Ambetter · PayerPolicy · AMBETTER-CP-VP-28
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 |
|---|---|---|
| 92235 | CPT | Covered |
| A18.53 | ICD10CM | Covered |
| B20 | ICD10CM | Covered |
| B39.4 | ICD10CM | Covered |
| B39.5 | ICD10CM | Covered |
| B39.9 | ICD10CM | Covered |
| B58.01 | ICD10CM | Covered |
| C69.21 | ICD10CM | Covered |
| C69.22 | ICD10CM | Covered |
| C69.31 | ICD10CM | Covered |
| C69.32 | ICD10CM | Covered |
| D31.21 | ICD10CM | Covered |
| D31.22 | ICD10CM | Covered |
| D31.31 | ICD10CM | Covered |
| D31.32 | ICD10CM | Covered |
| D86.83 | 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 |
| E13.37X1 | ICD10CM | Covered |
| E13.37X2 | ICD10CM | Covered |
| E13.37X3 | 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 |
| H20.821 | ICD10CM | Covered |
| H20.822 | ICD10CM | Covered |
| H20.823 | ICD10CM | Covered |
| H21.331 | ICD10CM | Covered |
| H21.332 | ICD10CM | Covered |
| H21.333 | 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 |
| H33.111 | 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 |
| 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 |
| H35.451 | 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 |
| H35.53 | 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 |
| H43.11 | ICD10CM | Covered |
| H43.12 | ICD10CM | Covered |
| H43.13 | ICD10CM | Covered |
| H43.21 | ICD10CM | Covered |
| H43.22 | ICD10CM | Covered |
| H43.23 | ICD10CM | Covered |
| H43.821 | ICD10CM | Covered |
| H43.822 | ICD10CM | Covered |
| H43.823 | ICD10CM | Covered |
| H44.011 | ICD10CM | Covered |
| H44.012 | ICD10CM | Covered |
| H44.013 | 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 |
| H44.641 | ICD10CM | Covered |
| H44.642 | ICD10CM | Covered |
| H44.643 | ICD10CM | Covered |
| H44.741 | ICD10CM | Covered |
| H44.742 | ICD10CM | Covered |
| H44.743 | 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 |
| H47.141 | ICD10CM | Covered |
| H47.142 | ICD10CM | Covered |
| H47.143 | ICD10CM | Covered |
| H47.22 | 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 |
| H53.131 | ICD10CM | Covered |
| H53.132 | ICD10CM | Covered |
| H53.133 | ICD10CM | Covered |
| H59.031 | ICD10CM | Covered |
| H59.032 | ICD10CM | Covered |
| H59.033 | ICD10CM | Covered |
| Q14.8 | ICD10CM | Covered |
| R94.111 | ICD10CM | Covered |