Ambetter · PayerPolicy · AMBETTER-CP-MP-242
Summary of the payer’s published policy. Not a coverage determination — confirm with Ambetter before submitting.
Free account. Policy pages stay open to everyone.
Each code’s status is what the policy records for it. This page does not show the policy’s criteria. Read them in the payer’s source.
| Code | Code system | Status in this policy |
|---|---|---|
| 94010 | CPT | Covered |
| 94060 | CPT | Covered |
| 94070 | CPT | Covered |
| 94200 | CPT | Covered |
| 94375 | CPT | Covered |
| 94450 | CPT | Covered |
| 94617 | CPT | Covered |
| 94618 | CPT | Covered |
| 94619 | CPT | Covered |
| 94621 | CPT | Covered |
| 94680 | CPT | Covered |
| 94681 | CPT | Covered |
| 94690 | CPT | Covered |
| 94726 | CPT | Covered |
| 94727 | CPT | Covered |
| 94728 | CPT | Covered |
| 94729 | CPT | Covered |
| 96417 | CPT | Covered |
| 96418 | CPT | Covered |
| 96419 | CPT | Covered |
| 96421 | CPT | Covered |
| A15.0 | ICD10CM | Covered |
| A15.4 | ICD10CM | Covered |
| A15.5 | ICD10CM | Covered |
| A15.6 | ICD10CM | Covered |
| A15.7 | ICD10CM | Covered |
| A15.8 | ICD10CM | Covered |
| A15.9 | ICD10CM | Covered |
| A31.0 | ICD10CM | Covered |
| A42.0 | ICD10CM | Covered |
| A43.0 | ICD10CM | Covered |
| A80.39 | ICD10CM | Covered |
| B37.1 | ICD10CM | Covered |
| B38.0 | ICD10CM | Covered |
| B38.1 | ICD10CM | Covered |
| B38.2 | ICD10CM | Covered |
| B39.1 | ICD10CM | Covered |
| B39.2 | ICD10CM | Covered |
| B40.0 | ICD10CM | Covered |
| B40.1 | ICD10CM | Covered |
| B40.2 | ICD10CM | Covered |
| B40.7 | ICD10CM | Covered |
| B40.89 | ICD10CM | Covered |
| B42.0 | ICD10CM | Covered |
| B42.7 | ICD10CM | Covered |
| B42.89 | ICD10CM | Covered |
| B44.81 | ICD10CM | Covered |
| B45.0 | ICD10CM | Covered |
| B45.7 | ICD10CM | Covered |
| B45.8 | ICD10CM | Covered |
| B46.0 | ICD10CM | Covered |
| B46.4 | ICD10CM | Covered |
| B47.1 | ICD10CM | Covered |
| B58.3 | ICD10CM | Covered |
| B59 | ICD10CM | Covered |
| B67.1 | ICD10CM | Covered |
| B77.81 | ICD10CM | Covered |
| B90.9 | ICD10CM | Covered |
| B91 | ICD10CM | Covered |
| B95.3 | ICD10CM | Covered |
| B96.0 | 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 |
| C37 | ICD10CM | Covered |
| C38.0 | ICD10CM | Covered |
| C38.1 | ICD10CM | Covered |
| C38.2 | ICD10CM | Covered |
| C38.3 | ICD10CM | Covered |
| C38.4 | ICD10CM | Covered |
| C38.8 | ICD10CM | Covered |
| C39.0 | ICD10CM | Covered |
| C39.9 | ICD10CM | Covered |
| C45.0 | ICD10CM | Covered |
| C45.2 | ICD10CM | Covered |
| C45.9 | ICD10CM | Covered |
| C46.51 | ICD10CM | Covered |
| C46.52 | ICD10CM | Covered |
| C78.00 | ICD10CM | Covered |
| C78.01 | ICD10CM | Covered |
| C78.02 | ICD10CM | Covered |
| C78.1 | ICD10CM | Covered |
| C78.2 | ICD10CM | Covered |
| C78.39 | ICD10CM | Covered |
