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Ambetter · PayerPolicy · AMBETTER-CP-VP-43

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
92285	CPT	Covered
A18.51	ICD10CM	Covered
A18.52	ICD10CM	Covered
A18.54	ICD10CM	Covered
A50.31	ICD10CM	Covered
B00.51	ICD10CM	Covered
B00.52	ICD10CM	Covered
B00.53	ICD10CM	Covered
B02.31	ICD10CM	Covered
B02.32	ICD10CM	Covered
B02.33	ICD10CM	Covered
B02.34	ICD10CM	Covered
B30.0	ICD10CM	Covered
B30.1	ICD10CM	Covered
B30.2	ICD10CM	Covered
B30.3	ICD10CM	Covered
B60.12	ICD10CM	Covered
B60.13	ICD10CM	Covered
C43.111	ICD10CM	Covered
C43.112	ICD10CM	Covered
C43.121	ICD10CM	Covered
C43.122	ICD10CM	Covered
C44.1021	ICD10CM	Covered
C44.1022	ICD10CM	Covered
C44.1091	ICD10CM	Covered
C44.1092	ICD10CM	Covered
C44.1121	ICD10CM	Covered
C44.1122	ICD10CM	Covered
C44.1191	ICD10CM	Covered
C44.1192	ICD10CM	Covered
C44.1221	ICD10CM	Covered
C44.1222	ICD10CM	Covered
C44.1291	ICD10CM	Covered
C44.1292	ICD10CM	Covered
C44.1321	ICD10CM	Covered
C44.1322	ICD10CM	Covered
C44.1391	ICD10CM	Covered
C44.1392	ICD10CM	Covered
C44.1921	ICD10CM	Covered
C44.1922	ICD10CM	Covered
C44.1991	ICD10CM	Covered
C44.1992	ICD10CM	Covered
C47.0	ICD10CM	Covered
C49.0	ICD10CM	Covered
C4A.111	ICD10CM	Covered
C4A.112	ICD10CM	Covered
C4A.121	ICD10CM	Covered
C4A.122	ICD10CM	Covered
C69.01	ICD10CM	Covered
C69.02	ICD10CM	Covered
C69.11	ICD10CM	Covered
C69.12	ICD10CM	Covered
C69.41	ICD10CM	Covered
C69.42	ICD10CM	Covered
C69.51	ICD10CM	Covered
C69.52	ICD10CM	Covered
C69.61	ICD10CM	Covered
C69.62	ICD10CM	Covered
C69.81	ICD10CM	Covered
C69.82	ICD10CM	Covered
D03.111	ICD10CM	Covered
D03.112	ICD10CM	Covered
D03.121	ICD10CM	Covered
D03.122	ICD10CM	Covered
D04.111	ICD10CM	Covered
D04.112	ICD10CM	Covered
D04.121	ICD10CM	Covered
D04.122	ICD10CM	Covered
D09.21	ICD10CM	Covered
D09.22	ICD10CM	Covered
D22.111	ICD10CM	Covered
D22.112	ICD10CM	Covered
D22.121	ICD10CM	Covered
D22.122	ICD10CM	Covered
D23.111	ICD10CM	Covered
D23.112	ICD10CM	Covered
D23.121	ICD10CM	Covered
D23.122	ICD10CM	Covered
D31.01	ICD10CM	Covered
D31.02	ICD10CM	Covered
D31.11	ICD10CM	Covered
D31.12	ICD10CM	Covered
D31.41	ICD10CM	Covered
D31.42	ICD10CM	Covered
D31.51	ICD10CM	Covered
D31.52	ICD10CM	Covered
G51.0	ICD10CM	Covered
H00.011	ICD10CM	Covered
H00.012	ICD10CM	Covered
H00.014	ICD10CM	Covered
H00.015	ICD10CM	Covered
H00.021	ICD10CM	Covered
H00.022	ICD10CM	Covered
H00.024	ICD10CM	Covered
H00.025	ICD10CM	Covered
H00.031	ICD10CM	Covered
H00.032	ICD10CM	Covered
H00.034	ICD10CM	Covered
H00.035	ICD10CM	Covered
H00.11	ICD10CM	Covered
H00.12	ICD10CM	Covered
H00.14	ICD10CM	Covered
H00.15	ICD10CM	Covered
H01.011	ICD10CM	Covered
