Extended Ophthalmoscopy

Ambetter · PayerPolicy · AMBETTER-CP-VP-26

Status: Active
Last checked by Backwork: October 1, 2026

Summary of the payer’s published policy. Not a coverage determination — confirm with Ambetter before submitting.

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Codes in this policy

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.

Codes this policy lists and each code’s status in the policy
Code	Code system	Status in this policy
92201	CPT	Covered
92202	CPT	Covered
A18.53	ICD10CM	Covered
A18.54	ICD10CM	Covered
B39.4	ICD10CM	Covered
B39.5	ICD10CM	Covered
B58.01	ICD10CM	Covered
C69.21	ICD10CM	Covered
C69.22	ICD10CM	Covered
C69.31	ICD10CM	Covered
C69.32	ICD10CM	Covered
C69.41	ICD10CM	Covered
C69.42	ICD10CM	Covered
C72.31	ICD10CM	Covered
C72.32	ICD10CM	Covered
C72.59	ICD10CM	Covered
D31.21	ICD10CM	Covered
D31.22	ICD10CM	Covered
D31.31	ICD10CM	Covered
D31.32	ICD10CM	Covered
D31.41	ICD10CM	Covered
D31.42	ICD10CM	Covered
D33.3	ICD10CM	Covered
E08.3211	ICD10CM	Covered
E08.3212	ICD10CM	Covered
E08.3213	ICD10CM	Covered
E08.3291	ICD10CM	Covered
E08.3292	ICD10CM	Covered
E08.3293	ICD10CM	Covered
E08.3311	ICD10CM	Covered
E08.3312	ICD10CM	Covered
E08.3313	ICD10CM	Covered
E08.3391	ICD10CM	Covered
E08.3392	ICD10CM	Covered
E08.3393	ICD10CM	Covered
E08.3411	ICD10CM	Covered
E08.3412	ICD10CM	Covered
E08.3413	ICD10CM	Covered
E08.3491	ICD10CM	Covered
E08.3492	ICD10CM	Covered
E08.3493	ICD10CM	Covered
E08.3511	ICD10CM	Covered
E08.3512	ICD10CM	Covered
E08.3513	ICD10CM	Covered
E08.3521	ICD10CM	Covered
E08.3522	ICD10CM	Covered
E08.3523	ICD10CM	Covered
E08.3531	ICD10CM	Covered
E08.3532	ICD10CM	Covered
E08.3533	ICD10CM	Covered
E08.3541	ICD10CM	Covered
E08.3542	ICD10CM	Covered
E08.3543	ICD10CM	Covered
E08.3551	ICD10CM	Covered
E08.3552	ICD10CM	Covered
E08.3553	ICD10CM	Covered
E08.3591	ICD10CM	Covered
E08.3592	ICD10CM	Covered
E08.3593	ICD10CM	Covered
E08.37X1	ICD10CM	Covered
E08.37X2	ICD10CM	Covered
E08.37X3	ICD10CM	Covered
E09.3211	ICD10CM	Covered
E09.3212	ICD10CM	Covered
E09.3213	ICD10CM	Covered
E09.3291	ICD10CM	Covered
E09.3292	ICD10CM	Covered
E09.3293	ICD10CM	Covered
E09.3311	ICD10CM	Covered
E09.3312	ICD10CM	Covered
E09.3313	ICD10CM	Covered
E09.3391	ICD10CM	Covered
E09.3392	ICD10CM	Covered
E09.3393	ICD10CM	Covered
E09.3411	ICD10CM	Covered
E09.3412	ICD10CM	Covered
E09.3413	ICD10CM	Covered
E09.3491	ICD10CM	Covered
E09.3492	ICD10CM	Covered
E09.3493	ICD10CM	Covered
E09.3511	ICD10CM	Covered
E09.3512	ICD10CM	Covered
E09.3513	ICD10CM	Covered
E09.3521	ICD10CM	Covered
E09.3522	ICD10CM	Covered
E09.3523	ICD10CM	Covered
E09.3531	ICD10CM	Covered
E09.3532	ICD10CM	Covered
E09.3533	ICD10CM	Covered
E09.3541	ICD10CM	Covered
E09.3542	ICD10CM	Covered
E09.3543	ICD10CM	Covered
E09.3551	ICD10CM	Covered
E09.3552	ICD10CM	Covered
E09.3553	ICD10CM	Covered
E09.3591	ICD10CM	Covered