| C7A.090 | ICD10CM | Covered |
| C7A.091 | ICD10CM | Covered |
| C81.12 | ICD10CM | Covered |
| C81.22 | ICD10CM | Covered |
| C81.32 | ICD10CM | Covered |
| C81.42 | ICD10CM | Covered |
| C81.72 | ICD10CM | Covered |
| C81.92 | ICD10CM | Covered |
| C82.02 | ICD10CM | Covered |
| C82.12 | ICD10CM | Covered |
| C82.22 | ICD10CM | Covered |
| C82.32 | ICD10CM | Covered |
| C82.42 | ICD10CM | Covered |
| C82.52 | ICD10CM | Covered |
| C82.62 | ICD10CM | Covered |
| C82.82 | ICD10CM | Covered |
| C82.92 | ICD10CM | Covered |
| C83.02 | ICD10CM | Covered |
| C83.12 | ICD10CM | Covered |
| C83.32 | ICD10CM | Covered |
| C83.52 | ICD10CM | Covered |
| C83.82 | ICD10CM | Covered |
| C83.92 | ICD10CM | Covered |
| C84.02 | ICD10CM | Covered |
| C84.12 | ICD10CM | Covered |
| C84.42 | ICD10CM | Covered |
| C84.62 | ICD10CM | Covered |
| C84.72 | ICD10CM | Covered |
| C84.A2 | ICD10CM | Covered |
| C84.Z2 | ICD10CM | Covered |
| C85.12 | ICD10CM | Covered |
| C85.22 | ICD10CM | Covered |
| C85.82 | ICD10CM | Covered |
| C85.92 | ICD10CM | Covered |
| C88.0 | ICD10CM | Covered |
| C96.5 | ICD10CM | Covered |
| C96.6 | ICD10CM | Covered |
| D02.20 | ICD10CM | Covered |
| D02.21 | ICD10CM | Covered |
| D02.22 | ICD10CM | Covered |
| D14.2 | ICD10CM | Covered |
| D14.30 | ICD10CM | Covered |
| D14.31 | ICD10CM | Covered |
| D14.32 | ICD10CM | Covered |
| D15.0 | ICD10CM | Covered |
| D15.2 | ICD10CM | Covered |
| D18.1 | ICD10CM | Covered |
| D19.0 | ICD10CM | Covered |
| D38.1 | ICD10CM | Covered |
| D38.2 | ICD10CM | Covered |
| D38.3 | ICD10CM | Covered |
| D38.4 | ICD10CM | Covered |
| D38.5 | ICD10CM | Covered |
| D49.1 | ICD10CM | Covered |
| D57.1 | ICD10CM | Covered |
| D68.61 | ICD10CM | Covered |
| D75.1 | ICD10CM | Covered |
| D86.0 | ICD10CM | Covered |
| D86.1 | ICD10CM | Covered |
| D86.2 | ICD10CM | Covered |
| D86.3 | ICD10CM | Covered |
| D86.81 | ICD10CM | Covered |
| D86.82 | ICD10CM | Covered |
| D86.85 | ICD10CM | Covered |
| D86.87 | ICD10CM | Covered |
| D86.89 | ICD10CM | Covered |
| D86.9 | ICD10CM | Covered |
| E66.01 | ICD10CM | Covered |
| E66.2 | ICD10CM | Covered |
| E74.02 | ICD10CM | Covered |
| E84.0 | ICD10CM | Covered |
| E84.19 | ICD10CM | Covered |
| E84.8 | ICD10CM | Covered |
| E84.9 | ICD10CM | Covered |
| E85.4 | ICD10CM | Covered |
| E88.89 | ICD10CM | Covered |
| F51.8 | ICD10CM | Covered |
| G12.0 | ICD10CM | Covered |
| G12.1 | ICD10CM | Covered |
| G12.20 | ICD10CM | Covered |
| G12.21 | ICD10CM | Covered |
| G12.22 | ICD10CM | Covered |
| G12.23 | ICD10CM | Covered |
| G12.24 | ICD10CM | Covered |
| G12.25 | ICD10CM | Covered |
| G12.29 | ICD10CM | Covered |
| G12.8 | ICD10CM | Covered |
| G12.9 | ICD10CM | Covered |
| G14 | ICD10CM | Covered |
| G61.0 | ICD10CM | Covered |
| G65.0 | ICD10CM | Covered |
| G70.00 | ICD10CM | Covered |
