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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08.00.62j
Abatacept (Orencia®) for Injection for Intravenous Use
08.00.62j
Attachment A (ICD-10 CODES AND NARRATIVES) to 08.00.62j Abatacept (Orencia®) for Injection for Intravenous Use
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12.00.01f
Acupuncture (Independence)
12.00.01f
Attachment A (ICD-10 CM Codes Eligible to be Reported for Acupuncture) to 12.00.01f Acupuncture (Independence)
12.04.04a
Acute Care Facility Inpatient Transfers
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08.01.11e
Ado-Trastuzumab Emtansine (Kadcyla®)
08.01.11e
Attachment A (ICD-10-CM Codes and Narratives) to 08.01.11e Ado-Trastuzumab Emtansine (Kadcyla®)
08.00.69b
Agalsidase beta (Fabrazyme®)
12.04.03c
Air Ambulance Services
08.01.22d
Alemtuzumab (Lemtrada®)
08.00.72h
Alglucosidase alfa (e.g., Lumizyme®)
07.00.21i
Allergy Immunotherapy
06.02.29d
AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators)
08.00.91d
Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)
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00.01.52i
Always Bundled Procedure Codes
00.01.52i
Attachment A (CPT Codes and HCPCS Codes) to 00.01.52i Always Bundled Procedure Codes
07.02.09g
Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
07.02.21e
Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
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05.00.39o
Ankle-Foot/Knee-Ankle-Foot Orthoses
05.00.39o
Attachment A (HCPCS Codes) to 05.00.39o Ankle-Foot/Knee-Ankle-Foot Orthoses
06.03.04n
Apheresis Therapy
11.08.05g
Application and Removal of Tattoos
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08.01.41c
Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
08.01.41c
Attachment A (Risk of Emesis Without Prophylaxis: Intravenous and Oral Antineoplastic Agents) to 08.01.41c Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
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11.05.16h
Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
11.05.16h
Attachment A (ICD-10 codes ) to 11.05.16h Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
11.14.19o
Artificial Intervertebral Disc Insertion
08.01.35b
Asparaginase Erwinia Chrysanthemi (Erwinaze®)
06.02.27l
Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (Independence Administrators)
07.10.06h
Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation
11.14.06i
Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions
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05.00.29k
Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
05.00.29k
Attachment A (ICD-10 Codes used to represent the Wearable Automatic External Defibrillator (AED):) to 05.00.29k Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
05.00.29k
Attachment B (ICD-10 codes used to represent the Nonwearable Automatic External Defibrillator (AED):) to 05.00.29k Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
07.03.23c
Autonomic Nervous System Testing
11.16.06j
Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
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11.03.02s
Bariatric Surgery
11.03.02s
Attachment A (Body Mass Index (BMI) Charts) to 11.03.02s Bariatric Surgery
11.03.02s
Attachment B (Tanner Staging System Criteria for Adolescents) to 11.03.02s Bariatric Surgery
11.03.02s
Attachment C (ICD-10-CM codes) to 11.03.02s Bariatric Surgery
08.00.99c
Belimumab (Benlysta®) for Intravenous Use
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08.00.66n
Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
08.00.66n
Attachment A (Dosing and Frequency Requirements) to 08.00.66n Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
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00.10.39l
Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
00.10.39l
Attachment A to 00.10.39l Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
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00.10.38a
Billing Requirements for Multiple Births for Professional Providers
00.10.38a
Attachment A (MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ROUTINE OBSTETRIC (GLOBALE MATERNITY/OBSTETRIC [OB]) CARE WAS PROVIDED) to 00.10.38a Billing Requirements for Multiple Births for Professional Providers
00.10.38a
Attachment B (MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ANETEPARTUM CARE IS NOT PROVIDED) to 00.10.38a Billing Requirements for Multiple Births for Professional Providers
00.10.38a
Attachment C (CODING SCENARIOS FOR REPORTING HIGH-ORDER MULTIPLE (TRIPLETS, QUADRUPLETS, ETC) BIRTHS WHEN ROUTINE OBSTETRIC (GLOBAL MATERNITY/OBSTETRIC [OB]) CARE WAS PROVIDED) to 00.10.38a Billing Requirements for Multiple Births for Professional Providers
00.10.38a
Attachment D (MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF HIGH-ORDER MULTIPLES WHEN ANTEPARTUM CARE IS NOT PROVIDED) to 00.10.38a Billing Requirements for Multiple Births for Professional Providers
07.00.01i
Biofeedback Therapy
07.06.03b
Bioimpedance for the Detection of Lymphedema
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11.05.02i
Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