E09.3592	ICD10CM	Covered
E09.3593	ICD10CM	Covered
E09.37X1	ICD10CM	Covered
E09.37X2	ICD10CM	Covered
E09.37X3	ICD10CM	Covered
E10.3211	ICD10CM	Covered
E10.3212	ICD10CM	Covered
E10.3213	ICD10CM	Covered
E10.3291	ICD10CM	Covered
E10.3292	ICD10CM	Covered
E10.3293	ICD10CM	Covered
E10.3311	ICD10CM	Covered
E10.3312	ICD10CM	Covered
E10.3313	ICD10CM	Covered
E10.3391	ICD10CM	Covered
E10.3392	ICD10CM	Covered
E10.3393	ICD10CM	Covered
E10.3411	ICD10CM	Covered
E10.3412	ICD10CM	Covered
E10.3413	ICD10CM	Covered
E10.3491	ICD10CM	Covered
E10.3492	ICD10CM	Covered
E10.3493	ICD10CM	Covered
E10.3511	ICD10CM	Covered
E10.3512	ICD10CM	Covered
E10.3513	ICD10CM	Covered
E10.3521	ICD10CM	Covered
E10.3522	ICD10CM	Covered
E10.3523	ICD10CM	Covered
E10.3531	ICD10CM	Covered
E10.3532	ICD10CM	Covered
E10.3533	ICD10CM	Covered
E10.3541	ICD10CM	Covered
E10.3542	ICD10CM	Covered
E10.3543	ICD10CM	Covered
E10.3551	ICD10CM	Covered
E10.3552	ICD10CM	Covered
E10.3553	ICD10CM	Covered
E10.3591	ICD10CM	Covered
E10.3592	ICD10CM	Covered
E10.3593	ICD10CM	Covered
E10.37X1	ICD10CM	Covered
E10.37X2	ICD10CM	Covered
E10.37X3	ICD10CM	Covered
E11.3211	ICD10CM	Covered
E11.3212	ICD10CM	Covered
E11.3213	ICD10CM	Covered
E11.3291	ICD10CM	Covered
E11.3292	ICD10CM	Covered
E11.3293	ICD10CM	Covered
E11.3311	ICD10CM	Covered
E11.3312	ICD10CM	Covered
E11.3313	ICD10CM	Covered
E11.3391	ICD10CM	Covered
E11.3392	ICD10CM	Covered
E11.3393	ICD10CM	Covered
E11.3411	ICD10CM	Covered
E11.3412	ICD10CM	Covered
E11.3413	ICD10CM	Covered
E11.3491	ICD10CM	Covered
E11.3492	ICD10CM	Covered
E11.3493	ICD10CM	Covered
E11.3511	ICD10CM	Covered
E11.3512	ICD10CM	Covered
E11.3513	ICD10CM	Covered
E11.3521	ICD10CM	Covered
E11.3522	ICD10CM	Covered
E11.3523	ICD10CM	Covered
E11.3531	ICD10CM	Covered
E11.3532	ICD10CM	Covered
E11.3533	ICD10CM	Covered
E11.3541	ICD10CM	Covered
E11.3542	ICD10CM	Covered
E11.3543	ICD10CM	Covered
E11.3551	ICD10CM	Covered
E11.3552	ICD10CM	Covered
E11.3553	ICD10CM	Covered
E11.3591	ICD10CM	Covered
E11.3592	ICD10CM	Covered
E11.3593	ICD10CM	Covered
E11.37X1	ICD10CM	Covered
E11.37X2	ICD10CM	Covered
E11.37X3	ICD10CM	Covered
E13.3211	ICD10CM	Covered
E13.3212	ICD10CM	Covered
E13.3213	ICD10CM	Covered
E13.3291	ICD10CM	Covered
E13.3292	ICD10CM	Covered
E13.3293	ICD10CM	Covered
E13.3311	ICD10CM	Covered
E13.3312	ICD10CM	Covered
E13.3313	ICD10CM	Covered
E13.3391	ICD10CM	Covered
E13.3392	ICD10CM	Covered
E13.3393	ICD10CM	Covered
E13.3411	ICD10CM	Covered
E13.3412	ICD10CM	Covered
E13.3413	ICD10CM	Covered
E13.3491	ICD10CM	Covered
E13.3492	ICD10CM	Covered
E13.3493	ICD10CM	Covered
E13.3511	ICD10CM	Covered
E13.3512	ICD10CM	Covered
E13.3513	ICD10CM	Covered
E13.3521	ICD10CM	Covered
E13.3522	ICD10CM	Covered
E13.3523	ICD10CM	Covered
E13.3531	ICD10CM	Covered
E13.3532	ICD10CM	Covered
E13.3533	ICD10CM	Covered
E13.3541	ICD10CM	Covered
E13.3542	ICD10CM	Covered
