Policy Bulletins
The Policy Bulletins listed below represent our catalogue of medical and claim payment policies. If you are looking for a specific type of policy, choose a category from the menu on the right. You may also use the search function in the top menu to search for policies by word or phrase.
 
   

Policy #
Policy Bulletin Title
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MA08.028c
Abatacept (Orencia®) for Injection for Intravenous Use
MA08.028c
Attachment A (ICD-10 codes) to MA08.028c Abatacept (Orencia®) for Injection for Intravenous Use
MA11.010a
Abortion
MA12.003
Acute Care Facility Inpatient Transfers
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MA08.066b
Ado-Trastuzumab Emtansine (Kadcyla®)
MA08.066b
Attachment A (ICD-10 CODES AND NARRATIVES) to MA08.066b Ado-Trastuzumab Emtansine (Kadcyla®)
MA08.033a
Agalsidase beta (Fabrazyme®)
MA12.007
Air or Sea Ambulance Transport Services
MA08.015c
Alemtuzumab (Lemtrada™)
MA08.036b
Alglucosidase alfa (e.g., Lumizyme®)
MA07.055c
Allergy Immunotherapy
MA06.015c
AlloMap™ Molecular Expression Testing for Heart Transplant Rejection
MA08.050
Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)
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MA00.026e
Always Bundled Procedure Codes
MA00.026e
Attachment A (CPT Codes and HCPCS Codes) to MA00.026e Always Bundled Procedure Codes
MA07.005a
Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
MA07.026c
Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
MA01.001
Anesthesia Services for a Cancelled or Discontinued Procedure
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MA05.010d
Ankle-Foot/Knee-Ankle-Foot Orthoses
MA05.010d
Attachment A (HCPCS CODES FOR ANKLE-FOOT/ KNEE-ANKLE FOOT ORTHOSIS) to MA05.010d Ankle-Foot/Knee-Ankle-Foot Orthoses
MA07.018a
Anorectal Manometry, Electromyography (EMG) of Anorectal or Urethral Sphincters; Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters
MA06.001e
Apheresis Therapy
MA11.072
Application and Removal of Tattoos
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MA08.091c
Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
MA08.091c
Attachment A (Risk of Emesis Without Prophylaxis: Intravenous and Oral Antineoplastic Agents) to MA08.091c Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
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MA11.105e
Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
MA11.105e
Attachment A to MA11.105e Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
MA11.011c
Artificial Hearts and Ventricular Assist Devices (VADs)
MA11.044d
Artificial Intervertebral Disc Insertion
MA08.085a
Asparaginase Erwinia Chrysanthemi (Erwinaze®)
MA06.020a
Autologous Blood Services (Collection, Storage, Transfusion, and Perioperative Salvage)
MA11.082c
Autologous Chondrocyte Implantation (ACI)/Carticel® and Other Cell-based Treatments of Focal Articular Cartilage Lesions
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MA05.005c
Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
MA05.005c
Attachment A (ICD-10 codes used to represent the Wearable Automatic External Defibrillator (AED):) to MA05.005c Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
MA05.005c
Attachment B (ICD-10 codes used to represent the Nonwearable Automatic External Defibrillator (AED):) to MA05.005c Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
MA07.027b
Autonomic Nervous System Testing
MA11.100c
Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
MA08.061
Belatacept (Nulojix®)
MA08.057a
Belimumab (Benlysta®) for Intravenous Use
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MA08.072c
Bevacizumab (Avastin®) and related biosimilars
MA08.072c
Attachment A (Dosing and Frequency Requirements) to MA08.072c Bevacizumab (Avastin®) and related biosimilars
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MA00.037f
Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
MA00.037f
Attachment A (CPT/HCPCS Codes) to MA00.037f Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
MA07.010a
Biofeedback Therapy
MA07.052
Bioimpedance for the Detection of Lymphedema
MA06.022e
Biomarkers for Oncology
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MA11.047c
Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
MA11.047c
Attachment A (ICD-10 Coding) to MA11.047c Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
MA08.058c
Blinatumomab (Blincyto®)
MA11.049c
Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
MA08.037f
Bortezomib (Bortezomib for Injection, Velcade®)
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MA08.017c
Botulinum Toxin Agents
MA08.017c
Attachment A (ICD-10 Diagnosis Codes) to MA08.017c Botulinum Toxin Agents
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MA08.068c
Brentuximab Vedotin (Adcetris®)
MA08.068c
Attachment A ( ICD 10 CODES AND NARRATIVES) to MA08.068c Brentuximab Vedotin (Adcetris®)
MA11.006b
Bronchial Thermoplasty
MA08.099a
Burosumab-twza (Crysvita®)
MA08.054b
Cabazitaxel (Jevtana®)
MA08.101
Canakinumab (Ilaris®)
MA05.052b
Canes and Crutches
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MA10.002b
Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
MA10.002b
Attachment A (Medically Necessary ICD-10 Codes) to MA10.002b Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
MA00.006e
Care Management and Care Planning Services
MA08.062c
Carfilzomib (Kyprolis™)
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MA00.012b
Cast and Splint Applications and Associated Supplies Provided in the Office Setting
MA00.012b
Attachment A to MA00.012b Cast and Splint Applications and Associated Supplies Provided in the Office Setting
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MA11.054b
Cataract Surgery
MA11.054b
Attachment A (ICD-10 codes) to MA11.054b Cataract Surgery
MA11.060b
Catheter Ablation of Cardiac Arrhythmias
MA08.089b
Cerliponase alfa (Brineura™)
MA05.009
Cervical Traction Devices for In-home Use
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MA08.031c
Cetuximab (Erbitux®)
MA08.031c
Attachment A (Dosing and Frequency Requirements) to MA08.031c Cetuximab (Erbitux®)
MA08.031c
Attachment B (ICD-10 Codes for Cetuximab (Erbitux®)) to MA08.031c Cetuximab (Erbitux®)
MA11.103a
Chemical Peels
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MA08.093d