H01.012	ICD10CM	Covered
H01.014	ICD10CM	Covered
H01.015	ICD10CM	Covered
H01.01A	ICD10CM	Covered
H01.01B	ICD10CM	Covered
H01.021	ICD10CM	Covered
H01.022	ICD10CM	Covered
H01.024	ICD10CM	Covered
H01.025	ICD10CM	Covered
H01.02A	ICD10CM	Covered
H01.02B	ICD10CM	Covered
H01.111	ICD10CM	Covered
H01.112	ICD10CM	Covered
H01.114	ICD10CM	Covered
H01.115	ICD10CM	Covered
H01.121	ICD10CM	Covered
H01.122	ICD10CM	Covered
H01.124	ICD10CM	Covered
H01.125	ICD10CM	Covered
H01.131	ICD10CM	Covered
H01.132	ICD10CM	Covered
H01.134	ICD10CM	Covered
H01.135	ICD10CM	Covered
H01.141	ICD10CM	Covered
H01.142	ICD10CM	Covered
H01.144	ICD10CM	Covered
H01.145	ICD10CM	Covered
H02.011	ICD10CM	Covered
H02.012	ICD10CM	Covered
H02.014	ICD10CM	Covered
H02.015	ICD10CM	Covered
H02.021	ICD10CM	Covered
H02.022	ICD10CM	Covered
H02.024	ICD10CM	Covered
H02.025	ICD10CM	Covered
H02.031	ICD10CM	Covered
H02.032	ICD10CM	Covered
H02.034	ICD10CM	Covered
H02.035	ICD10CM	Covered
H02.041	ICD10CM	Covered
H02.042	ICD10CM	Covered
H02.044	ICD10CM	Covered
H02.045	ICD10CM	Covered
H02.051	ICD10CM	Covered
H02.052	ICD10CM	Covered
H02.054	ICD10CM	Covered
H02.055	ICD10CM	Covered
H02.111	ICD10CM	Covered
H02.112	ICD10CM	Covered
H02.114	ICD10CM	Covered
H02.115	ICD10CM	Covered
H02.121	ICD10CM	Covered
H02.122	ICD10CM	Covered
H02.124	ICD10CM	Covered
H02.125	ICD10CM	Covered
H02.131	ICD10CM	Covered
H02.132	ICD10CM	Covered
H02.134	ICD10CM	Covered
H02.135	ICD10CM	Covered
H02.141	ICD10CM	Covered
H02.142	ICD10CM	Covered
H02.144	ICD10CM	Covered
H02.145	ICD10CM	Covered
H02.151	ICD10CM	Covered
H02.152	ICD10CM	Covered
H02.154	ICD10CM	Covered
H02.155	ICD10CM	Covered
H02.211	ICD10CM	Covered
H02.212	ICD10CM	Covered
H02.214	ICD10CM	Covered
H02.215	ICD10CM	Covered
H02.21A	ICD10CM	Covered
H02.21B	ICD10CM	Covered
H02.21C	ICD10CM	Covered
H02.221	ICD10CM	Covered
H02.222	ICD10CM	Covered
H02.224	ICD10CM	Covered
H02.225	ICD10CM	Covered
H02.22A	ICD10CM	Covered
H02.22B	ICD10CM	Covered
H02.22C	ICD10CM	Covered
H02.231	ICD10CM	Covered
H02.232	ICD10CM	Covered
H02.234	ICD10CM	Covered
H02.235	ICD10CM	Covered
H02.23A	ICD10CM	Covered
H02.23B	ICD10CM	Covered
H02.23C	ICD10CM	Covered
H02.31	ICD10CM	Covered
H02.32	ICD10CM	Covered
H02.34	ICD10CM	Covered
H02.35	ICD10CM	Covered
H02.411	ICD10CM	Covered
H02.412	ICD10CM	Covered
H02.413	ICD10CM	Covered
H02.421	ICD10CM	Covered
H02.422	ICD10CM	Covered
H02.423	ICD10CM	Covered
H02.431	ICD10CM	Covered
H02.432	ICD10CM	Covered
H02.433	ICD10CM	Covered
H02.511	ICD10CM	Covered
H02.512	ICD10CM	Covered
H02.514	ICD10CM	Covered
H02.515	ICD10CM	Covered
H02.521	ICD10CM	Covered
H02.522	ICD10CM	Covered
H02.524	ICD10CM	Covered
H02.525	ICD10CM	Covered