E13.3543	ICD10CM	Covered
E13.3551	ICD10CM	Covered
E13.3552	ICD10CM	Covered
E13.3553	ICD10CM	Covered
E13.3591	ICD10CM	Covered
E13.3592	ICD10CM	Covered
E13.3593	ICD10CM	Covered
G45.3	ICD10CM	Covered
H15.031	ICD10CM	Covered
H15.032	ICD10CM	Covered
H15.033	ICD10CM	Covered
H16.241	ICD10CM	Covered
H16.242	ICD10CM	Covered
H16.243	ICD10CM	Covered
H20.01	ICD10CM	Covered
H20.011	ICD10CM	Covered
H20.012	ICD10CM	Covered
H20.013	ICD10CM	Covered
H20.02	ICD10CM	Covered
H20.021	ICD10CM	Covered
H20.022	ICD10CM	Covered
H20.023	ICD10CM	Covered
H20.03	ICD10CM	Covered
H20.031	ICD10CM	Covered
H20.032	ICD10CM	Covered
H20.033	ICD10CM	Covered
H20.041	ICD10CM	Covered
H20.042	ICD10CM	Covered
H20.043	ICD10CM	Covered
H20.11	ICD10CM	Covered
H20.12	ICD10CM	Covered
H20.13	ICD10CM	Covered
H20.21	ICD10CM	Covered
H20.22	ICD10CM	Covered
H20.23	ICD10CM	Covered
H20.811	ICD10CM	Covered
H20.812	ICD10CM	Covered
H20.813	ICD10CM	Covered
H20.821	ICD10CM	Covered
H20.822	ICD10CM	Covered
H20.823	ICD10CM	Covered
H21.301	ICD10CM	Covered
H21.302	ICD10CM	Covered
H21.303	ICD10CM	Covered
H21.311	ICD10CM	Covered
H21.312	ICD10CM	Covered
H21.313	ICD10CM	Covered
H21.321	ICD10CM	Covered
H21.322	ICD10CM	Covered
H21.323	ICD10CM	Covered
H21.331	ICD10CM	Covered
H21.332	ICD10CM	Covered
H21.333	ICD10CM	Covered
H21.341	ICD10CM	Covered
H21.342	ICD10CM	Covered
H21.343	ICD10CM	Covered
H21.351	ICD10CM	Covered
H21.352	ICD10CM	Covered
H21.353	ICD10CM	Covered
H21.531	ICD10CM	Covered
H21.532	ICD10CM	Covered
H21.533	ICD10CM	Covered
H21.541	ICD10CM	Covered
H21.542	ICD10CM	Covered
H21.543	ICD10CM	Covered
H21.551	ICD10CM	Covered
H21.552	ICD10CM	Covered
H21.553	ICD10CM	Covered
H27.111	ICD10CM	Covered
H27.112	ICD10CM	Covered
H27.113	ICD10CM	Covered
H27.131	ICD10CM	Covered
H27.132	ICD10CM	Covered
H27.133	ICD10CM	Covered
H30.011	ICD10CM	Covered
H30.012	ICD10CM	Covered
H30.013	ICD10CM	Covered
H30.021	ICD10CM	Covered
H30.022	ICD10CM	Covered
H30.023	ICD10CM	Covered
H30.031	ICD10CM	Covered
H30.032	ICD10CM	Covered
H30.033	ICD10CM	Covered
H30.041	ICD10CM	Covered
H30.042	ICD10CM	Covered
H30.043	ICD10CM	Covered
H30.111	ICD10CM	Covered
H30.112	ICD10CM	Covered
H30.113	ICD10CM	Covered
H30.121	ICD10CM	Covered
H30.122	ICD10CM	Covered
H30.123	ICD10CM	Covered
H30.131	ICD10CM	Covered
H30.132	ICD10CM	Covered
H30.133	ICD10CM	Covered
H30.141	ICD10CM	Covered
H30.142	ICD10CM	Covered
H30.143	ICD10CM	Covered
H30.21	ICD10CM	Covered
H30.22	ICD10CM	Covered
H30.23	ICD10CM	Covered
H30.811	ICD10CM	Covered
H30.812	ICD10CM	Covered
H30.813	ICD10CM	Covered
H31.011	ICD10CM	Covered
H31.012	ICD10CM	Covered
H31.013	ICD10CM	Covered
H31.021	ICD10CM	Covered
H31.022	ICD10CM	Covered
H31.023	ICD10CM	Covered
H31.111	ICD10CM	Covered
H31.112	ICD10CM	Covered
H31.113	ICD10CM	Covered
H31.121	ICD10CM	Covered
H31.122	ICD10CM	Covered
H31.123	ICD10CM	Covered
H31.21	ICD10CM	Covered
