Ambetter · PayerPolicy · AMBETTER-CP-VP-31
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 |
|---|---|---|
| 92020 | CPT | 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 |
| H20.011 | ICD10CM | Covered |
| H20.012 | ICD10CM | Covered |
| H20.013 | ICD10CM | Covered |
| H20.021 | ICD10CM | Covered |
| H20.022 | ICD10CM | Covered |
| H20.023 | 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 |
| H20.051 | ICD10CM | Covered |
| H20.052 | ICD10CM | Covered |
| H20.053 | 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 |
| H21.01 | ICD10CM | Covered |
| H21.02 | ICD10CM | Covered |
| H21.03 | ICD10CM | Covered |
| H21.1X1 | ICD10CM | Covered |
| H21.1X2 | ICD10CM | Covered |
| H21.1X3 | ICD10CM | Covered |
| H21.211 | ICD10CM | Covered |
| H21.212 | ICD10CM | Covered |
| H21.213 | ICD10CM | Covered |
| H21.221 | ICD10CM | Covered |
| H21.222 | ICD10CM | Covered |
| H21.223 | ICD10CM | Covered |
| H21.231 | ICD10CM | Covered |
| H21.232 | ICD10CM | Covered |
| H21.233 | ICD10CM | Covered |
| H21.241 | ICD10CM | Covered |
| H21.242 | ICD10CM | Covered |
| H21.243 | ICD10CM | Covered |
| H21.251 | ICD10CM | Covered |
| H21.252 | ICD10CM | Covered |
| H21.253 | ICD10CM | Covered |
| H21.261 | ICD10CM | Covered |
| H21.262 | ICD10CM | Covered |
| H21.263 | ICD10CM | Covered |
| H21.271 | ICD10CM | Covered |
| H21.272 | ICD10CM | Covered |
| H21.273 | ICD10CM | Covered |
| H21.531 | ICD10CM | Covered |
| H21.532 | ICD10CM | Covered |
| H21.533 | ICD10CM | Covered |
| H27.01 | ICD10CM | Covered |
| H27.02 | ICD10CM | Covered |
| H27.03 | ICD10CM | Covered |
| H27.111 | ICD10CM | Covered |
| H27.112 | ICD10CM | Covered |
| H27.113 | ICD10CM | Covered |
| H27.121 | ICD10CM | Covered |
| H27.122 | ICD10CM | Covered |
| H27.123 | ICD10CM | Covered |
| H27.131 | ICD10CM | Covered |
| H27.132 | ICD10CM | Covered |
| H27.133 | 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 |
| H35.09 | 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 |
| 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 |
| H44.601 | ICD10CM | Covered |
| H44.602 | ICD10CM | Covered |
| H44.603 | ICD10CM | Covered |
| H44.701 | ICD10CM | Covered |
| H44.702 | ICD10CM | Covered |
| H44.703 | ICD10CM | Covered |
| Q15.0 | 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 |
| S05.51XA | 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 |