H02.531	ICD10CM	Covered
H02.532	ICD10CM	Covered
H02.534	ICD10CM	Covered
H02.535	ICD10CM	Covered
H02.61	ICD10CM	Covered
H02.62	ICD10CM	Covered
H02.64	ICD10CM	Covered
H02.65	ICD10CM	Covered
H02.711	ICD10CM	Covered
H02.712	ICD10CM	Covered
H02.714	ICD10CM	Covered
H02.715	ICD10CM	Covered
H02.721	ICD10CM	Covered
H02.722	ICD10CM	Covered
H02.724	ICD10CM	Covered
H02.725	ICD10CM	Covered
H02.731	ICD10CM	Covered
H02.732	ICD10CM	Covered
H02.734	ICD10CM	Covered
H02.735	ICD10CM	Covered
H02.811	ICD10CM	Covered
H02.812	ICD10CM	Covered
H02.814	ICD10CM	Covered
H02.815	ICD10CM	Covered
H02.821	ICD10CM	Covered
H02.822	ICD10CM	Covered
H02.824	ICD10CM	Covered
H02.825	ICD10CM	Covered
H02.831	ICD10CM	Covered
H02.832	ICD10CM	Covered
H02.834	ICD10CM	Covered
H02.835	ICD10CM	Covered
H02.841	ICD10CM	Covered
H02.842	ICD10CM	Covered
H02.844	ICD10CM	Covered
H02.845	ICD10CM	Covered
H02.851	ICD10CM	Covered
H02.852	ICD10CM	Covered
H02.854	ICD10CM	Covered
H02.855	ICD10CM	Covered
H02.861	ICD10CM	Covered
H02.862	ICD10CM	Covered
H02.864	ICD10CM	Covered
H02.865	ICD10CM	Covered
H02.871	ICD10CM	Covered
H02.872	ICD10CM	Covered
H02.874	ICD10CM	Covered
H02.875	ICD10CM	Covered
H02.881	ICD10CM	Covered
H02.882	ICD10CM	Covered
H02.884	ICD10CM	Covered
H02.885	ICD10CM	Covered
H02.88A	ICD10CM	Covered
H02.88B	ICD10CM	Covered
H04.011	ICD10CM	Covered
H04.012	ICD10CM	Covered
H04.013	ICD10CM	Covered
H04.021	ICD10CM	Covered
H04.022	ICD10CM	Covered
H04.023	ICD10CM	Covered
H04.031	ICD10CM	Covered
H04.032	ICD10CM	Covered
H04.033	ICD10CM	Covered
H04.111	ICD10CM	Covered
H04.112	ICD10CM	Covered
H04.113	ICD10CM	Covered
H04.131	ICD10CM	Covered
H04.132	ICD10CM	Covered
H04.133	ICD10CM	Covered
H04.161	ICD10CM	Covered
H04.162	ICD10CM	Covered
H04.163	ICD10CM	Covered
H04.311	ICD10CM	Covered
H04.312	ICD10CM	Covered
H04.313	ICD10CM	Covered
H04.321	ICD10CM	Covered
H04.322	ICD10CM	Covered
H04.323	ICD10CM	Covered
H04.331	ICD10CM	Covered
H04.332	ICD10CM	Covered
H04.333	ICD10CM	Covered
H04.411	ICD10CM	Covered
H04.412	ICD10CM	Covered
H04.413	ICD10CM	Covered
H04.421	ICD10CM	Covered
H04.422	ICD10CM	Covered
H04.423	ICD10CM	Covered
H04.431	ICD10CM	Covered
H04.432	ICD10CM	Covered
H04.433	ICD10CM	Covered
H04.511	ICD10CM	Covered
H04.512	ICD10CM	Covered
H04.513	ICD10CM	Covered
H04.521	ICD10CM	Covered
H04.522	ICD10CM	Covered
H04.523	ICD10CM	Covered
H04.531	ICD10CM	Covered
H04.532	ICD10CM	Covered
H04.533	ICD10CM	Covered
H05.011	ICD10CM	Covered
H05.012	ICD10CM	Covered
H05.013	ICD10CM	Covered
H05.021	ICD10CM	Covered
H05.022	ICD10CM	Covered
H05.023	ICD10CM	Covered
H05.031	ICD10CM	Covered
H05.032	ICD10CM	Covered
H05.033	ICD10CM	Covered
H05.041	ICD10CM	Covered