Chimeric Antigen Receptor (CAR) Therapy
MA08.093d
Attachment A (ICD-10 CODES AND NARRATIVES) to MA08.093d Chimeric Antigen Receptor (CAR) Therapy
MA10.004e
Chiropractic Services
MA06.030
Circulating Tumor Cell (CTC) Assay
MA08.004n
Coagulation Factors
MA11.039c
Cochlear Implantation
MA05.035b
Cold Therapy Devices
MA05.036b
Commode Chairs
MA12.001c
Complementary and Integrative Health Services
MA07.042
Complete Decongestive Therapy (CDT)
MA11.112
Composite Tissue Allotransplantation of the Hand(s) and Face
MA05.045a
Compression Garments
MA11.088b
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
MA09.014a
Computer Aided Detection (CAD) System for Use with Chest Radiographs
MA06.009a
Computer Analysis and Generation of Automated Data in Conjunction with Diagnostic Studies
MA00.049
Consultation Services
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MA00.002f
Continuous Glucose Monitors and Artificial Pancreas Device Systems (APDS)
MA00.002f
Attachment A (ICD-10: Short term CGM) to MA00.002f Continuous Glucose Monitors and Artificial Pancreas Device Systems (APDS)
MA00.002f
Attachment B (THERAPEUTIC LONG-TERM INTERSTITIAL CGMS ) to MA00.002f Continuous Glucose Monitors and Artificial Pancreas Device Systems (APDS)
MA01.004a
Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump
MA05.019a
Continuous Passive Motion (CPM) Devices in the Home Setting
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MA07.046e
Corneal Pachymetry Using Ultrasound
MA07.046e
Attachment A (ICD-10-CM Codes Eligible to be Reported for Corneal Pachymetry Using Ultrasound) to MA07.046e Corneal Pachymetry Using Ultrasound
MA12.009
Cosmetic Procedures
MA00.044a
Criteria for Reimbursement of Emergency Room Services
MA11.022a
Cryosurgical Ablation of the Prostate Gland
MA08.079d
Daratumumab (Darzalex™)
MA10.005a
Day Rehabilitation
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MA11.014d
Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
MA11.014d
Attachment A (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (A30.0 -E10.21)) to MA11.014d Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
MA11.014d
Attachment B (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E10.22 - E13.3512), Continued) to MA11.014d Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
MA11.014d
Attachment C (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E13.3513 - I87.093), Continued) to MA11.014d Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
MA11.014d
Attachment D (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (I87.099 - S86.891S), Continued) to MA11.014d Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
MA11.014d
Attachment E (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (S86.892A - Z79.01), Continued) to MA11.014d Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
MA11.005c
Deep Brain Stimulation (DBS)
MA11.102f
Denervation of the Spinal Nerves for Chronic Pain
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MA08.052e
Denosumab (Prolia®, Xgeva®)
MA08.052e
Attachment A (ICD-10-CM Codes) to MA08.052e Denosumab (Prolia®, Xgeva®)
MA04.001
Dental Extractions Prior to Cardiac Surgery, Radiation Therapy, or Transplant Surgery
MA08.074
Deoxycholic Acid (Kybella™)
MA00.032a
Direct Access Obstetrics/Gynecology (OB/GYN)
MA08.021a
Dofetilide (Tikosyn®) Use in the Inpatient Setting
MA07.041a
Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
MA05.028d
Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
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MA05.044f
Durable Medical Equipment (DME)
MA05.044f
Attachment A1 (Equipment that Meets the Definition of Durable Medical Equipment (DME)) to MA05.044f Durable Medical Equipment (DME)
MA05.044f
Attachment A2 (Equipment that Meets the Definition of Durable Medical Equipment (DME)) to MA05.044f Durable Medical Equipment (DME)
MA05.044f
Attachment B (Items that Do Not Meet the Definition of Durable Medical Equipment (DME) or Excluded from Coverage by Medicare) to MA05.044f Durable Medical Equipment (DME)
MA09.004a
Echocardiography Contrast Agents
MA08.044c
Eculizumab (Soliris®)
MA08.092a
Edaravone (Radicava™)
MA05.059
Electrical Continence Aid
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MA07.013c
Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
MA07.013c
Attachment A (ICD-10 Coding) to MA07.013c Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
MA03.015
Electrocardiogram (ECG/EKG) Reported with Single Photon Emission Computed Tomography (SPECT) for Myocardial Perfusion Imaging (MPI)
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MA07.050e
Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050e
Attachment A (Recommended Guidelines for Electrodiagnostic Studies) to MA07.050e Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050e
Attachment B (ICD-10) to MA07.050e Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050e
Attachment C (ICD-10 Codes) to MA07.050e Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050e
Attachment D (ICD-10 Codes) to MA07.050e Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050e
Attachment E (ICD-10 Codes) to MA07.050e Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050e
Attachment F (ICD-10 Codes) to MA07.050e Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050e
Attachment G (ICD-10 Codes) to MA07.050e Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050e
Attachment H (ICD-10 Codes) to MA07.050e Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050e
Attachment I (ICD-10 Codes) to MA07.050e Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050e
Attachment J (ICD-10 Codes) to MA07.050e Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050e
Attachment K (ICD-10 Codes) to MA07.050e Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA09.011a
Electron Beam Computed Tomography (EBCT) for Screening Evaluations
MA08.104
Emapalumab-lzsg (Gamifant®)
MA11.065d
Endometrial Ablation
MA11.012c
Endovascular Grafts for Abdominal Aortic Aneurysms, Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms
MA11.062a
Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions
MA08.003d
Enteral Nutritional Therapy
MA08.023a
Enzyme Replacement for the Treatment of Gaucher's Disease
MA08.034C
Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, Elaprase™, Vimizim™, Naglazyme®, Mepsevii™, etc.)
