About this policy
Jurisdiction: JK MAC Part B. States: Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, Vermont. Type: Active LCD
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 |
|---|---|---|
| 81105 | CPT | Covered |
| 81106 | CPT | Covered |
| 81107 | CPT | Covered |
| 81108 | CPT | Covered |
| 81109 | CPT | Covered |
| 81110 | CPT | Covered |
| 81111 | CPT | Covered |
| 81112 | CPT | Covered |
| 81120 | CPT | Covered |
| 81121 | CPT | Covered |
| 81161 | CPT | Covered |
| 81162 | CPT | Covered |
| 81163 | CPT | Covered |
| 81164 | CPT | Covered |
| 81165 | CPT | Covered |
| 81166 | CPT | Covered |
| 81167 | CPT | Covered |
| 81168 | CPT | Covered |
| 81170 | CPT | Covered |
| 81171 | CPT | Covered |
| 81172 | CPT | Covered |
| 81173 | CPT | Covered |
| 81174 | CPT | Covered |
| 81175 | CPT | Covered |
| 81176 | CPT | Covered |
| 81177 | CPT | Covered |
| 81178 | CPT | Covered |
| 81179 | CPT | Covered |
| 81180 | CPT | Covered |
| 81181 | CPT | Covered |
| 81182 | CPT | Covered |
| 81183 | CPT | Covered |
| 81184 | CPT | Covered |
| 81185 | CPT | Covered |
| 81186 | CPT | Covered |
| 81187 | CPT | Covered |
| 81188 | CPT | Covered |
| 81189 | CPT | Covered |
| 81190 | CPT | Covered |
| 81191 | CPT | Covered |
| 81192 | CPT | Covered |
| 81193 | CPT | Covered |
| 81194 | CPT | Covered |
| 81200 | CPT | Covered |
| 81201 | CPT | Covered |
| 81202 | CPT | Covered |
| 81203 | CPT | Covered |
| 81204 | CPT | Covered |
| 81205 | CPT | Covered |
| 81206 | CPT | Covered |
| 81207 | CPT | Covered |
| 81208 | CPT | Covered |
| 81209 | CPT | Covered |
| 81210 | CPT | Covered |
| 81212 | CPT | Covered |
| 81215 | CPT | Covered |
| 81216 | CPT | Covered |
| 81217 | CPT | Covered |
| 81218 | CPT | Covered |
| 81219 | CPT | Covered |
| 81220 | CPT | Covered |
| 81221 | CPT | Covered |
| 81222 | CPT | Covered |
| 81223 | CPT | Covered |
| 81224 | CPT | Covered |
| 81228 | CPT | Covered |
| 81229 | CPT | Covered |
| 81233 | CPT | Covered |
| 81234 | CPT | Covered |
| 81235 | CPT | Covered |
| 81236 | CPT | Covered |
| 81237 | CPT | Covered |
| 81238 | CPT | Covered |
| 81239 | CPT | Covered |
| 81240 | CPT | Covered |
| 81241 | CPT | Covered |
| 81242 | CPT | Covered |
| 81243 | CPT | Covered |
| 81244 | CPT | Covered |
| 81245 | CPT | Covered |
| 81246 | CPT | Covered |
| 81248 | CPT | Covered |
| 81249 | CPT | Covered |
| 81250 | CPT | Covered |
| 81252 | CPT | Covered |
| 81253 | CPT | Covered |
| 81254 | CPT | Covered |
| 81255 | CPT | Covered |
| 81256 | CPT | Covered |
| 81257 | CPT | Covered |
| 81258 | CPT | Covered |
| 81259 | CPT | Covered |
| 81260 | CPT | Covered |
| 81261 | CPT | Covered |
| 81262 | CPT | Covered |
| 81263 | CPT | Covered |
| 81264 | CPT | Covered |
| 81265 | CPT | Covered |
| 81266 | CPT | Covered |