H05.042	ICD10CM	Covered
H05.043	ICD10CM	Covered
H05.111	ICD10CM	Covered
H05.112	ICD10CM	Covered
H05.113	ICD10CM	Covered
H05.121	ICD10CM	Covered
H05.122	ICD10CM	Covered
H05.123	ICD10CM	Covered
H05.211	ICD10CM	Covered
H05.212	ICD10CM	Covered
H05.213	ICD10CM	Covered
H05.221	ICD10CM	Covered
H05.222	ICD10CM	Covered
H05.223	ICD10CM	Covered
H05.231	ICD10CM	Covered
H05.232	ICD10CM	Covered
H05.233	ICD10CM	Covered
H05.241	ICD10CM	Covered
H05.242	ICD10CM	Covered
H05.243	ICD10CM	Covered
H05.251	ICD10CM	Covered
H05.252	ICD10CM	Covered
H05.253	ICD10CM	Covered
H05.261	ICD10CM	Covered
H05.262	ICD10CM	Covered
H05.263	ICD10CM	Covered
H05.311	ICD10CM	Covered
H05.312	ICD10CM	Covered
H05.313	ICD10CM	Covered
H05.321	ICD10CM	Covered
H05.322	ICD10CM	Covered
H05.323	ICD10CM	Covered
H05.331	ICD10CM	Covered
H05.332	ICD10CM	Covered
H05.333	ICD10CM	Covered
H05.341	ICD10CM	Covered
H05.342	ICD10CM	Covered
H05.343	ICD10CM	Covered
H05.351	ICD10CM	Covered
H05.352	ICD10CM	Covered
H05.353	ICD10CM	Covered
H05.411	ICD10CM	Covered
H05.412	ICD10CM	Covered
H05.413	ICD10CM	Covered
H05.421	ICD10CM	Covered
H05.422	ICD10CM	Covered
H05.423	ICD10CM	Covered
H05.51	ICD10CM	Covered
H05.52	ICD10CM	Covered
H05.53	ICD10CM	Covered
H05.811	ICD10CM	Covered
H05.812	ICD10CM	Covered
H05.813	ICD10CM	Covered
H05.821	ICD10CM	Covered
H05.822	ICD10CM	Covered
H05.823	ICD10CM	Covered
H10.011	ICD10CM	Covered
H10.012	ICD10CM	Covered
H10.013	ICD10CM	Covered
H10.11	ICD10CM	Covered
H10.12	ICD10CM	Covered
H10.13	ICD10CM	Covered
H10.211	ICD10CM	Covered
H10.212	ICD10CM	Covered
H10.213	ICD10CM	Covered
H10.221	ICD10CM	Covered
H10.222	ICD10CM	Covered
H10.223	ICD10CM	Covered
H10.231	ICD10CM	Covered
H10.232	ICD10CM	Covered
H10.233	ICD10CM	Covered
H10.411	ICD10CM	Covered
H10.412	ICD10CM	Covered
H10.413	ICD10CM	Covered
H10.421	ICD10CM	Covered
H10.422	ICD10CM	Covered
H10.423	ICD10CM	Covered
H10.431	ICD10CM	Covered
H10.432	ICD10CM	Covered
H10.433	ICD10CM	Covered
H10.44	ICD10CM	Covered
H10.511	ICD10CM	Covered
H10.512	ICD10CM	Covered
H10.513	ICD10CM	Covered
H10.521	ICD10CM	Covered
H10.522	ICD10CM	Covered
H10.523	ICD10CM	Covered
H10.531	ICD10CM	Covered
H10.532	ICD10CM	Covered
H10.533	ICD10CM	Covered
H10.811	ICD10CM	Covered
H10.812	ICD10CM	Covered
H10.813	ICD10CM	Covered
H10.821	ICD10CM	Covered
H10.822	ICD10CM	Covered
H10.823	ICD10CM	Covered
H11.011	ICD10CM	Covered
H11.012	ICD10CM	Covered
H11.013	ICD10CM	Covered
H11.021	ICD10CM	Covered
H11.022	ICD10CM	Covered
H11.023	ICD10CM	Covered
H11.031	ICD10CM	Covered
H11.032	ICD10CM	Covered
H11.033	ICD10CM	Covered
H11.041	ICD10CM	Covered
H11.042	ICD10CM	Covered
H11.043	ICD10CM	Covered
H11.051	ICD10CM	Covered