H31.22	ICD10CM	Covered
H31.23	ICD10CM	Covered
H31.311	ICD10CM	Covered
H31.312	ICD10CM	Covered
H31.313	ICD10CM	Covered
H31.321	ICD10CM	Covered
H31.322	ICD10CM	Covered
H31.323	ICD10CM	Covered
H31.411	ICD10CM	Covered
H31.412	ICD10CM	Covered
H31.413	ICD10CM	Covered
H31.421	ICD10CM	Covered
H31.422	ICD10CM	Covered
H31.423	ICD10CM	Covered
H33.011	ICD10CM	Covered
H33.012	ICD10CM	Covered
H33.013	ICD10CM	Covered
H33.021	ICD10CM	Covered
H33.022	ICD10CM	Covered
H33.023	ICD10CM	Covered
H33.031	ICD10CM	Covered
H33.032	ICD10CM	Covered
H33.033	ICD10CM	Covered
H33.041	ICD10CM	Covered
H33.042	ICD10CM	Covered
H33.043	ICD10CM	Covered
H33.051	ICD10CM	Covered
H33.052	ICD10CM	Covered
H33.053	ICD10CM	Covered
H33.111	ICD10CM	Covered
H33.112	ICD10CM	Covered
H33.113	ICD10CM	Covered
H33.121	ICD10CM	Covered
H33.122	ICD10CM	Covered
H33.123	ICD10CM	Covered
H33.21	ICD10CM	Covered
H33.22	ICD10CM	Covered
H33.23	ICD10CM	Covered
H33.311	ICD10CM	Covered
H33.312	ICD10CM	Covered
H33.313	ICD10CM	Covered
H33.321	ICD10CM	Covered
H33.322	ICD10CM	Covered
H33.323	ICD10CM	Covered
H33.331	ICD10CM	Covered
H33.332	ICD10CM	Covered
H33.333	ICD10CM	Covered
H33.41	ICD10CM	Covered
H33.42	ICD10CM	Covered
H33.43	ICD10CM	Covered
H34.01	ICD10CM	Covered
H34.02	ICD10CM	Covered
H34.03	ICD10CM	Covered
H34.11	ICD10CM	Covered
H34.12	ICD10CM	Covered
H34.13	ICD10CM	Covered
H34.211	ICD10CM	Covered
H34.212	ICD10CM	Covered
H34.213	ICD10CM	Covered
H34.231	ICD10CM	Covered
H34.232	ICD10CM	Covered
H34.233	ICD10CM	Covered
H34.8110	ICD10CM	Covered
H34.8111	ICD10CM	Covered
H34.8112	ICD10CM	Covered
H34.8120	ICD10CM	Covered
H34.8121	ICD10CM	Covered
H34.8122	ICD10CM	Covered
H34.8130	ICD10CM	Covered
H34.8131	ICD10CM	Covered
H34.8132	ICD10CM	Covered
H34.821	ICD10CM	Covered
H34.822	ICD10CM	Covered
H34.823	ICD10CM	Covered
H34.8310	ICD10CM	Covered
H34.8311	ICD10CM	Covered
H34.8312	ICD10CM	Covered
H34.8320	ICD10CM	Covered
H34.8321	ICD10CM	Covered
H34.8322	ICD10CM	Covered
H34.8330	ICD10CM	Covered
H34.8331	ICD10CM	Covered
H34.8332	ICD10CM	Covered
H35.011	ICD10CM	Covered
H35.012	ICD10CM	Covered
H35.013	ICD10CM	Covered
H35.021	ICD10CM	Covered
H35.022	ICD10CM	Covered
H35.023	ICD10CM	Covered
H35.031	ICD10CM	Covered
H35.032	ICD10CM	Covered
H35.033	ICD10CM	Covered
H35.041	ICD10CM	Covered
H35.042	ICD10CM	Covered
H35.043	ICD10CM	Covered
H35.051	ICD10CM	Covered
H35.052	ICD10CM	Covered
H35.053	ICD10CM	Covered
H35.061	ICD10CM	Covered
H35.062	ICD10CM	Covered
H35.063	ICD10CM	Covered
H35.071	ICD10CM	Covered
H35.072	ICD10CM	Covered
H35.073	ICD10CM	Covered
H35.111	ICD10CM	Covered
H35.112	ICD10CM	Covered
H35.113	ICD10CM	Covered
H35.121	ICD10CM	Covered
H35.122	ICD10CM	Covered
H35.123	ICD10CM	Covered
H35.131	ICD10CM	Covered
H35.132	ICD10CM	Covered
H35.133	ICD10CM	Covered
H35.141	ICD10CM	Covered
H35.142	ICD10CM	Covered
H35.143	ICD10CM	Covered
H35.151	ICD10CM	Covered