MA11.026d
Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
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MA08.056c
Eribulin Mesylate (Halaven®)
MA08.056c
Attachment A (ICD-10 Codes and Narratives ) to MA08.056c Eribulin Mesylate (Halaven®)
MA08.011d
Erythropoiesis Stimulating Agents (ESAs)
MA07.015a
Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS)
MA11.079c
Evaluation and Treatment of Erectile Dysfunction (ED)
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MA00.005q
Experimental/Investigational Services
MA00.005q
Attachment A (Experimental/Investigational Services Represented by a Specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code.) to MA00.005q Experimental/Investigational Services
MA00.005q
Attachment B ( Experimental/Investigational Services without a Specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code. ) to MA00.005q Experimental/Investigational Services
MA00.005q
Attachment C (Experimental/Investigational services with a specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code, that are reported for other services.) to MA00.005q Experimental/Investigational Services
MA05.033a
External Breast Prosthesis
MA07.012a
External Counterpulsation (ECP)
MA11.087b
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions
MA04.002
Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth
MA05.050a
Eye Prostheses and Scleral Cover Shell
MA00.040a
Facility Reporting of Observation Services
MA07.006a
Fecal Microbiota Transplantation (FMT)
MA05.040a
Food and Drug Administration (FDA) Approval of Medical Devices
MA09.012a
Full-Body Computerized Tomography (CT) Scan Screening
MA06.010b
Genetic Testing for Inherited Breast Cancer 1 (BRCA1) and Breast Cancer 2 (BRCA2) Mutations
MA06.012c
Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome)
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MA08.070c
Golimumab (Simponi® Aria™) Intravenous (IV) Injection
MA08.070c
Attachment A (Medically Necessary ICD-10 Codes) to MA08.070c Golimumab (Simponi® Aria™) Intravenous (IV) Injection
MA08.083a
Gonadotropin-Releasing Hormone Agonist (Eligard®, Lupron Depot®)
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MA11.046a
Hair Transplants and Cranial Prostheses (Wigs)
MA11.046a
Attachment A (ICD10 Diagnoses Codes) to MA11.046a Hair Transplants and Cranial Prostheses (Wigs)
MA05.029b
Heating Pads and Heat Lamps
MA11.002g
Hematopoietic Stem Cell Transplantation
MA05.001c
High-Frequency Chest Wall Oscillation Devices
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MA09.002h
High-Technology Radiology Services
MA09.002h
Attachment A (High-Technology Radiology Services Code List) to MA09.002h High-Technology Radiology Services
MA09.005a
High Osmolar Contrast Agents
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MA08.055d
Histone Deacetylase Inhibitors for Peripheral T-cell Lymphoma (e.g., Istodax®, Beleodaq®)
MA08.055d
Attachment A (ICD-10 Codes and Narratives) to MA08.055d Histone Deacetylase Inhibitors for Peripheral T-cell Lymphoma (e.g., Istodax®, Beleodaq®)
MA05.022
Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD)
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MA05.015c
Home Blood Glucose Monitors and Supplies
MA05.015c
Attachment A (ICD-10 diagnosis codes) to MA05.015c Home Blood Glucose Monitors and Supplies
MA02.003a
Home Health Care Services
MA05.017b
Home Oxygen Therapy
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MA05.016d
Home Prothrombin Time Monitoring
MA05.016d
Attachment A (ICD-10 codes used for Home Prothrombin Time Monitoring ) to MA05.016d Home Prothrombin Time Monitoring
MA05.016d
Attachment A (ICD-10 codes used for Home Prothrombin Time Monitoring ) to MA05.016d Home Prothrombin Time Monitoring
MA05.061
Home Use of Interferential and Sequential Stimulation Devices
MA02.001a
Hospice Care
MA05.002c
Hospital Beds and Accessories
MA06.011a
Human Immunodeficiency Virus (HIV) Genotyping and Phenotyping
MA00.042a
Humanitarian Use Devices (HUDs)
MA11.023h
Hyaluronan Acid Therapies for Osteoarthritis of the Knee
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MA07.001a
Hyperbaric Oxygen Therapy
MA07.001a
Attachment A (Recommended Utilization Guidelines for Medically necessary conditions using Hyperbaric Oxygen Therapy (HBO)) to MA07.001a Hyperbaric Oxygen Therapy
MA07.017c
Hyperthermic Intraperitoneal Chemotherapy for Select IntraAbdominal and Pelvic Malignancies
MA08.096a
Ibalizumab-uiyk (Trogarzo™)
MA06.018a
Immune Cell Function Assay
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MA08.009f
Immune Globulin: Intravenous (IVIG), Subcutaneous (SCIG)
MA08.009f
Attachment A (ICD-10 DIAGNOSIS CODES) to MA08.009f Immune Globulin: Intravenous (IVIG), Subcutaneous (SCIG)
MA08.009f
Attachment B (Dosage and Frequency Requirements) to MA08.009f Immune Globulin: Intravenous (IVIG), Subcutaneous (SCIG)
MA05.053f
Implantable and External Infusion Pumps
MA11.107b
Implantable Steroid-Eluting Sinus Stents
MA06.002b
In Vitro Allergy Testing
MA06.021c
In Vitro Chemosensitivity and Chemoresistance Assays
MA06.004a
In Vivo Allergy Sensitivity Testing
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MA08.019f
Infliximab and Related Biosimilars
MA08.019f
Attachment A (Dosing and Frequency Requirements for Infliximab and Related Biosimilars) to MA08.019f Infliximab and Related Biosimilars
MA08.019f
Attachment B (ICD-10-CM codes) to MA08.019f Infliximab and Related Biosimilars
MA05.021a
Injectable Dermal Fillers
MA00.023a
Inpatient Hospital Readmission
MA03.016
Insertion or Application of Urinary Catheters and the Associated Supplies Provided in the Office Setting
MA07.048a
Instrument-Based Vision Screening
MA08.024e
Interleukin-5 (IL-5) Antagonist (e.g., Cinqair®, Nucala®) and IL-5 Receptor Antagonist (e.g., Fasenra™)
MA07.051e
Intraoperative Neurophysiological Testing
MA07.025d
Intrauterine Systems (IUSs) (e.g., Mirena®, Skyla®, Liletta®, Kyleena®)
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MA07.016b
Intravenous Chelation Therapy
MA07.016b
Attachment A (ICD-10 Codes) to MA07.016b Intravenous Chelation Therapy
MA00.022
Intravenous (IV) Administration of Fluids as a Treatment of a Medical Condition or for the Preparation of Pharmaceuticals, Biologics, and other Substances
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MA08.073e
Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists (e.g., ranibizumab [Lucentis®], pegaptanib sodium [Macugen®], aflibercept [Eylea®], and related biosimilars)
MA08.073e
Attachment A (ICD-10 Codes and Narratives) to MA08.073e Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists (e.g., ranibizumab [Lucentis®], pegaptanib sodium [Macugen®], aflibercept [Eylea®], and related biosimilars)
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MA08.059e
Ipilimumab (Yervoy®)
MA08.059e