| G70.01 | ICD10CM | Covered |
| G70.80 | ICD10CM | Covered |
| G70.81 | ICD10CM | Covered |
| G71.01 | ICD10CM | Covered |
| G71.02 | ICD10CM | Covered |
| G71.09 | ICD10CM | Covered |
| G71.11 | ICD10CM | Covered |
| G71.29 | ICD10CM | Covered |
| G73.1 | ICD10CM | Covered |
| G80.9 | ICD10CM | Covered |
| G82.51 | ICD10CM | Covered |
| G82.52 | ICD10CM | Covered |
| G82.53 | ICD10CM | Covered |
| G82.54 | ICD10CM | Covered |
| G83.81 | ICD10CM | Covered |
| G83.82 | ICD10CM | Covered |
| G83.83 | ICD10CM | Covered |
| G83.84 | ICD10CM | Covered |
| G83.89 | ICD10CM | Covered |
| I26.01 | ICD10CM | Covered |
| I26.02 | ICD10CM | Covered |
| I26.09 | ICD10CM | Covered |
| I26.90 | ICD10CM | Covered |
| I26.92 | ICD10CM | Covered |
| I26.94 | ICD10CM | Covered |
| I26.99 | ICD10CM | Covered |
| I27.0 | ICD10CM | Covered |
| I27.1 | ICD10CM | Covered |
| I27.20 | ICD10CM | Covered |
| I27.21 | ICD10CM | Covered |
| I27.22 | ICD10CM | Covered |
| I27.23 | ICD10CM | Covered |
| I27.24 | ICD10CM | Covered |
| I27.29 | ICD10CM | Covered |
| I27.81 | ICD10CM | Covered |
| I27.82 | ICD10CM | Covered |
| I27.83 | ICD10CM | Covered |
| I27.89 | ICD10CM | Covered |
| I27.9 | ICD10CM | Covered |
| I28.1 | ICD10CM | Covered |
| I28.8 | ICD10CM | Covered |
| I28.88 | ICD10CM | Covered |
| I34.0 | ICD10CM | Covered |
| I34.2 | ICD10CM | Covered |
| I35.0 | ICD10CM | Covered |
| I35.1 | ICD10CM | Covered |
| I35.8 | ICD10CM | Covered |
| I36.1 | ICD10CM | Covered |
| I37.0 | ICD10CM | Covered |
| I37.1 | ICD10CM | Covered |
| I37.2 | ICD10CM | Covered |
| I37.8 | ICD10CM | Covered |
| I37.9 | ICD10CM | Covered |
| I42.0 | ICD10CM | Covered |
| I42.0-I42.8 | ICD10CM | Covered |
| I42.1 | ICD10CM | Covered |
| I42.2 | ICD10CM | Covered |
| I42.3 | ICD10CM | Covered |
| I42.4 | ICD10CM | Covered |
| I42.5 | ICD10CM | Covered |
| I42.6 | ICD10CM | Covered |
| I42.7 | ICD10CM | Covered |
| I42.8 | ICD10CM | Covered |
| I42.9 | ICD10CM | Covered |
| I43 | ICD10CM | Covered |
| I50.1 | ICD10CM | Covered |
| I50.20 | ICD10CM | Covered |
| I50.21 | ICD10CM | Covered |
| I50.22 | ICD10CM | Covered |
| I50.23 | ICD10CM | Covered |
| I50.30 | ICD10CM | Covered |
| I50.31 | ICD10CM | Covered |
| I50.32 | ICD10CM | Covered |
| I50.33 | ICD10CM | Covered |
| I50.40 | ICD10CM | Covered |
| I50.41 | ICD10CM | Covered |
| I50.42 | ICD10CM | Covered |
| I50.43 | ICD10CM | Covered |
| I50.810 | ICD10CM | Covered |
| I50.811 | ICD10CM | Covered |
| I50.812 | ICD10CM | Covered |
| I50.813 | ICD10CM | Covered |
| I50.814 | ICD10CM | Covered |
| I50.82 | ICD10CM | Covered |
| I50.83 | ICD10CM | Covered |
| I50.84 | ICD10CM | Covered |
| I50.89 | ICD10CM | Covered |
| I50.9 | ICD10CM | Covered |
| J12.81 | ICD10CM | Covered |
| J12.82 | ICD10CM | Covered |
| J12.89 | ICD10CM | Covered |