| 81267 | CPT | Covered |
| 81268 | CPT | Covered |
| 81269 | CPT | Covered |
| 81270 | CPT | Covered |
| 81271 | CPT | Covered |
| 81272 | CPT | Covered |
| 81273 | CPT | Covered |
| 81274 | CPT | Covered |
| 81275 | CPT | Covered |
| 81276 | CPT | Covered |
| 81277 | CPT | Covered |
| 81284 | CPT | Covered |
| 81285 | CPT | Covered |
| 81286 | CPT | Covered |
| 81287 | CPT | Covered |
| 81288 | CPT | Covered |
| 81289 | CPT | Covered |
| 81290 | CPT | Covered |
| 81291 | CPT | Covered |
| 81292 | CPT | Covered |
| 81293 | CPT | Covered |
| 81294 | CPT | Covered |
| 81295 | CPT | Covered |
| 81296 | CPT | Covered |
| 81297 | CPT | Covered |
| 81298 | CPT | Covered |
| 81299 | CPT | Covered |
| 81300 | CPT | Covered |
| 81301 | CPT | Covered |
| 81302 | CPT | Covered |
| 81303 | CPT | Covered |
| 81304 | CPT | Covered |
| 81305 | CPT | Covered |
| 81307 | CPT | Covered |
| 81308 | CPT | Covered |
| 81309 | CPT | Covered |
| 81310 | CPT | Covered |
| 81311 | CPT | Covered |
| 81312 | CPT | Covered |
| 81314 | CPT | Covered |
| 81315 | CPT | Covered |
| 81316 | CPT | Covered |
| 81317 | CPT | Covered |
| 81318 | CPT | Covered |
| 81319 | CPT | Covered |
| 81320 | CPT | Covered |
| 81321 | CPT | Covered |
| 81322 | CPT | Covered |
| 81323 | CPT | Covered |
| 81324 | CPT | Covered |
| 81325 | CPT | Covered |
| 81326 | CPT | Covered |
| 81327 | CPT | Covered |
| 81329 | CPT | Covered |
| 81330 | CPT | Covered |
| 81331 | CPT | Covered |
| 81332 | CPT | Covered |
| 81333 | CPT | Covered |
| 81334 | CPT | Covered |
| 81336 | CPT | Covered |
| 81337 | CPT | Covered |
| 81338 | CPT | Covered |
| 81339 | CPT | Covered |
| 81340 | CPT | Covered |
| 81341 | CPT | Covered |
| 81342 | CPT | Covered |
| 81343 | CPT | Covered |
| 81344 | CPT | Covered |
| 81345 | CPT | Covered |
| 81347 | CPT | Covered |
| 81348 | CPT | Covered |
| 81349 | CPT | Covered |
| 81351 | CPT | Covered |
| 81352 | CPT | Covered |
| 81353 | CPT | Covered |
| 81357 | CPT | Covered |
| 81360 | CPT | Covered |
| 81361 | CPT | Covered |
| 81362 | CPT | Covered |
| 81363 | CPT | Covered |
| 81364 | CPT | Covered |
| 81370 | CPT | Covered |
| 81371 | CPT | Covered |
| 81372 | CPT | Covered |
| 81373 | CPT | Covered |
| 81375 | CPT | Covered |
| 81376 | CPT | Covered |
| 81378 | CPT | Covered |
| 81379 | CPT | Covered |
| 81380 | CPT | Covered |
| 81382 | CPT | Covered |
| 81400 | CPT | Covered |
| 81401 | CPT | Covered |
| 81402 | CPT | Covered |
| 81403 | CPT | Covered |
| 81404 | CPT | Covered |
| 81405 | CPT | Covered |
| 81406 | CPT | Covered |
| 81407 | CPT | Covered |
| 81408 | CPT | Covered |
| 81410 | CPT | Covered |
| 81411 | CPT | Covered |
| 81412 | CPT | Covered |
| 81413 | CPT | Covered |
| 81414 | CPT | Covered |
| 81415 | CPT | Covered |
| 81416 | CPT | Covered |