Attachment A (Dosing and Frequency Requirements For Ipilimumab (Yervoy®)) to MA08.059e Ipilimumab (Yervoy®)
MA08.059e
Attachment B (ICD-10 Diagnosis codes) to MA08.059e Ipilimumab (Yervoy®)
MA11.007
Islet Cell Transplantation
MA05.013c
Knee Orthoses
MA11.067d
Labiaplasty
MA07.031
Laboratory-Based Vestibular Function Testing
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MA00.030m
Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
MA00.030m
Attachment A1 (CPT CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE) to MA00.030m Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
MA00.030m
Attachment A2 (HCPCS CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE) to MA00.030m Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
MA00.030m
Attachment B1 (SERVICES ELIGIBLE FOR REIMBURSEMENT WHEN PERFORMED IN THE SPECIALIST OFFICE (THIS INCLUDES THE CERTIFIED REGISTERED NURSE PRACTITIONER (CRNP) AND PHYSICIAN ASSISTANT (PA) PRACTICING WITHIN THE SCOPE OF THEIR SPECIALTY) ) to MA00.030m Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
MA00.030m
Attachment B2 (SERVICES ELIGIBLE FOR REIMBURSEMENT IN THE OUTPATIENT HOSPITAL LABORATORY) to MA00.030m Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
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MA08.090a
Lanreotide (Somatuline® Depot)
MA08.090a
Attachment A to MA08.090a Lanreotide (Somatuline® Depot)
MA05.067a
Leadless Pacemakers
MA11.070a
Lipectomy and Liposuction
MA06.007b
Loss-of-Heterozygosity-Based Topographic Genotyping with PathFinderTG®
MA07.036b
Low-Level Laser Therapy
MA09.008a
Low Osmolar Contrast Agents
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MA05.024c
Lower Limb Prostheses
MA05.024c
Attachment A (HCPCS Level II Codes Number(s) and Narrative(s)) to MA05.024c Lower Limb Prostheses
MA11.048c
Lumbar Interspinous Process Decompression System
MA06.006d
Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic Treatment
MA11.095a
Lysis of Epidural Adhesions
MA07.014
Magnetic Pelvic Floor Stimulation (MPFS)
MA09.021c
Magnetic Resonance Imaging (MRI)--Guided Focused Ultrasound Ablation
MA09.010a
Magnetic Resonance Imaging (MRI) Contrast Agents
MA07.039a
Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI)
MA11.091b
Manipulation Under Anesthesia
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MA05.026a
Manual Wheelchairs
MA05.026a
Attachment A (HCPCS Codes for Manual Wheelchairs) to MA05.026a Manual Wheelchairs
MA00.038a
Marijuana for Medical Use
MA07.044b
Measurement of Exhaled Nitric Oxide and Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders
MA06.019a
Measurement of Serum Antibodies to and Measurement of Serum Levels of Infliximab and Adalimumab
MA05.043a
Mechanical Stretching Devices for the Treatment of Joint Stiffness or Contractures
MA07.024b
Medical and Surgical Treatment of Temporomandibular Joint Disorder
MA12.008
Medical Necessity
MA00.017
Medical Team Conferences
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MA08.007n
Medicare Part B vs. Part D Crossover Drugs
MA08.007n
Attachment A (Part B drugs that can be accessed through the Part D pharmacy benefit: pharmacy claims process at Medicare Part B cost share with no true out-of-pocket (TrOOP) expenses applied) to MA08.007n Medicare Part B vs. Part D Crossover Drugs
MA08.007n
Attachment B (Drugs that are usually self-administered: considered Part D only – excluded from Part B coverage) to MA08.007n Medicare Part B vs. Part D Crossover Drugs
MA08.007n
Attachment C (Vaccination and inoculation coverage.) to MA08.007n Medicare Part B vs. Part D Crossover Drugs
MA08.007n
Attachment D (Hepatitis B vaccine indications and diagnosis codes that are covered under the Medicare medical benefit (Part B).) to MA08.007n Medicare Part B vs. Part D Crossover Drugs
MA08.007n
Attachment E (Indications for when selected drugs that are being administered on an external infusion pump are covered under the Medicare medical benefit Part B) to MA08.007n Medicare Part B vs. Part D Crossover Drugs
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MA11.081a
Meniscal Allograft Transplantation
MA11.081a
Attachment A (ICD-10-CM codes) to MA11.081a Meniscal Allograft Transplantation
MA11.080a
Mentoplasty or Genioplasty
MA11.098
Migraine Deactivation Surgery
MA03.009c
Modifier 24: Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period
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MA03.003f
Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
MA03.003f
Attachment A (E&M codes appended with modifier 25 should be reimbursed at 50 percent of the applicable fee schedule amount when submitted on the same date of service, by the same professional provider or other qualified health care provider, as a minor procedure. ) to MA03.003f Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
MA03.003f
Attachment B (Problem-focused E&M codes appended with modifier 25 should be reimbursed at 50 percent of the applicable fee schedule amount when submitted on the same date of service, by the same professional provider or other qualified health care provider, as a preventive E&M.) to MA03.003f Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
MA03.002b
Modifier 50: Bilateral Procedure
MA03.014
Modifier 52 Reduced Services
MA03.018
Modifier 53: Discontinued Procedure
MA03.010c
Modifier 57: Decision for Surgery
MA00.011d
Modifier 62: Two Surgeons
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MA00.014c
Modifier 66: Surgical Team
MA00.014c
Attachment A (Team Surgery Review Form) to MA00.014c Modifier 66: Surgical Team
MA03.001
Modifier 76: Repeat Procedure by Same Physician
MA03.007
Modifier 77: Repeat Procedure by Another Physician
MA03.008a
Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following the Initial Procedure for a Related Procedure During the Postoperative Period
MA03.012b
Modifier 79: Unrelated Procedure or Service by the Same Physician During the Postoperative Period
MA03.011d
Modifiers 26 (Professional Component) and TC (Technical Component)
MA00.015c
Modifiers for Assistant-at-Surgery Services: 80, 81, 82, and AS
MA03.017a
Modifiers for Shared or Split Surgical Services (Modifiers 54, 55, 56)
MA03.005a
Modifiers XE, XS, XP, XU, 59
MA08.102
Mogamulizumab-kpkc (Poteligeo®)
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MA11.018c
Mohs' Micrographic Surgery (MMS)
MA11.018c
Attachment A (ICD 10 Codes) to MA11.018c Mohs' Micrographic Surgery (MMS)
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MA06.017o
Molecular Diagnostics
MA06.017o
Attachment A (Services that are Considered Medically Necessary) to MA06.017o Molecular Diagnostics
MA06.017o
Attachment B (Services that are Considered Medically Necessary with Criteria) to MA06.017o Molecular Diagnostics
MA06.017o
Attachment C (Services that are Considered Experimental/Investigational ) to MA06.017o Molecular Diagnostics