| J12.9 | ICD10CM | Covered |
| J13 | ICD10CM | Covered |
| J15.1 | ICD10CM | Covered |
| J15.6 | 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 |
| J20.7 | ICD10CM | Covered |
| J20.8 | ICD10CM | Covered |
| J20.9 | ICD10CM | Covered |
| J21.0 | ICD10CM | Covered |
| J21.1 | ICD10CM | Covered |
| J21.8 | ICD10CM | Covered |
| J21.9 | ICD10CM | Covered |
| J22 | ICD10CM | Covered |
| J39.8 | ICD10CM | Covered |
| J39.9 | ICD10CM | Covered |
| J40 | ICD10CM | Covered |
| J41.0 | ICD10CM | Covered |
| J41.1 | ICD10CM | Covered |
| J41.8 | ICD10CM | Covered |
| J42 | ICD10CM | Covered |
| J43.0 | ICD10CM | Covered |
| J43.1 | ICD10CM | Covered |
| J43.2 | ICD10CM | Covered |
| J43.8 | ICD10CM | Covered |
| J43.9 | ICD10CM | Covered |
| J44.0 | ICD10CM | Covered |
| J44.1 | ICD10CM | Covered |
| J44.9 | 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 |
| J45.990 | ICD10CM | Covered |
| J45.991 | ICD10CM | Covered |
| J45.998 | ICD10CM | Covered |
| J47.0 | ICD10CM | Covered |
| J47.1 | ICD10CM | Covered |
| J47.9 | ICD10CM | Covered |
| J60 | ICD10CM | Covered |
| J61 | ICD10CM | Covered |
| J62.0 | ICD10CM | Covered |
| J62.8 | ICD10CM | Covered |
| J63.0 | ICD10CM | Covered |
| J63.1 | ICD10CM | Covered |
| J63.2 | ICD10CM | Covered |
| J63.3 | ICD10CM | Covered |
| J63.4 | ICD10CM | Covered |
| J63.5 | ICD10CM | Covered |
| J63.6 | ICD10CM | Covered |
| J64 | ICD10CM | Covered |
| J65 | ICD10CM | Covered |
| J66.0 | ICD10CM | Covered |
| J66.1 | ICD10CM | Covered |
| J66.2 | ICD10CM | Covered |
| J66.8 | ICD10CM | Covered |
| J67.0 | ICD10CM | Covered |
| J67.1 | ICD10CM | Covered |
| J67.2 | ICD10CM | Covered |
| J67.3 | ICD10CM | Covered |
| J67.4 | ICD10CM | Covered |
| J67.5 | ICD10CM | Covered |
| J67.6 | ICD10CM | Covered |
| J67.7 | ICD10CM | Covered |
| J67.8 | ICD10CM | Covered |
| J67.9 | ICD10CM | Covered |
| J68.0 | ICD10CM | Covered |
| J68.1 | ICD10CM | Covered |
| J68.2 | ICD10CM | Covered |
| J68.3 | ICD10CM | Covered |
| J68.4 | ICD10CM | Covered |
| J68.8 | ICD10CM | Covered |
| J68.9 | ICD10CM | Covered |
| J69.0 | ICD10CM | Covered |
| J69.1 | ICD10CM | Covered |
| J69.8 | ICD10CM | Covered |
| J70.0 | ICD10CM | Covered |
| J70.1 | ICD10CM | Covered |
| J70.2 | ICD10CM | Covered |
| J70.3 | ICD10CM | Covered |
| J70.4 | ICD10CM | Covered |
| J70.5 | ICD10CM | Covered |
| J70.8 | ICD10CM | Covered |
| J70.9 | ICD10CM | Covered |
| J80 | ICD10CM | Covered |
| J81.0 | ICD10CM | Covered |
| J81.1 | ICD10CM | Covered |
| J82.81 | ICD10CM | Covered |
| J82.82 | ICD10CM | Covered |
| J82.83 | ICD10CM | Covered |
| J82.89 | ICD10CM | Covered |
| J84.01 | ICD10CM | Covered |
| J84.02 | ICD10CM | Covered |
| J84.03 | ICD10CM | Covered |
| J84.09 | ICD10CM | Covered |
| J84.10 | ICD10CM | Covered |
| J84.111 | ICD10CM | Covered |
