Covered |
| T47.7X5A | ICD10CM | Covered |
| T47.7X5D | ICD10CM | Covered |
| T47.7X5S | ICD10CM | Covered |
| T47.8X5A | ICD10CM | Covered |
| T47.8X5D | ICD10CM | Covered |
| T47.8X5S | ICD10CM | Covered |
| T48.0X5A | ICD10CM | Covered |
| T48.0X5D | ICD10CM | Covered |
| T48.0X5S | ICD10CM | Covered |
| T48.1X5A | ICD10CM | Covered |
| T48.1X5D | ICD10CM | Covered |
| T48.1X5S | ICD10CM | Covered |
| T48.295A | ICD10CM | Covered |
| T48.295D | ICD10CM | Covered |
| T48.295S | ICD10CM | Covered |
| T48.3X5A | ICD10CM | Covered |
| T48.3X5D | ICD10CM | Covered |
| T48.3X5S | ICD10CM | Covered |
| T48.4X5A | ICD10CM | Covered |
| T48.4X5D | ICD10CM | Covered |
| T48.4X5S | ICD10CM | Covered |
| T48.5X5A | ICD10CM | Covered |
| T48.5X5D | ICD10CM | Covered |
| T48.5X5S | ICD10CM | Covered |
| T48.6X5A | ICD10CM | Covered |
| T48.6X5D | ICD10CM | Covered |
| T48.6X5S | ICD10CM | Covered |
| T48.995A | ICD10CM | Covered |
| T48.995D | ICD10CM | Covered |
| T48.995S | ICD10CM | Covered |
| T49.0X5A | ICD10CM | Covered |
| T49.0X5D | ICD10CM | Covered |
| T49.0X5S | ICD10CM | Covered |
| T49.1X5A | ICD10CM | Covered |
| T49.1X5D | ICD10CM | Covered |
| T49.1X5S | ICD10CM | Covered |
| T49.6X5A | ICD10CM | Covered |
| T49.6X5D | ICD10CM | Covered |
| T49.6X5S | ICD10CM | Covered |
| T49.7X5A | ICD10CM | Covered |
| T49.7X5D | ICD10CM | Covered |
| T49.7X5S | ICD10CM | Covered |
| T50.0X5A | ICD10CM | Covered |
| T50.0X5D | ICD10CM | Covered |
| T50.0X5S | ICD10CM | Covered |
| T50.1X5A | ICD10CM | Covered |
| T50.1X5D | ICD10CM | Covered |
| T50.1X5S | ICD10CM | Covered |
| T50.2X5A | ICD10CM | Covered |
| T50.2X5D | ICD10CM | Covered |
| T50.2X5S | ICD10CM | Covered |
| T50.3X5A | ICD10CM | Covered |
| T50.3X5D | ICD10CM | Covered |
| T50.3X5S | ICD10CM | Covered |
| T50.4X5A | ICD10CM | Covered |
| T50.4X5D | ICD10CM | Covered |
| T50.4X5S | ICD10CM | Covered |
| T50.5X5A | ICD10CM | Covered |
| T50.5X5D | ICD10CM | Covered |
| T50.5X5S | ICD10CM | Covered |
| T50.6X5A | ICD10CM | Covered |
| T50.6X5D | ICD10CM | Covered |
| T50.6X5S | ICD10CM | Covered |
| T50.7X5A | ICD10CM | Covered |
| T50.7X5D | ICD10CM | Covered |
| T50.7X5S | ICD10CM | Covered |
| T50.8X5A | ICD10CM | Covered |
| T50.8X5D | ICD10CM | Covered |
| T50.8X5S | ICD10CM | Covered |
| T50.915A | ICD10CM | Covered |
| T50.915D | ICD10CM | Covered |
| T50.915S | ICD10CM | Covered |
| T50.995A | ICD10CM | Covered |
| T50.995D | ICD10CM | Covered |
| T50.995S | ICD10CM | Covered |
| T50.A15A | ICD10CM | Covered |
| T50.A15D | ICD10CM | Covered |
| T50.A15S | ICD10CM | Covered |
| T50.A25A | ICD10CM | Covered |
| T50.A25D | ICD10CM | Covered |
| T50.A25S | ICD10CM | Covered |
| T50.A95A | ICD10CM | Covered |
| T50.A95D | ICD10CM | Covered |
| T50.A95S | ICD10CM | Covered |
| T50.B15A | ICD10CM | Covered |