H11.052	ICD10CM	Covered
H11.053	ICD10CM	Covered
H11.061	ICD10CM	Covered
H11.062	ICD10CM	Covered
H11.063	ICD10CM	Covered
H11.111	ICD10CM	Covered
H11.112	ICD10CM	Covered
H11.113	ICD10CM	Covered
H11.121	ICD10CM	Covered
H11.122	ICD10CM	Covered
H11.123	ICD10CM	Covered
H11.131	ICD10CM	Covered
H11.132	ICD10CM	Covered
H11.133	ICD10CM	Covered
H11.151	ICD10CM	Covered
H11.152	ICD10CM	Covered
H11.153	ICD10CM	Covered
H11.211	ICD10CM	Covered
H11.212	ICD10CM	Covered
H11.213	ICD10CM	Covered
H11.221	ICD10CM	Covered
H11.222	ICD10CM	Covered
H11.223	ICD10CM	Covered
H11.231	ICD10CM	Covered
H11.232	ICD10CM	Covered
H11.233	ICD10CM	Covered
H11.241	ICD10CM	Covered
H11.242	ICD10CM	Covered
H11.243	ICD10CM	Covered
H11.31	ICD10CM	Covered
H11.32	ICD10CM	Covered
H11.33	ICD10CM	Covered
H11.411	ICD10CM	Covered
H11.412	ICD10CM	Covered
H11.413	ICD10CM	Covered
H11.421	ICD10CM	Covered
H11.422	ICD10CM	Covered
H11.423	ICD10CM	Covered
H11.431	ICD10CM	Covered
H11.432	ICD10CM	Covered
H11.433	ICD10CM	Covered
H11.441	ICD10CM	Covered
H11.442	ICD10CM	Covered
H11.443	ICD10CM	Covered
H11.811	ICD10CM	Covered
H11.812	ICD10CM	Covered
H11.813	ICD10CM	Covered
H11.821	ICD10CM	Covered
H11.822	ICD10CM	Covered
H11.823	ICD10CM	Covered
H15.011	ICD10CM	Covered
H15.012	ICD10CM	Covered
H15.013	ICD10CM	Covered
H15.021	ICD10CM	Covered
H15.022	ICD10CM	Covered
H15.023	ICD10CM	Covered
H15.031	ICD10CM	Covered
H15.032	ICD10CM	Covered
H15.033	ICD10CM	Covered
H15.041	ICD10CM	Covered
H15.042	ICD10CM	Covered
H15.043	ICD10CM	Covered
H15.051	ICD10CM	Covered
H15.052	ICD10CM	Covered
H15.053	ICD10CM	Covered
H15.111	ICD10CM	Covered
H15.112	ICD10CM	Covered
H15.113	ICD10CM	Covered
H15.121	ICD10CM	Covered
H15.122	ICD10CM	Covered
H15.123	ICD10CM	Covered
H15.811	ICD10CM	Covered
H15.812	ICD10CM	Covered
H15.813	ICD10CM	Covered
H15.821	ICD10CM	Covered
H15.822	ICD10CM	Covered
H15.823	ICD10CM	Covered
H15.831	ICD10CM	Covered
H15.832	ICD10CM	Covered
H15.833	ICD10CM	Covered
H15.841	ICD10CM	Covered
H15.842	ICD10CM	Covered
H15.843	ICD10CM	Covered
H15.851	ICD10CM	Covered
H15.852	ICD10CM	Covered
H15.853	ICD10CM	Covered
H16.011	ICD10CM	Covered
H16.012	ICD10CM	Covered
H16.013	ICD10CM	Covered
H16.021	ICD10CM	Covered
H16.022	ICD10CM	Covered
H16.023	ICD10CM	Covered
H16.031	ICD10CM	Covered
H16.032	ICD10CM	Covered
H16.033	ICD10CM	Covered
H16.041	ICD10CM	Covered
H16.042	ICD10CM	Covered
H16.043	ICD10CM	Covered
H16.051	ICD10CM	Covered
H16.052	ICD10CM	Covered
H16.053	ICD10CM	Covered
H16.061	ICD10CM	Covered
H16.062	ICD10CM	Covered
H16.063	ICD10CM	Covered
H16.071	ICD10CM	Covered
H16.072	ICD10CM	Covered
H16.073	ICD10CM	Covered
H16.111	ICD10CM	Covered
H16.112	ICD10CM	Covered