MA06.017o
Attachment D (Services that are Considered Exclusions) to MA06.017o Molecular Diagnostics
MA06.017o
Attachment E (Services that are coverable via Coverage with Evidence Development (CED), registry-based approach, or other properly-designed designs) to MA06.017o Molecular Diagnostics
MA08.103a
Moxetumomab pasudotox-tdfk (Lumoxiti™)
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MA01.005c
Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services
MA01.005c
Attachment A (Multiple Reduction Diagnostic Services) to MA01.005c Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services
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MA11.032d
Multiple Surgical Reduction Guidelines
MA11.032d
Attachment A1 (CPT Codes To Which Multiple Surgical Reduction Guidelines Apply) to MA11.032d Multiple Surgical Reduction Guidelines
MA11.032d
Attachment A2 (CPT Codes To Which Multiple Surgical Reduction Guidelines Apply) to MA11.032d Multiple Surgical Reduction Guidelines
MA11.032d
Attachment B (HCPCS Codes To Which Multiple Surgical Reduction Guidelines Apply) to MA11.032d Multiple Surgical Reduction Guidelines
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MA00.047b
Musculoskeletal Services
MA00.047b
Attachment A (Procedure Codes for Spine) to MA00.047b Musculoskeletal Services
MA00.047b
Attachment B (Procedure Codes for Joints) to MA00.047b Musculoskeletal Services
MA00.047b
Attachment C (Procedures Codes for Interventional Pain Management) to MA00.047b Musculoskeletal Services
MA08.029a
Natalizumab (Tysabri®)
MA00.041
National Correct Coding Initiative (NCCI) Code Pair Edits
MA05.007b
Nebulizers and Inhalation Solutions
MA05.008a
Negative Pressure Wound Therapy (NPWT) Systems
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MA07.033e
Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
MA07.033e
Attachment A (Recomended Guidelines for Electrodiagnostic Studies) to MA07.033e Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
MA07.033e
Attachment B (ICD-10 Codes) to MA07.033e Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
MA07.033e
Attachment C (ICD-10 Codes) to MA07.033e Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
MA07.033e
Attachment D (ICD-10 codes) to MA07.033e Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
MA07.033e
Attachment E (ICD-10 codes) to MA07.033e Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
MA07.033e
Attachment F (ICD-10 codes) to MA07.033e Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
MA07.033e
Attachment G (ICD-10 codes) to MA07.033e Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
MA07.033e
Attachment H (ICD-10 codes) to MA07.033e Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
MA07.033e
Attachment I (ICD-10 codes) to MA07.033e Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
MA07.033e
Attachment J (ICD-10 codes) to MA07.033e Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
MA07.033e
Attachment K (ICD-10 codes) to MA07.033e Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
MA06.023c
Nerve Fiber Density Testing
MA05.058a
Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES)
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MA07.038e
Neuropsychological Testing for Neurologically Based Conditions
MA07.038e
Attachment A (ICD-10 Codes) to MA07.038e Neuropsychological Testing for Neurologically Based Conditions
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MA00.039c
Never Events and Preventable Adverse Events
MA00.039c
Attachment A (Appendix I Hospital Acquired Conditions (HACS) List ) to MA00.039c Never Events and Preventable Adverse Events
MA00.039c
Attachment B (Never Event or Preventable Adverse Event Reporting Form ) to MA00.039c Never Events and Preventable Adverse Events
MA11.021a
Non-Surgical Spinal Decompression Therapy
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MA12.002a
Nonemergency Ambulance Transport
MA12.002a
Attachment A (Table of Medical Conditions) to MA12.002a Nonemergency Ambulance Transport
MA07.053
Nonemergent Inpatient Video Electroencephalogram (EEG) Monitoring and Ambulatory EEG Monitoring in the Home
MA06.024a
Noninvasive Techniques for the Evaluation and Monitoring of Individuals with Chronic Liver Disease
MA11.101
Nucleoplasty
MA08.086d
Nusinersen (Spinraza™)
MA00.001a
Obsolete or Unreliable Diagnostic Tests and Medical Services
MA08.088b
Ocrelizumab (Ocrevus™)
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MA08.065d
Octreotide Acetate (Sandostatin® LAR Depot)
MA08.065d
Attachment A (ICD 10 codes and narratives) to MA08.065d Octreotide Acetate (Sandostatin® LAR Depot)
MA08.048c
Ofatumumab (Arzerra™)
MA08.012a
Off-label Coverage for Prescription Drugs and/or Biologics
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MA08.025c
Omalizumab (Xolair®)
MA08.025c
Attachment A (Dosing and Frequency Requirements for Omalizumab (Xolair®)) to MA08.025c Omalizumab (Xolair®)
MA11.083a
Orthognathic Surgery
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MA05.012a
Orthopedic Footwear
MA05.012a
Attachment A to MA05.012a Orthopedic Footwear
MA05.012a
Attachment B to MA05.012a Orthopedic Footwear
MA11.086b
Osteochondral Allograft Transplantation
MA11.084b
Osteochondral Autograft Transplantation Procedure
MA05.018a
Osteogenic Stimulators (i.e., Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System)
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MA05.014a
Ostomy Supplies
MA05.014a
Attachment A (Ostomy Supply Codes) to MA05.014a Ostomy Supplies
MA11.058a
Otoplasty Otoplasty or Non-Surgical External Ear Molding
MA11.066b
Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome
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MA08.049e
Paclitaxel Protein-Bound Particles for Injectable Suspension (Albumin-bound)/(Abraxane® for Injectable Suspension)
MA08.049e
Attachment A (ICD-10 codes) to MA08.049e Paclitaxel Protein-Bound Particles for Injectable Suspension (Albumin-bound)/(Abraxane® for Injectable Suspension)
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MA07.047e
Pain Management of Peripheral Nerves by Injection
MA07.047e
Attachment A to MA07.047e Pain Management of Peripheral Nerves by Injection
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MA11.073c
Panniculectomy, Abdominoplasty, Abdominal Lipectomy, and Other Excisions of Redundant Skin
MA11.073c
Attachment A (ICD 10 codes for Abdominoplasty and/or Panniculectomy policy) to MA11.073c Panniculectomy, Abdominoplasty, Abdominal Lipectomy, and Other Excisions of Redundant Skin
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MA07.021b
Partial Coherence Interferometry
MA07.021b
Attachment A (ICD-10 Codes) to MA07.021b Partial Coherence Interferometry
MA05.031a
Patient Lifts
MA08.100a
Patisiran (Onpattro™)
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MA08.082a