| T50.B15D | ICD10CM | Covered |
| T50.B15S | ICD10CM | Covered |
| T50.B95A | ICD10CM | Covered |
| T50.B95D | ICD10CM | Covered |
| T50.B95S | ICD10CM | Covered |
| T50.Z95A | ICD10CM | Covered |
| T50.Z95D | ICD10CM | Covered |
| T50.Z95S | ICD10CM | Covered |
| T63.001A | ICD10CM | Covered |
| T63.001D | ICD10CM | Covered |
| T63.001S | ICD10CM | Covered |
| T63.004A | ICD10CM | Covered |
| T63.004D | ICD10CM | Covered |
| T63.004S | ICD10CM | Covered |
| T63.011A | ICD10CM | Covered |
| T63.011D | ICD10CM | Covered |
| T63.011S | ICD10CM | Covered |
| T63.014A | ICD10CM | Covered |
| T63.014D | ICD10CM | Covered |
| T63.014S | ICD10CM | Covered |
| T63.021A | ICD10CM | Covered |
| T63.021D | ICD10CM | Covered |
| T63.021S | ICD10CM | Covered |
| T63.024A | ICD10CM | Covered |
| T63.024D | ICD10CM | Covered |
| T63.024S | ICD10CM | Covered |
| T63.031A | ICD10CM | Covered |
| T63.031D | ICD10CM | Covered |
| T63.031S | ICD10CM | Covered |
| T63.034A | ICD10CM | Covered |
| T63.034D | ICD10CM | Covered |
| T63.034S | ICD10CM | Covered |
| T63.041A | ICD10CM | Covered |
| T63.041D | ICD10CM | Covered |
| T63.041S | ICD10CM | Covered |
| T63.044A | ICD10CM | Covered |
| T63.044D | ICD10CM | Covered |
| T63.044S | ICD10CM | Covered |
| T63.061A | ICD10CM | Covered |
| T63.061D | ICD10CM | Covered |
| T63.061S | ICD10CM | Covered |
| T63.064A | ICD10CM | Covered |
| T63.064D | ICD10CM | Covered |
| T63.064S | ICD10CM | Covered |
| T63.071A | ICD10CM | Covered |
| T63.071D | ICD10CM | Covered |
| T63.071S | ICD10CM | Covered |
| T63.074A | ICD10CM | Covered |
| T63.074D | ICD10CM | Covered |
| T63.074S | ICD10CM | Covered |
| T63.081A | ICD10CM | Covered |
| T63.081D | ICD10CM | Covered |
| T63.081S | ICD10CM | Covered |
| T63.084A | ICD10CM | Covered |
| T63.084D | ICD10CM | Covered |
| T63.084S | ICD10CM | Covered |
| T63.091A | ICD10CM | Covered |
| T63.091D | ICD10CM | Covered |
| T63.091S | ICD10CM | Covered |
| T63.094A | ICD10CM | Covered |
| T63.094D | ICD10CM | Covered |
| T63.094S | ICD10CM | Covered |
| T63.111A | ICD10CM | Covered |
| T63.111D | ICD10CM | Covered |
| T63.111S | ICD10CM | Covered |
| T63.114A | ICD10CM | Covered |
| T63.114D | ICD10CM | Covered |
| T63.114S | ICD10CM | Covered |
| T63.121A | ICD10CM | Covered |
| T63.121D | ICD10CM | Covered |
| T63.121S | ICD10CM | Covered |
| T63.124A | ICD10CM | Covered |
| T63.124D | ICD10CM | Covered |
| T63.124S | ICD10CM | Covered |
| T63.191A | ICD10CM | Covered |
| T63.191D | ICD10CM | Covered |
| T63.191S | ICD10CM | Covered |
| T63.194A | ICD10CM | Covered |
| T63.194D | ICD10CM | Covered |
| T63.194S | ICD10CM | Covered |
| T63.2X1A | ICD10CM | Covered |
| T63.2X1D | ICD10CM | Covered |
| T63.2X1S | ICD10CM | Covered |
| T63.2X4A | ICD10CM | Covered |
| T63.2X4D | ICD10CM | Covered |
