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
MA12.003a
Acute Care Facility Inpatient Transfers
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MA08.066c
Ado-Trastuzumab Emtansine (Kadcyla®)
MA08.066c
Attachment A (ICD-10 CODES AND NARRATIVES) to MA08.066c Ado-Trastuzumab Emtansine (Kadcyla®)
MA08.033b
Agalsidase beta (Fabrazyme®)
MA12.007a
Air Ambulance Services
MA08.015c
Alemtuzumab (Lemtrada™)
MA08.036c
Alglucosidase alfa (e.g., Lumizyme®)
MA07.055c
Allergy Immunotherapy
MA06.015c
AlloMap™ Molecular Expression Testing for Heart Transplant Rejection
MA08.050a
Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)
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MA00.026g
Always Bundled Procedure Codes
MA00.026g
Attachment A (CPT Codes and HCPCS Codes) to MA00.026g Always Bundled Procedure Codes
MA07.005c
Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
MA07.026e
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
MA07.018b
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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MA11.105f
Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
MA11.105f
Attachment A to MA11.105f Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
MA11.011c
Artificial Hearts and Ventricular Assist Devices (VADs)
MA11.044f
Artificial Intervertebral Disc Insertion
MA08.085b
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
MA11.100e
Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
MA08.057a
Belimumab (Benlysta®) for Intravenous Use
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MA08.072e
Bevacizumab (Avastin®) and Related Biosimilars
MA08.072e
Attachment A (Dosing and Frequency Requirements) to MA08.072e Bevacizumab (Avastin®) and Related Biosimilars
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MA00.037h
Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
MA00.037h
Attachment A (CPT/HCPCS Codes) to MA00.037h 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
MA06.022f
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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MA08.017d
Botulinum Toxin Agents
MA08.017d
Attachment A (ICD-10 Diagnosis Codes) to MA08.017d Botulinum Toxin Agents
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MA08.068d
Brentuximab Vedotin (Adcetris®)
MA08.068d
Attachment A (ICD 10 CODES AND NARRATIVES) to MA08.068d 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
MA00.006f
Care Management and Care Planning Services
MA08.062d
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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MA11.054c
Cataract Surgery
MA11.054c
Attachment A (ICD-10 codes) to MA11.054c Cataract Surgery
MA11.060c
Catheter Ablation of Cardiac Arrhythmias
MA08.089c
Cerliponase alfa (Brineura®)
MA05.009
Cervical Traction Devices for In-home Use
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MA08.031d
Cetuximab (Erbitux®)
MA08.031d
Attachment A (Dosing and Frequency Requirements) to MA08.031d Cetuximab (Erbitux®)
MA08.031d
Attachment B (ICD-10 Codes for Cetuximab (Erbitux®)) to MA08.031d Cetuximab (Erbitux®)
MA11.103a
Chemical Peels
MA08.093e
Chimeric Antigen Receptor (CAR) Therapy
MA10.004f
Chiropractic Services
MA06.030
Circulating Tumor Cell (CTC) Assay
MA08.004p
Coagulation Factors
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MA06.032
Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
MA06.032
Attachment A (ICD 10 CODES FOR MEDICALLY NECESSARY COBALAMIN (VITAMIN B12), FOLIC ACID, AND/OR HOMOCYSTEINE TESTING (CPT CODES 82607, 82746, AND 83090)) to MA06.032 Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
MA11.039d
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
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
MA09.004b
Contrast Agents Used in Conjunction with Echocardiography
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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
MA05.040b
Coverage of Medical Devices
MA05.066a
Cranial Electrotherapy Stimulation
MA00.044b
Criteria for Reimbursement of Emergency Room Services
MA11.022a
Cryosurgical Ablation of the Prostate Gland
MA08.079e
Daratumumab (Darzalex™)
MA10.005b
Day Rehabilitation
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MA11.014e
Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
MA11.014e
Attachment A (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (A30.0 -E10.21)) to MA11.014e Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
MA11.014e
Attachment B (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E10.22 - E13.3512), Continued) to MA11.014e Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
MA11.014e
Attachment C (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E13.3513 - I87.093), Continued) to MA11.014e Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
MA11.014e
Attachment D (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (I87.099 - S86.891S), Continued) to MA11.014e Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
MA11.014e
Attachment E (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (S86.892A - Z79.01), Continued) to MA11.014e Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
MA11.005c
Deep Brain Stimulation (DBS)
MA11.102g
Denervation of the Spinal Nerves for Chronic Pain
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MA08.052g
Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)
MA08.052g
Attachment A (ICD-10-CM Codes) to MA08.052g Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)
MA08.074
Deoxycholic Acid (Kybella™)
MA00.032b
Direct Access to Obstetrics/Gynecology (OB/GYN) Services
MA08.021b
Dofetilide (Tikosyn®) Use in the Inpatient Setting
MA07.041b
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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MA05.044g
Durable Medical Equipment (DME)
MA05.044g
Attachment A1 (Equipment that Meets the Definition of Durable Medical Equipment (DME)) to MA05.044g Durable Medical Equipment (DME)
MA05.044g
Attachment A2 (Equipment that Meets the Definition of Durable Medical Equipment (DME)) to MA05.044g Durable Medical Equipment (DME)
MA05.044g
Attachment B (Items that Do Not Meet the Definition of Durable Medical Equipment (DME) or Excluded from Coverage by Medicare) to MA05.044g Durable Medical Equipment (DME)
MA08.044e
Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™)
MA08.092a
Edaravone (Radicava™)
MA05.059
Electrical Continence Aid
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MA07.013d
Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
MA07.013d
Attachment A (ICD-10 Coding) to MA07.013d Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
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MA07.050f
Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050f
Attachment A (Recommended Guidelines for Electrodiagnostic Studies) to MA07.050f Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050f
Attachment B (ICD-10) to MA07.050f Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050f
Attachment C (ICD-10 Codes) to MA07.050f Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050f
Attachment D (ICD-10 Codes) to MA07.050f Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050f
Attachment E (ICD-10 Codes) to MA07.050f Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050f
Attachment F (ICD-10 Codes) to MA07.050f Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050f
Attachment G (ICD-10 Codes) to MA07.050f Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050f
Attachment H (ICD-10 Codes) to MA07.050f Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050f
Attachment I (ICD-10 Codes) to MA07.050f Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050f
Attachment J (ICD-10 Codes) to MA07.050f Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.050f
Attachment K (ICD-10 Codes) to MA07.050f Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA09.011a
Electron Beam Computed Tomography (EBCT) for Screening Evaluations
MA08.104b
Emapalumab-lzsg (Gamifant®)
MA11.065d
Endometrial Ablation
MA11.012d
Endovascular Grafts for Abdominal Aortic Aneurysms, Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms
MA11.062
Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions
MA08.003d
Enteral Nutritional Therapy
MA08.023b
Enzyme Replacement for the Treatment of Gaucher's Disease
MA08.034d
Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, Elaprase®, Vimizim®, Naglazyme®, Mepsevii™, etc.)
MA11.026e
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®)
MA08.011e
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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MA00.005t
Experimental/Investigational Services
MA00.005t
Attachment A (Experimental/Investigational Services Represented by a Specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code.) to MA00.005t Experimental/Investigational Services
MA00.005t
Attachment B ( Experimental/Investigational Services without a Specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code. ) to MA00.005t Experimental/Investigational Services
MA00.005t
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 MA00.005t Experimental/Investigational Services
MA05.033b
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
MA08.114
Fam-trastuzumab deruxtecan-nxki (Enhertu®)
MA07.006a
Fecal Microbiota Transplantation (FMT)
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
MA08.083b
Gonadotropin-Releasing Hormone Agonist (Eligard®, Lupron Depot®)
MA12.002b
Ground Ambulance Transport Services (Emergency and Nonemergency)
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MA11.046b
Hair Transplants and Cranial Prostheses (Wigs)
MA11.046b
Attachment A (ICD-10 Diagnoses Codes) to MA11.046b Hair Transplants and Cranial Prostheses (Wigs)
MA05.029b
Heating Pads and Heat Lamps
MA11.002h
Hematopoietic Stem Cell Transplantation
MA05.001c
High-Frequency Chest Wall Oscillation Devices
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MA09.002l
High-Technology Radiology Services
MA09.002l
Attachment A (High-Technology Radiology Services Code List) to MA09.002l High-Technology Radiology Services
MA09.005a
High Osmolar Contrast Agents
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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MA05.016f
Home Prothrombin Time Monitoring
MA05.016f
Attachment A (ICD-10 codes used for Home Prothrombin Time Monitoring ) to MA05.016f 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
MA11.023i
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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MA08.009h
Immune Globulin: Intravenous (IVIG), Subcutaneous (SCIG)









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