Pegfilgrastim (Neulasta®) and Related Biosimilars
MA08.082a
Attachment A (EXAMPLES OF DISEASE SETTINGS AND CHEMOTHERAPY REGIMENS WITH A HIGH (>20%) OR INTERMEDIATE (10-20%) RISK FOR FEBRILE NEUTROPENIA) to MA08.082a Pegfilgrastim (Neulasta®) and Related Biosimilars
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MA08.060c
Pegloticase (Krystexxa®)
MA08.060c
Attachment A (ICD-10 Codes and Narratives) to MA08.060c Pegloticase (Krystexxa®)
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MA08.047c
Pemetrexed (Alimta®)
MA08.047c
Attachment A (ICD-10 CODES AND NARRATIVES) to MA08.047c Pemetrexed (Alimta®)
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MA11.113a
Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound
MA11.113a
Attachment A (Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound Code List) to MA11.113a Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound
MA11.096b
Percutaneous Discectomy
MA05.064
Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)
MA11.097c
Percutaneous Image-Guided Lumbar Decompression (PILD) for Spinal Stenosis
MA11.025
Percutaneous Intradiscal Annuloplasty (IDET/PIRFT)
MA11.013a
Percutaneous Left Atrial Appendage (LAA) Closure for Non-Valvular Atrial Fibrillation (NVAF)
MA11.056e
Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting and Extracranial- Intracranial (EC-IC) Arterial Bypass Surgery
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MA11.024d
Percutaneous Vertebroplasty and Percutaneous Vertebral Augmentation
MA11.024d
Attachment A (ICD-10 diagnosis codes) to MA11.024d Percutaneous Vertebroplasty and Percutaneous Vertebral Augmentation
MA08.053a
Personalized Vaccines (e.g., Provenge®)
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MA08.063b
Pertuzumab (Perjeta®)
MA08.063b
Attachment A (ICD-10-CM Codes and Narratives) to MA08.063b Pertuzumab (Perjeta®)
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MA06.008b
Pharmacogenetic Testing to Determine Drug Sensitivity
MA06.008b
Attachment A (Cytochrome p450 Genotyping for Assessment of Individuals Prior to Initiation of Clopidogrel Bisulfate (Plavix®)) to MA06.008b Pharmacogenetic Testing to Determine Drug Sensitivity
MA06.008b
Attachment B (Pharmacogenomic testing (CYP2C9 or VKORC1 alleles) for predicting warfarin response ) to MA06.008b Pharmacogenetic Testing to Determine Drug Sensitivity
MA06.008b
Attachment C (Pharmacogenetic Testing to Determine Cytochrome p450 (CYP2C19) Genetic Polymorphisms for Treatment/Management of Helicobacter Pylori (H. pylori) Infection) to MA06.008b Pharmacogenetic Testing to Determine Drug Sensitivity
MA06.008b
Attachment D (Pharmacogenetic Testing to Determine Cytochrome p450 (CYP2D6) Genetic Polymorphisms for Management of Tamoxifen Treatment for Women with, or at High Risk for Breast Cancer ) to MA06.008b Pharmacogenetic Testing to Determine Drug Sensitivity
MA06.008b
Attachment E (KRAS and BRAF Mutation Analysis in Metastatic Colorectal Cancer Prior to Use of Cetuximab (Erbitux®) and Pantiumumab (Vectibix®)) to MA06.008b Pharmacogenetic Testing to Determine Drug Sensitivity
MA06.008b
Attachment F (Pharmacogenetic Testing for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy by KIF6 Genotyping ) to MA06.008b Pharmacogenetic Testing to Determine Drug Sensitivity
MA06.008b
Attachment G (KRAS mutation analylsis to predict treatment response to erlotinib (Tarceva®) in non-small cell lung cancer (NSCLC)) to MA06.008b Pharmacogenetic Testing to Determine Drug Sensitivity
MA06.008b
Attachment H (Epidermal Growth Factor (EGFR) Mutation Analysis for individuals with non-small cell lung cancer) to MA06.008b Pharmacogenetic Testing to Determine Drug Sensitivity
MA06.008b
Attachment I (Pharmacogenetic testing for the BRAF (V600E) mutation in tumor tissue for select individuals for treatment with vemurafenib (Zelboraf®) ) to MA06.008b Pharmacogenetic Testing to Determine Drug Sensitivity
MA06.008b
Attachment J (BCR-ABL Testing for Monitoring of Individuals with Chronic Myelogenous Leukemia or Acute Myelogenous Leukemia, who are Receiving Imatinib MesylateTherapy) to MA06.008b Pharmacogenetic Testing to Determine Drug Sensitivity
MA06.014c
Pharmacogenetics and Metabolite Monitoring for Using Azathioprine (AZA)/6-Mercaptopurine (6-MP) Therapy
MA11.063a
Photocoagulation of Macular Drusen
MA07.003d
Photodynamic Therapy Using Verteporfin (Visudyne®)
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MA07.056c
Photodynamic Therapy (PDT) Using Levulan® Kerastick® (Aminolevulinic Acid HCl [ALA]) or Metvixia® (Methyl Aminolevulinate [MAL])
MA07.056c
Attachment A (ICD-10 Diagnosis Code Number(s) and Narrative(s)) to MA07.056c Photodynamic Therapy (PDT) Using Levulan® Kerastick® (Aminolevulinic Acid HCl [ALA]) or Metvixia® (Methyl Aminolevulinate [MAL])
MA07.030b
Photodynamic Therapy (PDT) Using Porfimer Sodium (Photofrin®)
MA07.020a
Photography, including Documentation and Record-Keeping Photography, Whole Body Integumentary Photography, Dermoscopy, and Dermatoscopy
MA10.003e
Physical Medicine & Rehabilitation Services: Physical Therapy (PT) and Occupational Therapy (OT)
MA00.013
Physician/Nonphysician Standby Services
MA07.008a
Platelet-Rich Plasma (PRPs) for Chronic Non-Healing Wounds and Stem-Cell Therapy for Orthopedic Applications
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MA05.004c
Pneumatic Compression Therapy Devices
MA05.004c
Attachment A (ICD-10 Codes) to MA05.004c Pneumatic Compression Therapy Devices
MA09.015
Positron Emission Mammography (PEM)
MA05.032
Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices
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MA00.010t
PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
MA00.010t
Attachment A1 (DME Network Rules and Limited Circumstances) to MA00.010t PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
MA00.010t
Attachment A2 (DME Network Rules and Limited Circumstances cont'd.) to MA00.010t PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
MA00.010t
Attachment A3 (DME Network Rules and Limited Circumstances) to MA00.010t PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
MA00.010t
Attachment B1 (Laboratory Network Rules and Limited Circumstances) to MA00.010t PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
MA00.010t
Attachment B2 (Laboratory Network Rules and Limited Circumstances ) to MA00.010t PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
MA00.010t
Attachment B3 (Laboratory Network Rules and Limited Circumstances cont'd.) to MA00.010t PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
MA00.010t
Attachment C1 (Radiology Network Rules and Limited Circumstances) to MA00.010t PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
MA00.010t
Attachment C2 to MA00.010t PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