| 81417 | CPT | Covered |
| 81419 | CPT | Covered |
| 81420 | CPT | Covered |
| 81422 | CPT | Covered |
| 81425 | CPT | Covered |
| 81426 | CPT | Covered |
| 81427 | CPT | Covered |
| 81430 | CPT | Covered |
| 81431 | CPT | Covered |
| 81432 | CPT | Covered |
| 81434 | CPT | Covered |
| 81435 | CPT | Covered |
| 81437 | CPT | Covered |
| 81439 | CPT | Covered |
| 81440 | CPT | Covered |
| 81441 | CPT | Covered |
| 81442 | CPT | Covered |
| 81443 | CPT | Covered |
| 81448 | CPT | Covered |
| 81449 | CPT | Covered |
| 81456 | CPT | Covered |
| 81460 | CPT | Covered |
| 81465 | CPT | Covered |
| 81470 | CPT | Covered |
| 81471 | CPT | Covered |
| 81479 | CPT | Covered |
| 81493 | CPT | Covered |
| 81500 | CPT | Covered |
| 81503 | CPT | Covered |
| 81504 | CPT | Covered |
| 81507 | CPT | Covered |
| 81518 | CPT | Covered |
| 81519 | CPT | Covered |
| 81520 | CPT | Covered |
| 81521 | CPT | Covered |
| 81522 | CPT | Covered |
| 81523 | CPT | Covered |
| 81525 | CPT | Covered |
| 81529 | CPT | Covered |
| 81535 | CPT | Covered |
| 81536 | CPT | Covered |
| 81538 | CPT | Covered |
| 81540 | CPT | Covered |
| 81541 | CPT | Covered |
| 81542 | CPT | Covered |
| 81552 | CPT | Covered |
| 81554 | CPT | Covered |
| 81595 | CPT | Covered |
| 81599 | CPT | Covered |
| 0027U | HCPCS | Covered |
| 0119U | HCPCS | Covered |
| C17.0 | ICD10CM | Covered |
| C17.1 | ICD10CM | Covered |
| C17.2 | ICD10CM | Covered |
| C17.3 | ICD10CM | Covered |
| C17.8 | ICD10CM | Covered |
| C17.9 | ICD10CM | Covered |
| C18.0 | ICD10CM | Covered |
| C18.1 | ICD10CM | Covered |
| C18.2 | ICD10CM | Covered |
| C18.3 | ICD10CM | Covered |
| C18.4 | ICD10CM | Covered |
| C18.5 | ICD10CM | Covered |
| C18.6 | ICD10CM | Covered |
| C18.7 | ICD10CM | Covered |
| C18.8 | ICD10CM | Covered |
| C18.9 | ICD10CM | Covered |
| C19 | ICD10CM | Covered |
| C20 | ICD10CM | Covered |
| C21.1 | ICD10CM | Covered |
| C21.2 | ICD10CM | Covered |
| C21.8 | 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 |
| C33 | ICD10CM | Covered |
| C34.00 | ICD10CM | Covered |
| C34.01 | ICD10CM | Covered |
| C34.02 | ICD10CM | Covered |
| C34.10 | ICD10CM | Covered |
| C34.11 | ICD10CM | Covered |
| C34.12 | ICD10CM | Covered |
| C34.2 | ICD10CM | Covered |
| C34.30 | ICD10CM | Covered |
| C34.31 | ICD10CM | Covered |
| C34.32 | ICD10CM | Covered |
| C34.80 | ICD10CM | Covered |
| C34.81 | ICD10CM | Covered |
| C34.82 | ICD10CM | Covered |
| C34.90 | ICD10CM | Covered |
| C34.91 | ICD10CM | Covered |
| C34.92 | ICD10CM | Covered |
| C43.0 | ICD10CM | Covered |
| C43.10 | ICD10CM | Covered |
| C43.111 | ICD10CM | Covered |
| C43.112 | ICD10CM | Covered |
| C43.121 | ICD10CM | Covered |
| C43.122 | ICD10CM | Covered |
| C43.20 | ICD10CM | Covered |
| C43.21 | ICD10CM | Covered |