H16.113	ICD10CM	Covered
H16.121	ICD10CM	Covered
H16.122	ICD10CM	Covered
H16.123	ICD10CM	Covered
H16.131	ICD10CM	Covered
H16.132	ICD10CM	Covered
H16.133	ICD10CM	Covered
H16.141	ICD10CM	Covered
H16.142	ICD10CM	Covered
H16.143	ICD10CM	Covered
H16.211	ICD10CM	Covered
H16.212	ICD10CM	Covered
H16.213	ICD10CM	Covered
H16.221	ICD10CM	Covered
H16.222	ICD10CM	Covered
H16.223	ICD10CM	Covered
H16.231	ICD10CM	Covered
H16.232	ICD10CM	Covered
H16.233	ICD10CM	Covered
H16.241	ICD10CM	Covered
H16.242	ICD10CM	Covered
H16.243	ICD10CM	Covered
H16.251	ICD10CM	Covered
H16.252	ICD10CM	Covered
H16.253	ICD10CM	Covered
H16.261	ICD10CM	Covered
H16.262	ICD10CM	Covered
H16.263	ICD10CM	Covered
H16.311	ICD10CM	Covered
H16.312	ICD10CM	Covered
H16.313	ICD10CM	Covered
H16.321	ICD10CM	Covered
H16.322	ICD10CM	Covered
H16.323	ICD10CM	Covered
H16.331	ICD10CM	Covered
H16.332	ICD10CM	Covered
H16.333	ICD10CM	Covered
H16.411	ICD10CM	Covered
H16.412	ICD10CM	Covered
H16.413	ICD10CM	Covered
H16.421	ICD10CM	Covered
H16.422	ICD10CM	Covered
H16.423	ICD10CM	Covered
H16.431	ICD10CM	Covered
H16.432	ICD10CM	Covered
H16.433	ICD10CM	Covered
H16.441	ICD10CM	Covered
H16.442	ICD10CM	Covered
H16.443	ICD10CM	Covered
H17.01	ICD10CM	Covered
H17.02	ICD10CM	Covered
H17.03	ICD10CM	Covered
H17.11	ICD10CM	Covered
H17.12	ICD10CM	Covered
H17.13	ICD10CM	Covered
H17.811	ICD10CM	Covered
H17.812	ICD10CM	Covered
H17.813	ICD10CM	Covered
H17.821	ICD10CM	Covered
H17.822	ICD10CM	Covered
H17.823	ICD10CM	Covered
H18.011	ICD10CM	Covered
H18.012	ICD10CM	Covered
H18.013	ICD10CM	Covered
H18.021	ICD10CM	Covered
H18.022	ICD10CM	Covered
H18.023	ICD10CM	Covered
H18.031	ICD10CM	Covered
H18.032	ICD10CM	Covered
H18.033	ICD10CM	Covered
H18.041	ICD10CM	Covered
H18.042	ICD10CM	Covered
H18.043	ICD10CM	Covered
H18.051	ICD10CM	Covered
H18.052	ICD10CM	Covered
H18.053	ICD10CM	Covered
H18.061	ICD10CM	Covered
H18.062	ICD10CM	Covered
H18.063	ICD10CM	Covered
H18.11	ICD10CM	Covered
H18.12	ICD10CM	Covered
H18.13	ICD10CM	Covered
H18.211	ICD10CM	Covered
H18.212	ICD10CM	Covered
H18.213	ICD10CM	Covered
H18.221	ICD10CM	Covered
H18.222	ICD10CM	Covered
H18.223	ICD10CM	Covered
H18.231	ICD10CM	Covered
H18.232	ICD10CM	Covered
H18.233	ICD10CM	Covered
H18.311	ICD10CM	Covered
H18.312	ICD10CM	Covered
H18.313	ICD10CM	Covered
H18.321	ICD10CM	Covered
H18.322	ICD10CM	Covered
H18.323	ICD10CM	Covered
H18.331	ICD10CM	Covered
H18.332	ICD10CM	Covered
H18.333	ICD10CM	Covered
H18.411	ICD10CM	Covered
H18.412	ICD10CM	Covered
H18.413	ICD10CM	Covered
H18.421	ICD10CM	Covered
H18.422	ICD10CM	Covered
H18.423	ICD10CM	Covered
H18.441	ICD10CM	Covered
H18.442	ICD10CM	Covered
H18.443	ICD10CM	Covered