| J84.112 | ICD10CM | Covered |
| J84.113 | ICD10CM | Covered |
| J84.114 | ICD10CM | Covered |
| J84.115 | 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 |
| J84.83 | ICD10CM | Covered |
| J84.842 | ICD10CM | Covered |
| J84.843 | ICD10CM | Covered |
| J84.848 | ICD10CM | Covered |
| J84.89 | ICD10CM | Covered |
| J84.9 | ICD10CM | Covered |
| J85.0 | ICD10CM | Covered |
| J85.1 | ICD10CM | Covered |
| J85.2 | ICD10CM | Covered |
| J85.3 | ICD10CM | Covered |
| J86.0 | ICD10CM | Covered |
| J86.9 | ICD10CM | Covered |
| J90 | ICD10CM | Covered |
| J91.0 | ICD10CM | Covered |
| J91.8 | ICD10CM | Covered |
| J92.0 | ICD10CM | Covered |
| J92.9 | ICD10CM | Covered |
| J94.0 | ICD10CM | Covered |
| J94.1 | ICD10CM | Covered |
| J94.2 | ICD10CM | Covered |
| J94.8 | ICD10CM | Covered |
| J94.9 | ICD10CM | Covered |
| J95.02 | ICD10CM | Covered |
| J95.1 | ICD10CM | Covered |
| J95.2 | ICD10CM | Covered |
| J95.3 | ICD10CM | Covered |
| J95.4 | ICD10CM | Covered |
| J95.5 | ICD10CM | Covered |
| J95.84 | ICD10CM | Covered |
| J96.00 | ICD10CM | Covered |
| J96.01 | ICD10CM | Covered |
| J96.02 | ICD10CM | Covered |
| J96.10 | ICD10CM | Covered |
| J96.11 | ICD10CM | Covered |
| J96.12 | ICD10CM | Covered |
| J96.20 | ICD10CM | Covered |
| J96.21 | ICD10CM | Covered |
| J96.22 | ICD10CM | Covered |
| J96.90 | ICD10CM | Covered |
| J96.91 | ICD10CM | Covered |
| J96.92 | ICD10CM | Covered |
| J98.01 | ICD10CM | Covered |
| J98.09 | ICD10CM | Covered |
| J98.11 | ICD10CM | Covered |
| J98.19 | ICD10CM | Covered |
| J98.2 | ICD10CM | Covered |
| J98.3 | ICD10CM | Covered |
| J98.4 | ICD10CM | Covered |
| J98.59 | ICD10CM | Covered |
| J98.6 | ICD10CM | Covered |
| J98.8 | ICD10CM | Covered |
| J99 | ICD10CM | Covered |
| M05.10 | ICD10CM | Covered |
| M05.111 | ICD10CM | Covered |
| M05.112 | ICD10CM | Covered |
| M05.121 | ICD10CM | Covered |
| M05.122 | ICD10CM | Covered |
| M05.131 | ICD10CM | Covered |
| M05.132 | ICD10CM | Covered |
| M05.141 | ICD10CM | Covered |
| M05.142 | ICD10CM | Covered |
| M05.151 | ICD10CM | Covered |
| M05.152 | ICD10CM | Covered |
| M05.161 | ICD10CM | Covered |
| M05.162 | ICD10CM | Covered |
| M05.171 | ICD10CM | Covered |
| M05.172 | ICD10CM | Covered |
| M05.19 | ICD10CM | Covered |
| M06.1 | ICD10CM | Covered |
| M06.39 | ICD10CM | Covered |
| M08.1 | ICD10CM | Covered |
| M30.0 | ICD10CM | Covered |
| M30.1 | ICD10CM | Covered |
| M31.0 | ICD10CM | Covered |
| M31.2 | ICD10CM | Covered |
| M31.30 | ICD10CM | Covered |
| M31.31 | ICD10CM | Covered |
| M31.8 | ICD10CM | Covered |
| M31.9 | ICD10CM | Covered |
| M32.0 | ICD10CM | Covered |
| M32.10 | ICD10CM | Covered |
| M32.13 | ICD10CM | Covered |
| M32.8 | ICD10CM | Covered |
| M32.9 | ICD10CM | Covered |
| M33.00 | ICD10CM | Covered |
| M33.01 | ICD10CM | Covered |