| T63.2X4S | ICD10CM | Covered |
| T63.301A | ICD10CM | Covered |
| T63.301D | ICD10CM | Covered |
| T63.301S | ICD10CM | Covered |
| T63.304A | ICD10CM | Covered |
| T63.304D | ICD10CM | Covered |
| T63.304S | ICD10CM | Covered |
| T63.311A | ICD10CM | Covered |
| T63.311D | ICD10CM | Covered |
| T63.311S | ICD10CM | Covered |
| T63.314A | ICD10CM | Covered |
| T63.314D | ICD10CM | Covered |
| T63.314S | ICD10CM | Covered |
| T63.321A | ICD10CM | Covered |
| T63.321D | ICD10CM | Covered |
| T63.321S | ICD10CM | Covered |
| T63.324A | ICD10CM | Covered |
| T63.324D | ICD10CM | Covered |
| T63.324S | ICD10CM | Covered |
| T63.331A | ICD10CM | Covered |
| T63.331D | ICD10CM | Covered |
| T63.331S | ICD10CM | Covered |
| T63.334A | ICD10CM | Covered |
| T63.334D | ICD10CM | Covered |
| T63.334S | ICD10CM | Covered |
| T63.391A | ICD10CM | Covered |
| T63.391D | ICD10CM | Covered |
| T63.391S | ICD10CM | Covered |
| T63.394A | ICD10CM | Covered |
| T63.394D | ICD10CM | Covered |
| T63.394S | ICD10CM | Covered |
| T63.411A | ICD10CM | Covered |
| T63.411D | ICD10CM | Covered |
| T63.411S | ICD10CM | Covered |
| T63.414A | ICD10CM | Covered |
| T63.414D | ICD10CM | Covered |
| T63.414S | ICD10CM | Covered |
| T63.421A | ICD10CM | Covered |
| T63.421D | ICD10CM | Covered |
| T63.421S | ICD10CM | Covered |
| T63.424A | ICD10CM | Covered |
| T63.424D | ICD10CM | Covered |
| T63.424S | ICD10CM | Covered |
| T63.441A | ICD10CM | Covered |
| T63.441D | ICD10CM | Covered |
| T63.441S | ICD10CM | Covered |
| T63.444A | ICD10CM | Covered |
| T63.444D | ICD10CM | Covered |
| T63.444S | ICD10CM | Covered |
| T63.451A | ICD10CM | Covered |
| T63.451D | ICD10CM | Covered |
| T63.451S | ICD10CM | Covered |
| T63.454A | ICD10CM | Covered |
| T63.454D | ICD10CM | Covered |
| T63.454S | ICD10CM | Covered |
| T63.461A | ICD10CM | Covered |
| T63.461D | ICD10CM | Covered |
| T63.461S | ICD10CM | Covered |
| T63.464A | ICD10CM | Covered |
| T63.464D | ICD10CM | Covered |
| T63.464S | ICD10CM | Covered |
| T63.481A | ICD10CM | Covered |
| T63.481D | ICD10CM | Covered |
| T63.481S | ICD10CM | Covered |
| T63.484A | ICD10CM | Covered |
| T63.484D | ICD10CM | Covered |
| T63.484S | ICD10CM | Covered |
| T65.811A | ICD10CM | Covered |
| T65.811D | ICD10CM | Covered |
| T65.811S | ICD10CM | Covered |
| T65.814A | ICD10CM | Covered |
| T65.814D | ICD10CM | Covered |
| T65.814S | ICD10CM | Covered |
| T78.01XA | ICD10CM | Covered |
| T78.01XD | ICD10CM | Covered |
| T78.01XS | ICD10CM | Covered |
| T78.02XA | ICD10CM | Covered |
| T78.02XD | ICD10CM | Covered |
| T78.02XS | ICD10CM | Covered |
| T78.03XA | ICD10CM | Covered |
| T78.03XD | ICD10CM | Covered |
| T78.03XS | ICD10CM | Covered |
| T78.04XA | ICD10CM | Covered |
| T78.04XD | ICD10CM | Covered |
| T78.04XS | ICD10CM | Covered |