| C43.22 | ICD10CM | Covered |
| C43.30 | 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 |
| C43.60 | ICD10CM | Covered |
| C43.61 | ICD10CM | Covered |
| C43.62 | ICD10CM | Covered |
| C43.70 | ICD10CM | Covered |
| C43.71 | ICD10CM | Covered |
| C43.72 | ICD10CM | Covered |
| C43.8 | ICD10CM | Covered |
| C43.9 | ICD10CM | Covered |
| C48.1 | ICD10CM | Covered |
| C49.A0 | ICD10CM | Covered |
| C49.A1 | ICD10CM | Covered |
| C49.A2 | ICD10CM | Covered |
| C49.A3 | ICD10CM | Covered |
| C49.A4 | ICD10CM | Covered |
| C49.A5 | ICD10CM | Covered |
| C49.A9 | 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.A1 | ICD10CM | Covered |
| C50.A2 | ICD10CM | Covered |
| C56.1 | ICD10CM | Covered |
| C56.2 | ICD10CM | Covered |
| C56.3 | ICD10CM | Covered |
| C56.9 | ICD10CM | Covered |
| C57.00 | ICD10CM | Covered |
| C57.01 | ICD10CM | Covered |
| C57.02 | ICD10CM | Covered |
| C61 | ICD10CM | Covered |
| C71.0 | ICD10CM | Covered |
| C71.1 | ICD10CM | Covered |
| C71.2 | ICD10CM | Covered |
| C71.3 | ICD10CM | Covered |
| C71.4 | ICD10CM | Covered |
| C71.5 | ICD10CM | Covered |
| C71.6 | ICD10CM | Covered |
| C71.7 | ICD10CM | Covered |
| C71.8 | ICD10CM | Covered |
| C71.9 | ICD10CM | Covered |
| C73 | ICD10CM | Covered |
| C74.10 | ICD10CM | Covered |
| C74.11 | ICD10CM | Covered |
| C74.12 | ICD10CM | Covered |
| C75.0 | ICD10CM | Covered |
| C78.4 | ICD10CM | Covered |
| C78.5 | ICD10CM | Covered |
| C82.00 | ICD10CM | Covered |
| C82.01 | ICD10CM | Covered |
| C82.02 | ICD10CM | Covered |
| C82.03 | ICD10CM | Covered |
| C82.04 | ICD10CM | Covered |
| C82.05 | ICD10CM | Covered |
| C82.06 | ICD10CM | Covered |
| C82.07 | ICD10CM | Covered |
| C82.08 | ICD10CM | Covered |
| C82.09 | ICD10CM | Covered |
| C82.0A | ICD10CM | Covered |
| C82.10 | ICD10CM | Covered |
| C82.11 | ICD10CM | Covered |
| C82.12 | ICD10CM | Covered |
| C82.13 | ICD10CM | Covered |
| C82.14 | ICD10CM | Covered |
| C82.15 | ICD10CM | Covered |
| C82.16 | ICD10CM | Covered |
| C82.17 | ICD10CM | Covered |
| C82.18 | ICD10CM | Covered |
| C82.19 | ICD10CM | Covered |
| C82.1A | ICD10CM | Covered |
| C82.20 | ICD10CM | Covered |
| C82.21 | ICD10CM | Covered |
| C82.22 | ICD10CM | Covered |
| C82.23 | ICD10CM | Covered |
| C82.24 | ICD10CM | Covered |
| C82.25 | ICD10CM | Covered |
| C82.26 | ICD10CM | Covered |
| C82.27 | ICD10CM | Covered |
| C82.28 | ICD10CM | Covered |
| C82.29 | ICD10CM | Covered |
| C82.2A | ICD10CM | Covered |
| C82.30 | ICD10CM | Covered |
| C82.31 | ICD10CM | Covered |
| C82.32 | ICD10CM | Covered |
| C82.33 | ICD10CM | Covered |
| C82.34 | ICD10CM | Covered |
| C82.35 | ICD10CM | Covered |
| C82.36 | ICD10CM | Covered |
| C82.37 | ICD10CM | Covered |
| C82.38 | ICD10CM | Covered |
| C82.39 | ICD10CM | Covered |