H35.152	ICD10CM	Covered
H35.153	ICD10CM	Covered
H35.161	ICD10CM	Covered
H35.162	ICD10CM	Covered
H35.163	ICD10CM	Covered
H35.171	ICD10CM	Covered
H35.172	ICD10CM	Covered
H35.173	ICD10CM	Covered
H35.21	ICD10CM	Covered
H35.22	ICD10CM	Covered
H35.23	ICD10CM	Covered
H35.3111	ICD10CM	Covered
H35.3112	ICD10CM	Covered
H35.3113	ICD10CM	Covered
H35.3114	ICD10CM	Covered
H35.3121	ICD10CM	Covered
H35.3122	ICD10CM	Covered
H35.3123	ICD10CM	Covered
H35.3124	ICD10CM	Covered
H35.3131	ICD10CM	Covered
H35.3132	ICD10CM	Covered
H35.3133	ICD10CM	Covered
H35.3134	ICD10CM	Covered
H35.3211	ICD10CM	Covered
H35.3212	ICD10CM	Covered
H35.3213	ICD10CM	Covered
H35.3221	ICD10CM	Covered
H35.3222	ICD10CM	Covered
H35.3223	ICD10CM	Covered
H35.3231	ICD10CM	Covered
H35.3232	ICD10CM	Covered
H35.3233	ICD10CM	Covered
H35.33	ICD10CM	Covered
H35.341	ICD10CM	Covered
H35.342	ICD10CM	Covered
H35.343	ICD10CM	Covered
H35.351	ICD10CM	Covered
H35.352	ICD10CM	Covered
H35.353	ICD10CM	Covered
H35.361	ICD10CM	Covered
H35.362	ICD10CM	Covered
H35.363	ICD10CM	Covered
H35.371	ICD10CM	Covered
H35.372	ICD10CM	Covered
H35.373	ICD10CM	Covered
H35.381	ICD10CM	Covered
H35.382	ICD10CM	Covered
H35.383	ICD10CM	Covered
H35.411	ICD10CM	Covered
H35.412	ICD10CM	Covered
H35.413	ICD10CM	Covered
H35.421	ICD10CM	Covered
H35.422	ICD10CM	Covered
H35.423	ICD10CM	Covered
H35.431	ICD10CM	Covered
H35.432	ICD10CM	Covered
H35.433	ICD10CM	Covered
H35.441	ICD10CM	Covered
H35.442	ICD10CM	Covered
H35.443	ICD10CM	Covered
H35.451	ICD10CM	Covered
H35.452	ICD10CM	Covered
H35.453	ICD10CM	Covered
H35.461	ICD10CM	Covered
H35.462	ICD10CM	Covered
H35.463	ICD10CM	Covered
H35.51	ICD10CM	Covered
H35.52	ICD10CM	Covered
H35.54	ICD10CM	Covered
H35.61	ICD10CM	Covered
H35.62	ICD10CM	Covered
H35.63	ICD10CM	Covered
H35.711	ICD10CM	Covered
H35.712	ICD10CM	Covered
H35.713	ICD10CM	Covered
H35.721	ICD10CM	Covered
H35.722	ICD10CM	Covered
H35.723	ICD10CM	Covered
H35.731	ICD10CM	Covered
H35.732	ICD10CM	Covered
H35.733	ICD10CM	Covered
H35.81	ICD10CM	Covered
H35.82	ICD10CM	Covered
H36.811	ICD10CM	Covered
H36.812	ICD10CM	Covered
H36.813	ICD10CM	Covered
H36.821	ICD10CM	Covered
H36.822	ICD10CM	Covered
H36.823	ICD10CM	Covered
H40.011	ICD10CM	Covered
H40.012	ICD10CM	Covered
H40.013	ICD10CM	Covered
H40.021	ICD10CM	Covered
H40.022	ICD10CM	Covered
H40.023	ICD10CM	Covered
H40.031	ICD10CM	Covered
H40.032	ICD10CM	Covered
H40.033	ICD10CM	Covered
H40.041	ICD10CM	Covered
H40.042	ICD10CM	Covered
H40.043	ICD10CM	Covered
H40.051	ICD10CM	Covered
H40.052	ICD10CM	Covered
H40.053	ICD10CM	Covered
H40.061	ICD10CM	Covered
H40.062	ICD10CM	Covered
H40.063	ICD10CM	Covered
H40.1111	ICD10CM	Covered
H40.1112	ICD10CM	Covered
H40.1113	ICD10CM	Covered
H40.1121	ICD10CM	Covered
H40.1122	ICD10CM	Covered
H40.1123	ICD10CM	Covered
H40.1131	ICD10CM	Covered
H40.1132	ICD10CM	Covered
H40.1133	ICD10CM	Covered