| M33.11 | ICD10CM | Covered |
| M33.20 | ICD10CM | Covered |
| M33.21 | ICD10CM | Covered |
| M33.91 | ICD10CM | Covered |
| M34.1 | ICD10CM | Covered |
| M34.81 | ICD10CM | Covered |
| M34.9 | ICD10CM | Covered |
| M35.00 | ICD10CM | Covered |
| M35.02 | ICD10CM | Covered |
| M35.1 | ICD10CM | Covered |
| M35.89 | ICD10CM | Covered |
| M35.9 | ICD10CM | Covered |
| M36.0 | ICD10CM | Covered |
| M40.03 | ICD10CM | Covered |
| M40.04 | ICD10CM | Covered |
| M40.05 | ICD10CM | Covered |
| M40.292 | ICD10CM | Covered |
| M40.293 | ICD10CM | Covered |
| M40.294 | ICD10CM | Covered |
| M40.295 | ICD10CM | Covered |
| M40.30 | ICD10CM | Covered |
| M40.35 | ICD10CM | Covered |
| M40.45 | ICD10CM | Covered |
| M41.112 | ICD10CM | Covered |
| M41.113 | ICD10CM | Covered |
| M41.114 | ICD10CM | Covered |
| M41.115 | ICD10CM | Covered |
| M41.116 | ICD10CM | Covered |
| M41.117 | ICD10CM | Covered |
| M41.122 | ICD10CM | Covered |
| M41.123 | ICD10CM | Covered |
| M41.124 | ICD10CM | Covered |
| M41.125 | ICD10CM | Covered |
| M41.126 | ICD10CM | Covered |
| M41.127 | ICD10CM | Covered |
| M41.22 | ICD10CM | Covered |
| M41.23 | ICD10CM | Covered |
| M41.24 | ICD10CM | Covered |
| M41.25 | ICD10CM | Covered |
| M41.26 | ICD10CM | Covered |
| M41.27 | ICD10CM | Covered |
| M41.34 | ICD10CM | Covered |
| M41.35 | ICD10CM | Covered |
| M45.0 | ICD10CM | Covered |
| M45.2 | ICD10CM | Covered |
| M45.3 | ICD10CM | Covered |
| M45.4 | ICD10CM | Covered |
| M45.5 | ICD10CM | Covered |
| M47.12 | ICD10CM | Covered |
| M47.13 | ICD10CM | Covered |
| M47.14 | ICD10CM | Covered |
| M47.15 | ICD10CM | Covered |
| O29.011 | ICD10CM | Covered |
| O29.012 | ICD10CM | Covered |
| O29.013 | ICD10CM | Covered |
| O29.019 | ICD10CM | Covered |
| O29.021 | ICD10CM | Covered |
| O29.022 | ICD10CM | Covered |
| O29.023 | ICD10CM | Covered |
| O29.029 | ICD10CM | Covered |
| O29.091 | ICD10CM | Covered |
| O29.092 | ICD10CM | Covered |
| O29.093 | ICD10CM | Covered |
| O29.099 | ICD10CM | Covered |
| O99.511 | ICD10CM | Covered |
| O99.512 | ICD10CM | Covered |
| O99.513 | ICD10CM | Covered |
| O99.519 | ICD10CM | Covered |
| Q21.0-Q21.9 | ICD10CM | Covered |
| Q22.0 | ICD10CM | Covered |
| Q22.0-Q22.9 | ICD10CM | Covered |
| Q22.1 | ICD10CM | Covered |
| Q22.2 | ICD10CM | Covered |
| Q22.3 | ICD10CM | Covered |
| Q23.0-Q23.9 | ICD10CM | Covered |
| Q24.0-Q24.9 | ICD10CM | Covered |
| Q24.8 | ICD10CM | Covered |
| Q24.89 | ICD10CM | Covered |
| Q25.0-Q25.9 | ICD10CM | Covered |
| Q25.6 | ICD10CM | Covered |
| Q25.71 | ICD10CM | Covered |
| Q25.72 | ICD10CM | Covered |
| Q25.79 | ICD10CM | Covered |
| Q26.0-Q26.9 | ICD10CM | Covered |
| Q27.0-Q27.9 | ICD10CM | Covered |
| Q28.0-Q28.9 | ICD10CM | Covered |
| Q31.5 | ICD10CM | Covered |
| Q32.0 | ICD10CM | Covered |
| Q32.1 | ICD10CM | Covered |