| C82.3A | ICD10CM | Covered |
| C82.40 | ICD10CM | Covered |
| C82.41 | ICD10CM | Covered |
| C82.42 | ICD10CM | Covered |
| C82.43 | ICD10CM | Covered |
| C82.44 | ICD10CM | Covered |
| C82.45 | ICD10CM | Covered |
| C82.46 | ICD10CM | Covered |
| C82.47 | ICD10CM | Covered |
| C82.48 | ICD10CM | Covered |
| C82.49 | ICD10CM | Covered |
| C82.4A | ICD10CM | Covered |
| C82.50 | ICD10CM | Covered |
| C82.51 | ICD10CM | Covered |
| C82.52 | ICD10CM | Covered |
| C82.53 | ICD10CM | Covered |
| C82.54 | ICD10CM | Covered |
| C82.55 | ICD10CM | Covered |
| C82.56 | ICD10CM | Covered |
| C82.57 | ICD10CM | Covered |
| C82.58 | ICD10CM | Covered |
| C82.59 | ICD10CM | Covered |
| C82.5A | ICD10CM | Covered |
| C82.60 | ICD10CM | Covered |
| C82.61 | ICD10CM | Covered |
| C82.62 | ICD10CM | Covered |
| C82.63 | ICD10CM | Covered |
| C82.64 | ICD10CM | Covered |
| C82.65 | ICD10CM | Covered |
| C82.66 | ICD10CM | Covered |
| C82.67 | ICD10CM | Covered |
| C82.68 | ICD10CM | Covered |
| C82.69 | ICD10CM | Covered |
| C82.6A | ICD10CM | Covered |
| C82.80 | ICD10CM | Covered |
| C82.81 | ICD10CM | Covered |
| C82.82 | ICD10CM | Covered |
| C82.83 | ICD10CM | Covered |
| C82.84 | ICD10CM | Covered |
| C82.85 | ICD10CM | Covered |
| C82.86 | ICD10CM | Covered |
| C82.87 | ICD10CM | Covered |
| C82.88 | ICD10CM | Covered |
| C82.89 | ICD10CM | Covered |
| C82.8A | ICD10CM | Covered |
| C82.90 | ICD10CM | Covered |
| C82.91 | ICD10CM | Covered |
| C82.92 | ICD10CM | Covered |
| C82.93 | ICD10CM | Covered |
| C82.94 | ICD10CM | Covered |
| C82.95 | ICD10CM | Covered |
| C82.96 | ICD10CM | Covered |
| C82.97 | ICD10CM | Covered |
| C82.98 | ICD10CM | Covered |
| C82.99 | ICD10CM | Covered |
| C82.9A | ICD10CM | Covered |
| C83.00 | ICD10CM | Covered |
| C83.01 | ICD10CM | Covered |
| C83.02 | ICD10CM | Covered |
| C83.03 | ICD10CM | Covered |
| C83.04 | ICD10CM | Covered |
| C83.05 | ICD10CM | Covered |
| C83.06 | ICD10CM | Covered |
| C83.07 | ICD10CM | Covered |
| C83.08 | ICD10CM | Covered |
| C83.09 | ICD10CM | Covered |
| C83.0A | ICD10CM | Covered |
| C83.10 | ICD10CM | Covered |
| C83.11 | ICD10CM | Covered |
| C83.12 | ICD10CM | Covered |
| C83.13 | ICD10CM | Covered |
| C83.14 | ICD10CM | Covered |
| C83.15 | ICD10CM | Covered |
| C83.16 | ICD10CM | Covered |
| C83.17 | ICD10CM | Covered |
| C83.18 | ICD10CM | Covered |
| C83.19 | ICD10CM | Covered |
| C83.1A | ICD10CM | Covered |
| C83.30 | ICD10CM | Covered |
| C83.31 | ICD10CM | Covered |
| C83.32 | ICD10CM | Covered |
| C83.33 | ICD10CM | Covered |
| C83.34 | ICD10CM | Covered |
| C83.35 | ICD10CM | Covered |
| C83.36 | ICD10CM | Covered |
| C83.37 | ICD10CM | Covered |
| C83.38 | ICD10CM | Covered |
| C83.390 | ICD10CM | Covered |
| C83.398 | ICD10CM | Covered |
| C83.3A | ICD10CM | Covered |