| T78.05XA | ICD10CM | Covered |
| T78.05XD | ICD10CM | Covered |
| T78.05XS | ICD10CM | Covered |
| T78.06XA | ICD10CM | Covered |
| T78.06XD | ICD10CM | Covered |
| T78.06XS | ICD10CM | Covered |
| T78.070A | ICD10CM | Covered |
| T78.070D | ICD10CM | Covered |
| T78.070S | ICD10CM | Covered |
| T78.071A | ICD10CM | Covered |
| T78.071D | ICD10CM | Covered |
| T78.071S | ICD10CM | Covered |
| T78.079A | ICD10CM | Covered |
| T78.079D | ICD10CM | Covered |
| T78.079S | ICD10CM | Covered |
| T78.080A | ICD10CM | Covered |
| T78.080D | ICD10CM | Covered |
| T78.080S | ICD10CM | Covered |
| T78.081A | ICD10CM | Covered |
| T78.081D | ICD10CM | Covered |
| T78.081S | ICD10CM | Covered |
| T78.089A | ICD10CM | Covered |
| T78.089D | ICD10CM | Covered |
| T78.089S | ICD10CM | Covered |
| T78.09XA | ICD10CM | Covered |
| T78.09XD | ICD10CM | Covered |
| T78.09XS | ICD10CM | Covered |
| T78.110A | ICD10CM | Covered |
| T78.110D | ICD10CM | Covered |
| T78.110S | ICD10CM | Covered |
| T78.111A | ICD10CM | Covered |
| T78.111D | ICD10CM | Covered |
| T78.111S | ICD10CM | Covered |
| T78.119A | ICD10CM | Covered |
| T78.119D | ICD10CM | Covered |
| T78.119S | ICD10CM | Covered |
| T78.120A | ICD10CM | Covered |
| T78.120D | ICD10CM | Covered |
| T78.120S | ICD10CM | Covered |
| T78.121A | ICD10CM | Covered |
| T78.121D | ICD10CM | Covered |
| T78.121S | ICD10CM | Covered |
| T78.129A | ICD10CM | Covered |
| T78.129D | ICD10CM | Covered |
| T78.129S | ICD10CM | Covered |
| T78.3XXA | ICD10CM | Covered |
| T78.3XXD | ICD10CM | Covered |
| T78.3XXS | ICD10CM | Covered |
| T78.49XA | ICD10CM | Covered |
| T78.49XD | ICD10CM | Covered |
| T78.49XS | ICD10CM | Covered |
| T80.51XA | ICD10CM | Covered |
| T80.51XD | ICD10CM | Covered |
| T80.51XS | ICD10CM | Covered |
| T80.52XA | ICD10CM | Covered |
| T80.52XD | ICD10CM | Covered |
| T80.52XS | ICD10CM | Covered |
| T88.6XXA | ICD10CM | Covered |
| T88.6XXD | ICD10CM | Covered |
| T88.6XXS | ICD10CM | Covered |
| Z88.0 | ICD10CM | Covered |
| Z88.1 | ICD10CM | Covered |
| Z88.2 | ICD10CM | Covered |
| Z88.3 | ICD10CM | Covered |
| Z88.4 | ICD10CM | Covered |
| Z88.5 | ICD10CM | Covered |
| Z88.6 | ICD10CM | Covered |
| Z88.7 | ICD10CM | Covered |
| Z88.8 | ICD10CM | Covered |
| Z91.010 | ICD10CM | Covered |
| Z91.0110 | ICD10CM | Covered |
| Z91.0111 | ICD10CM | Covered |
| Z91.0112 | ICD10CM | Covered |
| Z91.0120 | ICD10CM | Covered |
| Z91.0121 | ICD10CM | Covered |
| Z91.0122 | ICD10CM | Covered |
| Z91.013 | ICD10CM | Covered |
| Z91.014 | ICD10CM | Covered |
| Z91.018 | ICD10CM | Covered |
| Z91.02 | ICD10CM | Covered |
| Z91.030 | ICD10CM | Covered |
| Z91.038 | ICD10CM | Covered |
| Z91.040 | ICD10CM | Covered |
| Z91.041 | ICD10CM | Covered |
| Z91.048 | ICD10CM | Covered |
| Z91.09 | ICD10CM | Covered |