| Q32.2 | ICD10CM | Covered |
| Q32.3 | ICD10CM | Covered |
| Q32.4 | ICD10CM | Covered |
| Q33.0 | ICD10CM | Covered |
| Q33.1 | ICD10CM | Covered |
| Q33.3 | ICD10CM | Covered |
| Q33.4 | ICD10CM | Covered |
| Q33.5 | ICD10CM | Covered |
| Q33.6 | ICD10CM | Covered |
| Q33.8 | ICD10CM | Covered |
| Q33.9 | ICD10CM | Covered |
| Q34.0 | ICD10CM | Covered |
| Q34.1 | ICD10CM | Covered |
| Q34.8 | ICD10CM | Covered |
| Q34.9 | ICD10CM | Covered |
| Q67.5 | ICD10CM | Covered |
| Q67.6 | ICD10CM | Covered |
| Q67.8 | ICD10CM | Covered |
| Q76.3 | ICD10CM | Covered |
| Q76.412 | ICD10CM | Covered |
| Q76.413 | ICD10CM | Covered |
| Q76.414 | ICD10CM | Covered |
| Q76.415 | ICD10CM | Covered |
| Q76.425 | ICD10CM | Covered |
| Q76.8 | ICD10CM | Covered |
| Q76.9 | ICD10CM | Covered |
| R04.2 | ICD10CM | Covered |
| R04.89 | ICD10CM | Covered |
| R05.1 | ICD10CM | Covered |
| R05.2 | ICD10CM | Covered |
| R05.3 | ICD10CM | Covered |
| R05.4 | ICD10CM | Covered |
| R05.8 | ICD10CM | Covered |
| R06.00 | ICD10CM | Covered |
| R06.01 | ICD10CM | Covered |
| R06.02 | ICD10CM | Covered |
| R06.03 | ICD10CM | Covered |
| R06.09 | ICD10CM | Covered |
| R06.1 | ICD10CM | Covered |
| R06.2 | ICD10CM | Covered |
| R06.3 | ICD10CM | Covered |
| R06.4 | ICD10CM | Covered |
| R06.82 | ICD10CM | Covered |
| R06.83 | ICD10CM | Covered |
| R06.89 | ICD10CM | Covered |
| R06.9 | ICD10CM | Covered |
| R07.1 | ICD10CM | Covered |
| R09.01 | ICD10CM | Covered |
| R09.02 | ICD10CM | Covered |
| R09.1 | ICD10CM | Covered |
| R09.89 | ICD10CM | Covered |
| R23.0 | ICD10CM | Covered |
| R79.81 | ICD10CM | Covered |
| R91.1 | ICD10CM | Covered |
| R91.8 | ICD10CM | Covered |
| R94.2 | ICD10CM | Covered |
| T50.0X1A-T50.0X5S | ICD10CM | Covered |
| T50.1X1A-T50.1X5S | ICD10CM | Covered |
| T50.2X1A-T50.2X5S | ICD10CM | Covered |
| T50.3X1A-T50.3X5S | ICD10CM | Covered |
| T50.905A-T50.905S | ICD10CM | Covered |
| T53.0X1A-T53.7X4S | ICD10CM | Covered |
| T57.3X1A-T57.3X4S | ICD10CM | Covered |
| T58.01XA-T58.2X4S | ICD10CM | Covered |
| T59.0X1A-T59.94XS | ICD10CM | Covered |
| T86.810 | ICD10CM | Covered |
| T86.811 | ICD10CM | Covered |
| T86.812 | ICD10CM | Covered |
| T86.818 | ICD10CM | Covered |
| T86.819 | ICD10CM | Covered |
| Z22.7 | ICD10CM | Covered |
| Z48.21 | ICD10CM | Covered |
| Z48.24 | ICD10CM | Covered |
| Z48.280 | ICD10CM | Covered |
| Z76.82 | ICD10CM | Covered |
| Z79.3 | ICD10CM | Covered |
| Z79.51 | ICD10CM | Covered |
| Z79.891 | ICD10CM | Covered |
| Z79.899 | ICD10CM | Covered |
| Z85.118 | ICD10CM | Covered |
| Z86.16 | ICD10CM | Covered |
| Z86.711 | ICD10CM | Covered |
| Z87.01 | ICD10CM | Covered |
| Z87.09 | ICD10CM | Covered |
| Z90.2 | ICD10CM | Covered |
| Z94.1 | ICD10CM | Covered |
| Z94.2 | ICD10CM | Covered |
| Z94.3 | ICD10CM | Covered |