| C83.50 | ICD10CM | Covered |
| C83.51 | ICD10CM | Covered |
| C83.52 | ICD10CM | Covered |
| C83.53 | ICD10CM | Covered |
| C83.54 | ICD10CM | Covered |
| C83.55 | ICD10CM | Covered |
| C83.56 | ICD10CM | Covered |
| C83.57 | ICD10CM | Covered |
| C83.58 | ICD10CM | Covered |
| C83.59 | ICD10CM | Covered |
| C83.5A | ICD10CM | Covered |
| C83.70 | ICD10CM | Covered |
| C83.71 | ICD10CM | Covered |
| C83.72 | ICD10CM | Covered |
| C83.73 | ICD10CM | Covered |
| C83.74 | ICD10CM | Covered |
| C83.75 | ICD10CM | Covered |
| C83.76 | ICD10CM | Covered |
| C83.77 | ICD10CM | Covered |
| C83.78 | ICD10CM | Covered |
| C83.79 | ICD10CM | Covered |
| C83.7A | ICD10CM | Covered |
| C83.80 | ICD10CM | Covered |
| C83.81 | ICD10CM | Covered |
| C83.82 | ICD10CM | Covered |
| C83.83 | ICD10CM | Covered |
| C83.84 | ICD10CM | Covered |
| C83.85 | ICD10CM | Covered |
| C83.86 | ICD10CM | Covered |
| C83.87 | ICD10CM | Covered |
| C83.88 | ICD10CM | Covered |
| C83.89 | ICD10CM | Covered |
| C83.8A | ICD10CM | Covered |
| C83.90 | ICD10CM | Covered |
| C83.91 | ICD10CM | Covered |
| C83.92 | ICD10CM | Covered |
| C83.93 | ICD10CM | Covered |
| C83.94 | ICD10CM | Covered |
| C83.95 | ICD10CM | Covered |
| C83.96 | ICD10CM | Covered |
| C83.97 | ICD10CM | Covered |
| C83.98 | ICD10CM | Covered |
| C83.99 | ICD10CM | Covered |
| C85.10 | ICD10CM | Covered |
| C85.11 | ICD10CM | Covered |
| C85.12 | ICD10CM | Covered |
| C85.13 | ICD10CM | Covered |
| C85.14 | ICD10CM | Covered |
| C85.15 | ICD10CM | Covered |
| C85.16 | ICD10CM | Covered |
| C85.17 | ICD10CM | Covered |
| C85.18 | ICD10CM | Covered |
| C85.19 | ICD10CM | Covered |
| C85.1A | ICD10CM | Covered |
| C85.20 | ICD10CM | Covered |
| C85.21 | ICD10CM | Covered |
| C85.22 | ICD10CM | Covered |
| C85.23 | ICD10CM | Covered |
| C85.24 | ICD10CM | Covered |
| C85.25 | ICD10CM | Covered |
| C85.26 | ICD10CM | Covered |
| C85.27 | ICD10CM | Covered |
| C85.28 | ICD10CM | Covered |
| C85.29 | ICD10CM | Covered |
| C85.2A | ICD10CM | Covered |
| C85.80 | ICD10CM | Covered |
| C85.81 | ICD10CM | Covered |
| C85.82 | ICD10CM | Covered |
| C85.83 | ICD10CM | Covered |
| C85.84 | ICD10CM | Covered |
| C85.85 | ICD10CM | Covered |
| C85.86 | ICD10CM | Covered |
| C85.87 | ICD10CM | Covered |
| C85.88 | ICD10CM | Covered |
| C85.89 | ICD10CM | Covered |
| C85.8A | ICD10CM | Covered |
| C85.90 | ICD10CM | Covered |
| C85.91 | ICD10CM | Covered |
| C85.92 | ICD10CM | Covered |
| C85.93 | ICD10CM | Covered |
| C85.94 | ICD10CM | Covered |
| C85.95 | ICD10CM | Covered |
| C85.96 | ICD10CM | Covered |
| C85.97 | ICD10CM | Covered |
| C85.98 | ICD10CM | Covered |
| C85.99 | ICD10CM | Covered |
| C88.00 | ICD10CM | Covered |
| C88.80 | ICD10CM | Covered |
| C91.00 | ICD10CM | Covered |