H18.451	ICD10CM	Covered
H18.452	ICD10CM	Covered
H18.453	ICD10CM	Covered
H18.461	ICD10CM	Covered
H18.462	ICD10CM	Covered
H18.463	ICD10CM	Covered
H18.511	ICD10CM	Covered
H18.512	ICD10CM	Covered
H18.513	ICD10CM	Covered
H18.521	ICD10CM	Covered
H18.522	ICD10CM	Covered
H18.523	ICD10CM	Covered
H18.531	ICD10CM	Covered
H18.532	ICD10CM	Covered
H18.533	ICD10CM	Covered
H18.541	ICD10CM	Covered
H18.542	ICD10CM	Covered
H18.543	ICD10CM	Covered
H18.551	ICD10CM	Covered
H18.552	ICD10CM	Covered
H18.553	ICD10CM	Covered
H18.591	ICD10CM	Covered
H18.592	ICD10CM	Covered
H18.593	ICD10CM	Covered
H18.611	ICD10CM	Covered
H18.612	ICD10CM	Covered
H18.613	ICD10CM	Covered
H18.621	ICD10CM	Covered
H18.622	ICD10CM	Covered
H18.623	ICD10CM	Covered
H18.711	ICD10CM	Covered
H18.712	ICD10CM	Covered
H18.713	ICD10CM	Covered
H18.721	ICD10CM	Covered
H18.722	ICD10CM	Covered
H18.723	ICD10CM	Covered
H18.731	ICD10CM	Covered
H18.732	ICD10CM	Covered
H18.733	ICD10CM	Covered
H18.811	ICD10CM	Covered
H18.812	ICD10CM	Covered
H18.813	ICD10CM	Covered
H18.821	ICD10CM	Covered
H18.822	ICD10CM	Covered
H18.823	ICD10CM	Covered
H18.831	ICD10CM	Covered
H18.832	ICD10CM	Covered
H18.833	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
H21.211	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
H21.301	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
H21.41	ICD10CM	Covered
H21.42	ICD10CM	Covered
H21.43	ICD10CM	Covered
H21.511	ICD10CM	Covered
H21.512	ICD10CM	Covered
H21.513	ICD10CM	Covered
H21.521	ICD10CM	Covered
H21.522	ICD10CM	Covered
H21.523	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
H21.561	ICD10CM	Covered
H21.562	ICD10CM	Covered
H21.563	ICD10CM	Covered
H21.81	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
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
H40.51X1	ICD10CM	Covered
H40.51X2	ICD10CM	Covered
H40.51X3	ICD10CM	Covered
H40.52X1	ICD10CM	Covered
H40.52X2	ICD10CM	Covered
H40.52X3	ICD10CM	Covered
H40.53.X1	ICD10CM	Covered
H40.53.X2	ICD10CM	Covered
H40.53.X3	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
H57.811	ICD10CM	Covered
H57.812	ICD10CM	Covered
H57.813	ICD10CM	Covered
L12.1	ICD10CM	Covered
Q10.0	ICD10CM	Covered
Q13.0	ICD10CM	Covered
S00.211A	ICD10CM	Covered
S00.212A	ICD10CM	Covered
S00.221A	ICD10CM	Covered
S00.222A	ICD10CM	Covered
S00.241A	ICD10CM	Covered
S00.242A	ICD10CM	Covered
S00.251A	ICD10CM	Covered
S00.252A	ICD10CM	Covered
S00.261A	ICD10CM	Covered
S00.262A	ICD10CM	Covered
S01.111A	ICD10CM	Covered
S01.111D	ICD10CM	Covered
S01.111S	ICD10CM	Covered
S01.112A	ICD10CM	Covered
S01.112D	ICD10CM	Covered
S01.112S	ICD10CM	Covered
S01.121A	ICD10CM	Covered
S01.121D	ICD10CM	Covered