H40.1211	ICD10CM	Covered
H40.1212	ICD10CM	Covered
H40.1213	ICD10CM	Covered
H40.1221	ICD10CM	Covered
H40.1222	ICD10CM	Covered
H40.1223	ICD10CM	Covered
H40.1231	ICD10CM	Covered
H40.1232	ICD10CM	Covered
H40.1233	ICD10CM	Covered
H40.1311	ICD10CM	Covered
H40.1312	ICD10CM	Covered
H40.1313	ICD10CM	Covered
H40.1321	ICD10CM	Covered
H40.1322	ICD10CM	Covered
H40.1323	ICD10CM	Covered
H40.1331	ICD10CM	Covered
H40.1332	ICD10CM	Covered
H40.1333	ICD10CM	Covered
H40.1411	ICD10CM	Covered
H40.1412	ICD10CM	Covered
H40.1413	ICD10CM	Covered
H40.1421	ICD10CM	Covered
H40.1422	ICD10CM	Covered
H40.1423	ICD10CM	Covered
H40.1431	ICD10CM	Covered
H40.1432	ICD10CM	Covered
H40.1433	ICD10CM	Covered
H40.151	ICD10CM	Covered
H40.152	ICD10CM	Covered
H40.153	ICD10CM	Covered
H40.211	ICD10CM	Covered
H40.212	ICD10CM	Covered
H40.213	ICD10CM	Covered
H40.2211	ICD10CM	Covered
H40.2212	ICD10CM	Covered
H40.2213	ICD10CM	Covered
H40.2221	ICD10CM	Covered
H40.2222	ICD10CM	Covered
H40.2223	ICD10CM	Covered
H40.2231	ICD10CM	Covered
H40.2232	ICD10CM	Covered
H40.2233	ICD10CM	Covered
H40.231	ICD10CM	Covered
H40.232	ICD10CM	Covered
H40.233	ICD10CM	Covered
H40.241	ICD10CM	Covered
H40.242	ICD10CM	Covered
H40.243	ICD10CM	Covered
H40.31X1	ICD10CM	Covered
H40.31X2	ICD10CM	Covered
H40.31X3	ICD10CM	Covered
H40.32X1	ICD10CM	Covered
H40.32X2	ICD10CM	Covered
H40.32X3	ICD10CM	Covered
H40.33X1	ICD10CM	Covered
H40.33X2	ICD10CM	Covered
H40.33X3	ICD10CM	Covered
H40.41X1	ICD10CM	Covered
H40.41X2	ICD10CM	Covered
H40.41X3	ICD10CM	Covered
H40.42X1	ICD10CM	Covered
H40.42X2	ICD10CM	Covered
H40.42X3	ICD10CM	Covered
H40.43X1	ICD10CM	Covered
H40.43X2	ICD10CM	Covered
H40.43X3	ICD10CM	Covered
H40.51X1	ICD10CM	Covered
H40.51X2	ICD10CM	Covered
H40.51X3	ICD10CM	Covered
H40.52X1	ICD10CM	Covered
H40.52X2	ICD10CM	Covered
H40.52X3	ICD10CM	Covered
H40.53X1	ICD10CM	Covered
H40.53X2	ICD10CM	Covered
H40.53X3	ICD10CM	Covered
H40.61X1	ICD10CM	Covered
H40.61X2	ICD10CM	Covered
H40.61X3	ICD10CM	Covered
H40.62X1	ICD10CM	Covered
H40.62X2	ICD10CM	Covered
H40.62X3	ICD10CM	Covered
H40.63X1	ICD10CM	Covered
H40.63X2	ICD10CM	Covered
H40.63X3	ICD10CM	Covered
H40.811	ICD10CM	Covered
H40.812	ICD10CM	Covered
H40.813	ICD10CM	Covered
H40.821	ICD10CM	Covered
H40.822	ICD10CM	Covered
H40.823	ICD10CM	Covered
H40.831	ICD10CM	Covered
H40.832	ICD10CM	Covered
H40.833	ICD10CM	Covered
H43.01	ICD10CM	Covered
H43.02	ICD10CM	Covered
H43.03	ICD10CM	Covered
H43.11	ICD10CM	Covered
H43.12	ICD10CM	Covered
H43.13	ICD10CM	Covered
H43.21	ICD10CM	Covered
H43.22	ICD10CM	Covered
H43.23	ICD10CM	Covered
H43.311	ICD10CM	Covered
H43.312	ICD10CM	Covered
H43.313	ICD10CM	Covered
H43.811	ICD10CM	Covered
H43.812	ICD10CM	Covered
H43.813	ICD10CM	Covered
H43.821	ICD10CM	Covered
H43.822	ICD10CM	Covered
H43.823	ICD10CM	Covered
H44.001	ICD10CM	Covered
H44.002	ICD10CM	Covered
H44.003	ICD10CM	Covered
H44.011	ICD10CM	Covered