| C91.01 | ICD10CM | Covered |
| C91.02 | ICD10CM | Covered |
| C91.10 | ICD10CM | Covered |
| C91.11 | ICD10CM | Covered |
| C91.12 | ICD10CM | Covered |
| C91.40 | ICD10CM | Covered |
| C91.41 | ICD10CM | Covered |
| C91.42 | ICD10CM | Covered |
| C92.00 | ICD10CM | Covered |
| C92.02 | ICD10CM | Covered |
| C92.10 | ICD10CM | Covered |
| C92.11 | ICD10CM | Covered |
| C92.12 | ICD10CM | Covered |
| C92.20 | ICD10CM | Covered |
| C92.21 | ICD10CM | Covered |
| C92.22 | ICD10CM | Covered |
| C92.30 | ICD10CM | Covered |
| C92.32 | ICD10CM | Covered |
| C92.40 | ICD10CM | Covered |
| C92.41 | ICD10CM | Covered |
| C92.42 | ICD10CM | Covered |
| C92.50 | ICD10CM | Covered |
| C92.52 | ICD10CM | Covered |
| C92.60 | ICD10CM | Covered |
| C92.62 | ICD10CM | Covered |
| C92.90 | ICD10CM | Covered |
| C92.91 | ICD10CM | Covered |
| C92.92 | ICD10CM | Covered |
| C92.A0 | ICD10CM | Covered |
| C92.A2 | ICD10CM | Covered |
| C92.Z0 | ICD10CM | Covered |
| C92.Z2 | ICD10CM | Covered |
| C93.00 | ICD10CM | Covered |
| C93.02 | ICD10CM | Covered |
| C93.10 | ICD10CM | Covered |
| C93.11 | ICD10CM | Covered |
| C93.12 | ICD10CM | Covered |
| C93.90 | ICD10CM | Covered |
| C93.92 | ICD10CM | Covered |
| C93.Z0 | ICD10CM | Covered |
| C93.Z2 | ICD10CM | Covered |
| C94.00 | ICD10CM | Covered |
| C94.02 | ICD10CM | Covered |
| C94.40 | ICD10CM | Covered |
| C94.41 | ICD10CM | Covered |
| C94.42 | ICD10CM | Covered |
| C94.6 | ICD10CM | Covered |
| C94.80 | ICD10CM | Covered |
| C94.82 | ICD10CM | Covered |
| C95.00 | ICD10CM | Covered |
| C95.02 | ICD10CM | Covered |
| C95.10 | ICD10CM | Covered |
| C95.11 | ICD10CM | Covered |
| C95.12 | ICD10CM | Covered |
| C95.90 | ICD10CM | Covered |
| C95.91 | ICD10CM | Covered |
| C95.92 | ICD10CM | Covered |
| C96.20 | ICD10CM | Covered |
| C96.21 | ICD10CM | Covered |
| C96.22 | ICD10CM | Covered |
| C96.29 | ICD10CM | Covered |
| C96.9 | ICD10CM | Covered |
| C96.Z | ICD10CM | Covered |
| D03.0 | ICD10CM | Covered |
| D03.10 | ICD10CM | Covered |
| D03.111 | ICD10CM | Covered |
| D03.112 | ICD10CM | Covered |
| D03.121 | ICD10CM | Covered |
| D03.122 | ICD10CM | Covered |
| D03.20 | ICD10CM | Covered |
| D03.21 | ICD10CM | Covered |
| D03.22 | ICD10CM | Covered |
| D03.30 | ICD10CM | Covered |
| D03.39 | ICD10CM | Covered |
| D03.4 | ICD10CM | Covered |
| D03.51 | ICD10CM | Covered |
| D03.52 | ICD10CM | Covered |
| D03.59 | ICD10CM | Covered |
| D03.60 | ICD10CM | Covered |
| D03.61 | ICD10CM | Covered |
| D03.62 | ICD10CM | Covered |
| D03.70 | ICD10CM | Covered |
| D03.71 | ICD10CM | Covered |
| D03.72 | ICD10CM | Covered |
| D03.8 | ICD10CM | Covered |
| D03.9 | ICD10CM | Covered |
| D05.00 | ICD10CM | Covered |
| D05.01 | ICD10CM | Covered |
| D05.02 | ICD10CM | Covered |
| D05.10 | ICD10CM | Covered |