MA00.010t
Attachment D (Physical Medicine & Rehabilitation Network Rules and Limited Circumstances) to MA00.010t PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
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MA08.043c
Pralatrexate (Folotyn®) for Injection
MA08.043c
Attachment A (ICD-10 Codes Eligible to be Reported for Pralatrexate (Folotyn®) for Injection) to MA08.043c Pralatrexate (Folotyn®) for Injection
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MA05.025b
Pressure-Reducing Support Surfaces
MA05.025b
Attachment A (ICD-10 Codes) to MA05.025b Pressure-Reducing Support Surfaces
MA06.025h
Presumptive and Definitive Drug Testing in Substance Abuse and Pain Management Treatments
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MA00.003j
Preventive Care Services
MA00.003j
Attachment A (Visits and Examinations) to MA00.003j Preventive Care Services
MA00.003j
Attachment B (Screening Services) to MA00.003j Preventive Care Services
MA00.003j
Attachment C (Therapy and Counseling) to MA00.003j Preventive Care Services
MA00.003j
Attachment C1 (Medical Nutrition Therapy ICD 10 Codes) to MA00.003j Preventive Care Services
MA00.003j
Attachment D (Vaccines) to MA00.003j Preventive Care Services
MA00.003j
Attachment D1 (Hepatitis B Vaccine ICD 10 Coding) to MA00.003j Preventive Care Services
MA02.002
Private Duty Nursing
MA11.109a
Procedures for the Treatment of Acne
MA11.055c
Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD)
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MA08.010j
Programmed Death Receptor-1 (PD-1) Antagonists (e.g., Keytruda®, Opdivo®) and Programmed Death-Ligand 1 (PD-L1) Antagonists (e.g., Tecentriq®, Bavencio®, Imfinzi™)
MA08.010j
Attachment A (ICD-10 Codes and Narratives) to MA08.010j Programmed Death Receptor-1 (PD-1) Antagonists (e.g., Keytruda®, Opdivo®) and Programmed Death-Ligand 1 (PD-L1) Antagonists (e.g., Tecentriq®, Bavencio®, Imfinzi™)
MA11.077c
Prophylactic Mastectomy, Oophorectomy/Salpingo-Oophorectomy, and Hysterectomy
MA11.016a
Prostate Mapping Biopsy
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MA07.007e
Pulmonary Function Tests
MA07.007e
Attachment A (Diagnosis Codes (ICD-10)) to MA07.007e Pulmonary Function Tests
MA10.001
Pulmonary Rehabilitation Services
MA05.042a
Pulse Oximeters in the Home Setting
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MA09.020h
Radiation Therapy Services
MA09.020h
Attachment A (CPT, HCPCS and Revenue Codes) to MA09.020h Radiation Therapy Services
MA11.052b
Radiofrequency Ablation and Cryosurgical Ablation of Lung Tumors
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MA00.019e
Radiologic Guidance of a Procedure
MA00.019e
Attachment A (Radiologic Guidance and Supervision and Interpretation Procedure Codes) to MA00.019e Radiologic Guidance of a Procedure
MA08.075c
Ramucirumab (Cyramza®)
MA11.030b
Reconstructive Breast Surgery
MA11.069b
Reduction Mammoplasty
MA11.008b
Refractive Keratoplasty
MA07.029b
Refractive Lenses
MA11.043
Reimbursement for a Presbyopia- or Astigmatism-Correcting Intraocular Lens
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MA01.006
Reimbursement for Components of Comprehensive Laboratory Panels
MA01.006
Attachment A (CPT Codes) to MA01.006 Reimbursement for Components of Comprehensive Laboratory Panels
MA09.009i
Reimbursement for Diagnostic and Therapeutic Radiopharmaceutical Agents for Professional Providers
MA00.045b
Reimbursement for Services Performed by Certified Registered Nurse Practitioners (CRNPs) or Physician Assistants (PAs)
MA07.019a
Reimbursement for the Administration of Immunizations
MA00.036d
Remote Patient Management: Telemedicine Services
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MA11.076c
Removal of Breast Implants
MA11.076c
Attachment A (ICD-10-CM codes) to MA11.076c Removal of Breast Implants
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MA05.062d
Repair and Replacement of Durable Medical Equipment (DME)
MA05.062d
Attachment A (A list of Healthcare Common Procedure Coding System (HCPCS) codes with narratives that are specific to repair or replacement) to MA05.062d Repair and Replacement of Durable Medical Equipment (DME)
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MA05.063c
Repair or Replacement of an External Prosthetic Device
MA05.063c
Attachment A (A list of Health Care Common Procedure Coding System (HCPCS) codes with repair or replacement in the narrative.) to MA05.063c Repair or Replacement of an External Prosthetic Device
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MA00.009f
Reporting and Documentation Requirements for Anesthesia Services
MA00.009f
Attachment A (AMA Anesthesia Procedure Codes) to MA00.009f Reporting and Documentation Requirements for Anesthesia Services
MA00.024b
Reporting Requirements for Drugs and Biologics
MA08.067a
Repository Corticotropin (H.P. Acthar® Gel Injection)
MA11.042a
Revision of a Previous Cosmetic Procedure
MA11.075a
Rhytidectomy and/or Cervicoplasty With or Without Liposuction and/or Platysmaplasty
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MA08.022f
Rituximab (Rituxan®) infusion, and rituximab and hyaluronidase human (Rituxan Hycela™) for subcutaneous injection
MA08.022f
Attachment A (Dosing and Frequency Requirements For Rituximab) to MA08.022f Rituximab (Rituxan®) infusion, and rituximab and hyaluronidase human (Rituxan Hycela™) for subcutaneous injection
MA08.022f
Attachment B (ICD-10 CODES AND NARRATIVES) to MA08.022f Rituximab (Rituxan®) infusion, and rituximab and hyaluronidase human (Rituxan Hycela™) for subcutaneous injection
MA11.057
Robotic-Assisted Surgery
MA00.004a
Routine Costs of Clinical Trials and Coverage of Investigational Devices A and B
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MA07.009f
Routine Foot Care for Certain Medical Conditions
MA07.009f
Attachment A (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (A30.0 -E10.21)) to MA07.009f Routine Foot Care for Certain Medical Conditions
MA07.009f
Attachment B (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (E10.22 - E13.3512), Continued) to MA07.009f Routine Foot Care for Certain Medical Conditions
MA07.009f
Attachment C (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (E13.3513 - I87.093), Continued) to MA07.009f Routine Foot Care for Certain Medical Conditions
MA07.009f
Attachment D (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (I87.099 - S86.891S), Continued) to MA07.009f Routine Foot Care for Certain Medical Conditions
MA07.009f
Attachment E (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (S86.892A - Z79.01), Continued) to MA07.009f Routine Foot Care for Certain Medical Conditions
MA11.028e
Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence
MA07.004d
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
MA11.078b
Scar Revision