H44.012	ICD10CM	Covered
H44.013	ICD10CM	Covered
H44.021	ICD10CM	Covered
H44.022	ICD10CM	Covered
H44.023	ICD10CM	Covered
H44.111	ICD10CM	Covered
H44.112	ICD10CM	Covered
H44.113	ICD10CM	Covered
H44.121	ICD10CM	Covered
H44.122	ICD10CM	Covered
H44.123	ICD10CM	Covered
H44.131	ICD10CM	Covered
H44.132	ICD10CM	Covered
H44.133	ICD10CM	Covered
H44.21	ICD10CM	Covered
H44.22	ICD10CM	Covered
H44.23	ICD10CM	Covered
H44.2A1	ICD10CM	Covered
H44.2A2	ICD10CM	Covered
H44.2A3	ICD10CM	Covered
H44.2B1	ICD10CM	Covered
H44.2B2	ICD10CM	Covered
H44.2B3	ICD10CM	Covered
H44.2C1	ICD10CM	Covered
H44.2C2	ICD10CM	Covered
H44.2C3	ICD10CM	Covered
H44.2D1	ICD10CM	Covered
H44.2D2	ICD10CM	Covered
H44.2D3	ICD10CM	Covered
H44.2E1	ICD10CM	Covered
H44.2E2	ICD10CM	Covered
H44.2E3	ICD10CM	Covered
H44.311	ICD10CM	Covered
H44.312	ICD10CM	Covered
H44.313	ICD10CM	Covered
H44.321	ICD10CM	Covered
H44.322	ICD10CM	Covered
H44.323	ICD10CM	Covered
H44.411	ICD10CM	Covered
H44.412	ICD10CM	Covered
H44.413	ICD10CM	Covered
H44.421	ICD10CM	Covered
H44.422	ICD10CM	Covered
H44.423	ICD10CM	Covered
H44.431	ICD10CM	Covered
H44.432	ICD10CM	Covered
H44.433	ICD10CM	Covered
H44.441	ICD10CM	Covered
H44.442	ICD10CM	Covered
H44.443	ICD10CM	Covered
H44.511	ICD10CM	Covered
H44.512	ICD10CM	Covered
H44.513	ICD10CM	Covered
H44.521	ICD10CM	Covered
H44.522	ICD10CM	Covered
H44.523	ICD10CM	Covered
H44.531	ICD10CM	Covered
H44.532	ICD10CM	Covered
H44.533	ICD10CM	Covered
H44.611	ICD10CM	Covered
H44.612	ICD10CM	Covered
H44.613	ICD10CM	Covered
H44.621	ICD10CM	Covered
H44.622	ICD10CM	Covered
H44.623	ICD10CM	Covered
H44.631	ICD10CM	Covered
H44.632	ICD10CM	Covered
H44.633	ICD10CM	Covered
H44.641	ICD10CM	Covered
H44.642	ICD10CM	Covered
H44.643	ICD10CM	Covered
H44.651	ICD10CM	Covered
H44.652	ICD10CM	Covered
H44.653	ICD10CM	Covered
H44.691	ICD10CM	Covered
H44.692	ICD10CM	Covered
H44.693	ICD10CM	Covered
H44.711	ICD10CM	Covered
H44.712	ICD10CM	Covered
H44.713	ICD10CM	Covered
H44.721	ICD10CM	Covered
H44.722	ICD10CM	Covered
H44.723	ICD10CM	Covered
H44.731	ICD10CM	Covered
H44.732	ICD10CM	Covered
H44.733	ICD10CM	Covered
H44.741	ICD10CM	Covered
H44.742	ICD10CM	Covered
H44.743	ICD10CM	Covered
H44.751	ICD10CM	Covered
H44.752	ICD10CM	Covered
H44.753	ICD10CM	Covered
H44.791	ICD10CM	Covered
H44.792	ICD10CM	Covered
H44.793	ICD10CM	Covered
H44.811	ICD10CM	Covered
H44.812	ICD10CM	Covered
H44.813	ICD10CM	Covered
H44.821	ICD10CM	Covered
H44.822	ICD10CM	Covered
H44.823	ICD10CM	Covered
H46.01	ICD10CM	Covered
H46.02	ICD10CM	Covered
H46.03	ICD10CM	Covered
H46.11	ICD10CM	Covered
H46.12	ICD10CM	Covered
H46.13	ICD10CM	Covered
H46.2	ICD10CM	Covered
H46.3	ICD10CM	Covered
H47.011	ICD10CM	Covered
H47.012	ICD10CM	Covered
H47.013	ICD10CM	Covered
H47.021	ICD10CM	Covered
H47.022	ICD10CM	Covered
H47.023	ICD10CM	Covered
H47.031	ICD10CM	Covered
H47.032	ICD10CM	Covered