| D05.11 | ICD10CM | Covered |
| D05.12 | ICD10CM | Covered |
| D05.80 | ICD10CM | Covered |
| D05.81 | ICD10CM | Covered |
| D05.82 | ICD10CM | Covered |
| D05.90 | ICD10CM | Covered |
| D05.91 | ICD10CM | Covered |
| D05.92 | ICD10CM | Covered |
| D35.1 | ICD10CM | Covered |
| D45 | ICD10CM | Covered |
| D46.0 | ICD10CM | Covered |
| D46.1 | ICD10CM | Covered |
| D46.20 | ICD10CM | Covered |
| D46.21 | ICD10CM | Covered |
| D46.22 | ICD10CM | Covered |
| D46.4 | ICD10CM | Covered |
| D46.9 | ICD10CM | Covered |
| D46.A | ICD10CM | Covered |
| D46.B | ICD10CM | Covered |
| D46.C | ICD10CM | Covered |
| D46.Z | ICD10CM | Covered |
| D47.01 | ICD10CM | Covered |
| D47.02 | ICD10CM | Covered |
| D47.09 | ICD10CM | Covered |
| D47.1 | ICD10CM | Covered |
| D47.3 | ICD10CM | Covered |
| D47.4 | ICD10CM | Covered |
| D47.9 | ICD10CM | Covered |
| D47.Z9 | ICD10CM | Covered |
| D48.110 | ICD10CM | Covered |
| D48.111 | ICD10CM | Covered |
| D48.112 | ICD10CM | Covered |
| D48.113 | ICD10CM | Covered |
| D48.114 | ICD10CM | Covered |
| D48.115 | ICD10CM | Covered |
| D48.116 | ICD10CM | Covered |
| D48.117 | ICD10CM | Covered |
| D48.118 | ICD10CM | Covered |
| D48.119 | ICD10CM | Covered |
| D48.19 | ICD10CM | Covered |
| D60.0 | ICD10CM | Covered |
| D60.1 | ICD10CM | Covered |
| D60.8 | ICD10CM | Covered |
| D61.01 | ICD10CM | Covered |
| D61.09 | ICD10CM | Covered |
| D61.1 | ICD10CM | Covered |
| D61.2 | ICD10CM | Covered |
| D61.3 | ICD10CM | Covered |
| D61.818 | ICD10CM | Covered |
| D61.89 | ICD10CM | Covered |
| D61.9 | ICD10CM | Covered |
| D69.49 | ICD10CM | Covered |
| D69.6 | ICD10CM | Covered |
| D69.8 | ICD10CM | Covered |
| D69.9 | ICD10CM | Covered |
| D70.8 | ICD10CM | Covered |
| D70.9 | ICD10CM | Covered |
| D72.810 | ICD10CM | Covered |
| D72.818 | ICD10CM | Covered |
| D72.819 | ICD10CM | Covered |
| D72.821 | ICD10CM | Covered |
| D72.828 | ICD10CM | Covered |
| D72.829 | ICD10CM | Covered |
| D72.89 | ICD10CM | Covered |
| D72.9 | ICD10CM | Covered |
| D75.1 | ICD10CM | Covered |
| D75.81 | ICD10CM | Covered |
| D75.89 | ICD10CM | Covered |
| D75.9 | ICD10CM | Covered |
| D77 | ICD10CM | Covered |
| E83.01 | ICD10CM | Covered |
| E83.10 | ICD10CM | Covered |
| E83.110 | ICD10CM | Covered |
| E83.118 | ICD10CM | Covered |
| E83.119 | ICD10CM | Covered |
| E83.19 | ICD10CM | Covered |
| E88.01 | ICD10CM | Covered |
| R16.1 | ICD10CM | Covered |
| R16.2 | ICD10CM | Covered |
| Z17.0 | ICD10CM | Covered |
| Z48.21 | ICD10CM | Covered |
| Z85.038 | ICD10CM | Covered |
| Z85.048 | ICD10CM | Covered |
| Z85.07 | ICD10CM | Covered |
| Z85.3 | ICD10CM | Covered |
| Z85.43 | ICD10CM | Covered |
| Z85.46 | ICD10CM | Covered |
| Z85.820 | ICD10CM | Covered |
| Z86.000 | ICD10CM | Covered |
| Z94.1 | ICD10CM | Covered |