11.05.02i
Attachment A (ICD-10 Codes) to 11.05.02i Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
08.01.21c
Blinatumomab (Blincyto®)
11.01.06e
Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
09.00.04k
Bone Mineral Density (BMD) Testing
08.00.73l
Bortezomib (Bortezomib for Injection, Velcade®)
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08.00.26w
Botulinum Toxin Agents
08.00.26w
Attachment A (ICD-10 Diagnosis Codes) to 08.00.26w Botulinum Toxin Agents
09.00.10z
Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (Independence Administrators)
05.00.76c
Breast Pumps
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08.01.13d
Brentuximab Vedotin (Adcetris®)
08.01.13d
Attachment A (ICD CODES AND NARRATIVES) to 08.01.13d Brentuximab Vedotin (Adcetris®)
11.16.07b
Bronchial Thermoplasty
08.01.49a
Burosumab-twza (Crysvita®)
08.00.96e
Cabazitaxel (Jevtana®)
08.01.51
Canakinumab (Ilaris®)
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10.01.01n
Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
10.01.01n
Attachment A (ICD-10 Codes) to 10.01.01n Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
00.01.59f
Care Management and Care Planning Services
08.01.05f
Carfilzomib (Kyprolis™)
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00.10.15c
Cast and Splint Applications and Associated Supplies Provided in the Office Setting
00.10.15c
Attachment A to 00.10.15c Cast and Splint Applications and Associated Supplies Provided in the Office Setting
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11.01.07e
Cataract Surgery
11.01.07e
Attachment A (ICD 10 codes for policy 11.01.07d, Cataract Surgery) to 11.01.07e Cataract Surgery
11.02.06m
Catheter Ablation of Cardiac Arrhythmias
08.01.39c
Cerliponase alfa (Brineura®)
05.00.61f
Cervical Traction Devices for In-home Use
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08.00.67l
Cetuximab (Erbitux®)
08.00.67l
Attachment A (Dosing and Frequency Requirements) to 08.00.67l Cetuximab (Erbitux®)
08.00.67l
Attachment B (ICD-10 Codes for Cetuximab (Erbitux®)) to 08.00.67l Cetuximab (Erbitux®)
11.08.08g
Chemical Peels
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08.01.43e
Chimeric Antigen Receptor (CAR) Therapy
08.01.43e
Attachment A (ICD-10 CODES AND NARRATIVES) to 08.01.43e Chimeric Antigen Receptor (CAR) Therapy
10.02.02j
Chiropractic Spinal and Extraspinal Manipulation Therapy
08.00.92ab
Coagulation Factors
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06.02.54
Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
06.02.54
Attachment A (MEDICALLY NECESSARY ICD 10 CODES FOR COBALAMIN (VITAMIN B12) AND/OR FOLIC ACID TESTING (CPT CODES 82607, 82608, 82746, AND 82747) ) to 06.02.54 Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
11.01.02o
Cochlear Implant
11.03.12s
Colorectal Cancer Screening
12.00.03g
Complementary and Integrative Health Services
07.06.01b
Complete Decongestive Therapy (CDT)
11.14.30
Composite Tissue Allotransplantation of the Hand(s) and Face
05.00.37f
Compression Garments
09.00.42c
Computer-Aided Detection (CAD) System for Use with Chest Radiographs
11.14.17d
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures
00.01.69
Consultation Services
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07.13.11i
Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
07.13.11i
Attachment A (ICD-10 Codes) to 07.13.11i Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
01.00.09c
Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump
05.00.08e
Continuous Passive Motion (CPM) Devices in the Home Setting
09.00.11d
Contrast Agents Used in Conjunction with Echocardiography
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07.13.07j
Corneal Pachymetry Using Ultrasound
07.13.07j
Attachment A (ICD-10-CM codes) to 07.13.07j Corneal Pachymetry Using Ultrasound
12.01.03
Cosmetic Procedures
05.00.04e
Coverage of Medical Devices
08.01.08d
Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical Benefit
05.00.80a
Cranial Electrotherapy Stimulation
05.00.25i
Cranial Remolding Orthoses (Helmets)
00.10.03j
Criteria for Reimbursement of Emergency Room Services
11.11.03d
Cryosurgical Ablation of the Prostate Gland
08.01.29e
Daratumumab (Darzalex™)
10.00.02c
Day Rehabilitation
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11.08.17i
Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.08.17i
Attachment A (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (A30.0 -E10.21)) to 11.08.17i Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.08.17i
Attachment B (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E10.22 - E13.3512), Continued) to 11.08.17i Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.08.17i
Attachment C (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E13.3513 - I87.093), Continued) to 11.08.17i Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.08.17i
Attachment D (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (I87.099 - S86.891S), Continued) to 11.08.17i Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.08.17i
Attachment E (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (S86.892A - Z79.01), Continued) to 11.08.17i Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.15.20o