H47.033	ICD10CM	Covered
H47.11	ICD10CM	Covered
H47.12	ICD10CM	Covered
H47.13	ICD10CM	Covered
H47.141	ICD10CM	Covered
H47.142	ICD10CM	Covered
H47.143	ICD10CM	Covered
H47.211	ICD10CM	Covered
H47.212	ICD10CM	Covered
H47.213	ICD10CM	Covered
H47.22	ICD10CM	Covered
H47.231	ICD10CM	Covered
H47.232	ICD10CM	Covered
H47.233	ICD10CM	Covered
H47.311	ICD10CM	Covered
H47.312	ICD10CM	Covered
H47.313	ICD10CM	Covered
H47.321	ICD10CM	Covered
H47.322	ICD10CM	Covered
H47.323	ICD10CM	Covered
H47.331	ICD10CM	Covered
H47.332	ICD10CM	Covered
H47.333	ICD10CM	Covered
H47.41	ICD10CM	Covered
H47.42	ICD10CM	Covered
H47.43	ICD10CM	Covered
H47.49	ICD10CM	Covered
H53.121	ICD10CM	Covered
H53.122	ICD10CM	Covered
H53.123	ICD10CM	Covered
H53.131	ICD10CM	Covered
H53.132	ICD10CM	Covered
H53.133	ICD10CM	Covered
H59.021	ICD10CM	Covered
H59.022	ICD10CM	Covered
H59.023	ICD10CM	Covered
H59.031	ICD10CM	Covered
H59.032	ICD10CM	Covered
H59.033	ICD10CM	Covered
P07.01	ICD10CM	Covered
P07.02	ICD10CM	Covered
P07.03	ICD10CM	Covered
P07.14	ICD10CM	Covered
P07.15	ICD10CM	Covered
P07.16	ICD10CM	Covered
P07.17	ICD10CM	Covered
P07.18	ICD10CM	Covered
P07.21	ICD10CM	Covered
P07.22	ICD10CM	Covered
P07.23	ICD10CM	Covered
P07.24	ICD10CM	Covered
P07.25	ICD10CM	Covered
P07.26	ICD10CM	Covered
P07.31	ICD10CM	Covered
P07.32	ICD10CM	Covered
P07.33	ICD10CM	Covered
P07.34	ICD10CM	Covered
P07.35	ICD10CM	Covered
P07.36	ICD10CM	Covered
P07.37	ICD10CM	Covered
P07.38	ICD10CM	Covered
P07.39	ICD10CM	Covered
Q14.0	ICD10CM	Covered
Q14.1	ICD10CM	Covered
Q14.2	ICD10CM	Covered
Q14.3	ICD10CM	Covered
Q14.8	ICD10CM	Covered
Q14.9	ICD10CM	Covered
Q15.0	ICD10CM	Covered
Q85.01	ICD10CM	Covered
Q85.02	ICD10CM	Covered
Q85.03	ICD10CM	Covered
Q85.1	ICD10CM	Covered
Q85.8	ICD10CM	Covered
Q85.9	ICD10CM	Covered
Q87.42	ICD10CM	Covered
S05.11XA	ICD10CM	Covered
S05.11XD	ICD10CM	Covered
S05.11XS	ICD10CM	Covered
S05.12XA	ICD10CM	Covered
S05.12XD	ICD10CM	Covered
S05.12XS	ICD10CM	Covered
S05.21XA	ICD10CM	Covered
S05.21XD	ICD10CM	Covered
S05.21XS	ICD10CM	Covered
S05.22XA	ICD10CM	Covered
S05.22XD	ICD10CM	Covered
S05.22XS	ICD10CM	Covered
S05.31XA	ICD10CM	Covered
S05.31XD	ICD10CM	Covered
S05.31XS	ICD10CM	Covered
S05.32XA	ICD10CM	Covered
S05.32XD	ICD10CM	Covered
S05.32XS	ICD10CM	Covered
S05.41XA	ICD10CM	Covered
S05.41XD	ICD10CM	Covered
S05.41XS	ICD10CM	Covered
S05.42XA	ICD10CM	Covered
S05.42XD	ICD10CM	Covered
S05.42XS	ICD10CM	Covered
S05.51XA	ICD10CM	Covered
S05.51XD	ICD10CM	Covered
S05.51XS	ICD10CM	Covered
S05.52XA	ICD10CM	Covered
S05.52XD	ICD10CM	Covered
S05.52XS	ICD10CM	Covered
S05.61XA	ICD10CM	Covered
S05.61XD	ICD10CM	Covered
S05.61XS	ICD10CM	Covered
S05.62XA	ICD10CM	Covered
S05.62XD	ICD10CM	Covered
S05.62XS	ICD10CM	Covered
T74.4XXA	ICD10CM	Covered
T74.4XXD	ICD10CM	Covered
T74.4XXS	ICD10CM	Covered
T85.22XA	ICD10CM	Covered
T85.22XD	ICD10CM	Covered
T85.22XS	ICD10CM	Covered