S01.121S	ICD10CM	Covered
S01.122A	ICD10CM	Covered
S01.122D	ICD10CM	Covered
S01.122S	ICD10CM	Covered
S01.131A	ICD10CM	Covered
S01.131D	ICD10CM	Covered
S01.131S	ICD10CM	Covered
S01.132A	ICD10CM	Covered
S01.132D	ICD10CM	Covered
S01.132S	ICD10CM	Covered
S01.141A	ICD10CM	Covered
S01.141D	ICD10CM	Covered
S01.141S	ICD10CM	Covered
S01.142A	ICD10CM	Covered
S01.142D	ICD10CM	Covered
S01.142S	ICD10CM	Covered
S01.151A	ICD10CM	Covered
S01.151D	ICD10CM	Covered
S01.151S	ICD10CM	Covered
S01.152A	ICD10CM	Covered
S01.152D	ICD10CM	Covered
S01.152S	ICD10CM	Covered
S02.31XA	ICD10CM	Covered
S02.31XB	ICD10CM	Covered
S02.31XD	ICD10CM	Covered
S02.31XG	ICD10CM	Covered
S02.31XK	ICD10CM	Covered
S02.31XS	ICD10CM	Covered
S02.32XA	ICD10CM	Covered
S02.32XB	ICD10CM	Covered
S02.32XD	ICD10CM	Covered
S02.32XG	ICD10CM	Covered
S02.32XK	ICD10CM	Covered
S02.32XS	ICD10CM	Covered
S05.01XA	ICD10CM	Covered
S05.01XD	ICD10CM	Covered
S05.01XS	ICD10CM	Covered
S05.02XA	ICD10CM	Covered
S05.02XD	ICD10CM	Covered
S05.02XS	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
S05.71XA	ICD10CM	Covered
S05.71XD	ICD10CM	Covered
S05.71XS	ICD10CM	Covered
S05.72XA	ICD10CM	Covered
S05.72XD	ICD10CM	Covered
S05.72XS	ICD10CM	Covered
T26.01XA	ICD10CM	Covered
T26.01XD	ICD10CM	Covered
T26.01XS	ICD10CM	Covered
T26.02XA	ICD10CM	Covered
T26.02XD	ICD10CM	Covered
T26.02XS	ICD10CM	Covered
T26.11XA	ICD10CM	Covered
T26.11XD	ICD10CM	Covered
T26.11XS	ICD10CM	Covered
T26.12XA	ICD10CM	Covered
T26.12XD	ICD10CM	Covered
T26.12XS	ICD10CM	Covered
T26.21XA	ICD10CM	Covered
T26.21XD	ICD10CM	Covered
T26.21XS	ICD10CM	Covered
T26.22XA	ICD10CM	Covered
T26.22XD	ICD10CM	Covered
T26.22XS	ICD10CM	Covered
T26.51XA	ICD10CM	Covered
T26.51XD	ICD10CM	Covered
T26.51XS	ICD10CM	Covered
T26.52XA	ICD10CM	Covered
T26.52XD	ICD10CM	Covered
T26.52XS	ICD10CM	Covered
T26.61XA	ICD10CM	Covered
T26.61XD	ICD10CM	Covered
T26.61XS	ICD10CM	Covered
T26.62XA	ICD10CM	Covered
T26.62XD	ICD10CM	Covered
T26.62XS	ICD10CM	Covered
T26.71XA	ICD10CM	Covered
T26.71XD	ICD10CM	Covered
T26.71XS	ICD10CM	Covered
T26.72XA	ICD10CM	Covered
T26.72XD	ICD10CM	Covered
T26.72XS	ICD10CM	Covered
T26.81XA	ICD10CM	Covered
T26.81XD	ICD10CM	Covered
T26.81XS	ICD10CM	Covered
T26.82XA	ICD10CM	Covered
T26.82XD	ICD10CM	Covered
T26.82XS	ICD10CM	Covered
T86.8401	ICD10CM	Covered
T86.8402	ICD10CM	Covered
T86.8403	ICD10CM	Covered
T86.8411	ICD10CM	Covered
T86.8412	ICD10CM	Covered
T86.8413	ICD10CM	Covered
T86.8421	ICD10CM	Covered
T86.8422	ICD10CM	Covered
T86.8423	ICD10CM	Covered
T86.8481	ICD10CM	Covered
T86.8482	ICD10CM	Covered
T86.8483	ICD10CM	Covered
T86.8491	ICD10CM	Covered
T86.8492	ICD10CM	Covered
T86.8493	ICD10CM	Covered