MA09.013a
Screening for Vertebral Fracture with Dual-Energy X-ray Absorptiometry (DEXA/DXA)
MA05.011a
Seat Lift Mechanisms
MA08.078c
Sebelipase alfa (Kanuma®)
MA11.071a
Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)
MA11.068c
Sentinel Lymph Node Biopsy
MA11.099a
Septoplasty, Rhinoplasty, and Septorhinoplasty
MA06.013b
Serodiagnosis of Inflammatory Bowel Disease (IBD) and the Prometheus® IBD sgi Diagnostic™ Test
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MA00.033f
Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
MA00.033f
Attachment A: DELAWARE (Delaware Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers ) to MA00.033f Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
MA00.033f
Attachment B: NEW JERSEY (New Jersey Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers) to MA00.033f Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
MA00.033f
Attachment C: PENNSYLVANIA (Pennsylvania Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers ) to MA00.033f Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
MA08.006e
Siltuximab (Sylvant®)
MA07.058f
Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies
MA07.043a
Smell and Taste Dysfunction Testing
MA11.033b
Solid Organ Transplantation and Procurement Cost of Organs and Tissues
MA05.003c
Speech and Non-Speech Generating Devices
MA10.007b
Speech Therapy
MA11.031g
Spinal Cord and Dorsal Root Ganglion Stimulation
MA11.029d
Spinal Discectomy
MA11.108c
Spinal Fusion
MA11.041b
Spinal Laminectomy
MA05.030c
Spinal Orthoses
MA05.055
Standing Frames
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MA00.021a
STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point-of-Service (POS) Products
MA00.021a
Attachment A to MA00.021a STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point-of-Service (POS) Products
MA05.027
Subcutaneous Implantable Cardioverter Defibrillator (S-ICD) for Treating Life-threatening Ventricular Tachyarrhythmia
MA10.008c
Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)
MA11.110
Surgery for Gynecomastia
MA11.004e
Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
MA11.090
Surgical Treatment of Femoroacetabular Impingement
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MA11.036c
Surgical Treatment of Nails
MA11.036c
Attachment A (ICD-10 Diagnosis Codes) to MA11.036c Surgical Treatment of Nails
MA11.093a
Surgical Treatments of Athletic Pubalgia
MA08.105
Tagraxofusp-erzs (Elzonris™)
MA08.077d
Talimogene laherparepvec (Imlygic™)
MA06.029
Therapeutic Drug Monitoring for Antidepressants, Antipsychotics, and Antiepileptics
MA09.006a
Therapeutic Radiology Port Films
Hide details for
MA05.020e
Therapeutic Shoes
MA05.020e
Attachment A (ICD-10 codes) to MA05.020e Therapeutic Shoes
MA08.098a
Tildrakizumab-asmn (Ilumya™)
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MA08.045e
Tocilizumab (Actemra®) for Intravenous Infusion
MA08.045e
Attachment A (ICD-10 CODES AND NARRATIVES) to MA08.045e Tocilizumab (Actemra®) for Intravenous Infusion
MA07.011a
Topical Oxygenation
MA08.008c
Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Nutrition (IPN)
MA05.034
Tracheostomy Care Supplies
MA11.027c
Transcatheter Aortic Valve Replacement (TAVR) and Transcatheter Mitral Valve Repair (TMVR)
MA07.040a
Transcatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies
MA11.040b
Transcatheter Closure of Cardiac Septal Defects
MA07.035c
Transcranial Magnetic Stimulation (TMS)
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MA05.006c
Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies
MA05.006c
Attachment A (ICD 10 Codes) to MA05.006c Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies
MA05.065
Transtympanic Micropressure Device as a Treatment of Meniere Disease
Hide details for
MA08.018b
Trastuzumab (Herceptin®) and Related Biosimilars
MA08.018b
Attachment A (Dosing & Frequency Requirements for Trastuzumab (Herceptin®)) to MA08.018b Trastuzumab (Herceptin®) and Related Biosimilars
MA08.018b
Attachment B (ICD-10 CM Codes and Narratives) to MA08.018b Trastuzumab (Herceptin®) and Related Biosimilars
MA11.106d
Treatment of Gender Dysphoria
MA11.050
Treatment of Medical and Surgical Complications
MA11.051a
Treatment of Obesity and Bariatric Surgery for Treatment of Morbid Obesity
MA05.047d
Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring in Adults
MA08.016d
Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents
MA11.001h
Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence
MA08.026e
Treatments for Complex Regional Pain Syndrome (CRPS)
MA08.097a
Triamcinolone Acetonide Extended-Release Injectable (Zilretta™)
MA11.017e
Trigger Point Injections
Hide details for
MA07.002c
Ultraviolet Light Therapy for the Treatment of Dermatological Conditions
MA07.002c
Attachment A (ICD-10-CM codes) to MA07.002c Ultraviolet Light Therapy for the Treatment of Dermatological Conditions
Hide details for
MA07.023e
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
MA07.023e
Attachment A (ICD-10 Coding) to MA07.023e Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
Hide details for
MA05.057c
Upper Limb Prostheses
MA05.057c
Attachment A (HCPCS Codes that Describe Upper-Limb Prosthesis) to MA05.057c Upper Limb Prostheses
MA05.054d
Urological Supplies
Hide details for
MA11.037d
Use of an Operating Microscope During a Surgical Procedure
MA11.037d
Attachment A to MA11.037d Use of an Operating Microscope During a Surgical Procedure
MA08.042g
Ustekinumab (Stelara®)
MA11.045c
Uterine Artery Embolization
MA11.019d
Vagus Nerve Stimulation (VNS)
Hide details for
MA08.001b
Vedolizumab (Entyvio®)
MA08.001b
Attachment A (ICD-10 CODES AND NARRATIVES) to MA08.001b Vedolizumab (Entyvio®)
MA06.031c
Vitamin D Assay Testing
MA08.094c
Voretigene Neparvovec-rzyl (Luxturna™)
MA05.037
Walkers
MA05.023a
Wheelchair Cushions and Seating
Hide details for
MA05.046d
Wheelchair Options and Accessories
MA05.046d
Attachment A (HCPCS LEVEL II CODES FOR WHEELCHAIR OPTIONS AND ACCESSORIES ) to MA05.046d Wheelchair Options and Accessories
MA07.022b
Wireless Capsule Endoscopy
Hide details for
MA11.015g
Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds
MA11.015g
Attachment A (Skin substitutes and their approved indications.) to MA11.015g Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds
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MA00.031d
X-rays Associated with Fractures in the Office Setting
MA00.031d
Attachment A (Codes eligible for reimbursement when billed by Hand Surgeons, Orthopedic Surgeons, or Sports Medicine Specialists) to MA00.031d X-rays Associated with Fractures in the Office Setting
MA00.031d
Attachment B (Codes eligible for reimbursement when billed by Podiatrists) to MA00.031d X-rays Associated with Fractures in the Office Setting









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