Deep Brain Stimulation (DBS)
11.15.09n
Denervation of the Spinal Nerves for Chronic Pain
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08.00.94m
Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)
08.00.94m
Attachment A (ICD-10-CM Codes) to 08.00.94m Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)
08.01.24a
Deoxycholic Acid (Kybella™)
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00.03.02aa
Diagnostic Radiology Services Included in Capitation
00.03.02aa
Attachment A (Diagnostic Radiology Procedure Codes Included in Capitation for Pennsylvania (PA) Health Maintenance Organization (HMO) Members ) to 00.03.02aa Diagnostic Radiology Services Included in Capitation
00.09.01f
Direct Access to Obstetrics/Gynecology (OB/GYN) Services
08.00.49e
Dofetilide (Tikosyn®) Use in the Inpatient Setting
07.05.07d
Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
08.01.37a
Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Naltrexone Implants, Probuphine Implant, Sublocade Injection, Vivitrol Injection)
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05.00.21u
Durable Medical Equipment (DME) and Consumable Medical Supplies
05.00.21u
Attachment A1 (Equipment that Meets the Definition of Durable Medical Equipment (DME)) to 05.00.21u Durable Medical Equipment (DME) and Consumable Medical Supplies
05.00.21u
Attachment A2 (Equipment that Meets the Definition of Durable Medical Equipment (DME)) to 05.00.21u Durable Medical Equipment (DME) and Consumable Medical Supplies
05.00.21u
Attachment B (Items that Do Not Meet the Definition of Durable Medical Equipment (DME)) to 05.00.21u Durable Medical Equipment (DME) and Consumable Medical Supplies
05.00.48j
Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
08.00.84g
Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris®)
08.01.42a
Edaravone (Radicava™)
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11.06.02i
Elective Abortion
11.06.02i
Attachment A (Diagnosis codes ICD-10) to 11.06.02i Elective Abortion
05.00.09h
Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System
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07.03.09p
Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment A (Recommended Guidelines for Electrodiagnostic Studies) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment B (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment C (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment D (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment E (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment F (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment G (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment H (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment I (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment J (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment K (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
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07.03.21k
Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
07.03.21k
Attachment A (ICD-10-CM codes) to 07.03.21k Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
09.00.02e
Electron Beam Computed Tomography (EBCT) for Screening Evaluations
08.01.54b
Emapalumab-lzsg (Gamifant®)
11.06.05f
Endometrial Ablation
11.02.10n
Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms
11.02.17f
Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions
08.00.43a
Enfortumab vedotin-ejfv (Padcev™)
08.00.51j
Enzyme Replacement for the Treatment of Gaucher's Disease
08.01.26c
Enzyme Replacement Therapy for Adenosine Deaminase Severe Combined Immune Deficiency (e.g., elapegademase-lvlr [Revcovi™)
08.00.70e
Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, Elaprase®, Vimizim®, Naglazyme®, Mepsevii™, etc.)
11.15.23i
Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
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08.00.45a
Eptinezumab-jjmr (VYEPTI™)
08.00.45a
Attachment A (ICD 10 Diagnosis list G43.001   Migraine without aura, not intractable, with status migrainosus G43.009   Migraine without aura, not intractable, without status migrainosus G43.011   Migraine without aura, intractable, with status migrainosus G43.019   Migraine without aura, intractable, without status migrainosus G43.101   Migraine with aura, not intractable, with status migrainosus G43.109   Migraine with aura, not intractable, without status migrainosus G43.111   Migraine with aura, intractable, with status migrainosus G43.119   Migraine with aura, intractable, without status migrainosus G43.401   Hemiplegic migraine, not intractable, with status migrainosus G43.409   Hemiplegic migraine, not intractable, without status migrainosus G43.411   Hemiplegic migraine, intractable, with status migrainosus G43.419   Hemiplegic migraine, intractable, without status migrainosus G43.501   Persistent migraine aura without cerebral infarction, not intractable, with status migrainosus G43.509   Persistent migraine aura without cerebral infarction, not intractable, without status migrainosus G43.511   Persistent migraine aura without cerebral infarction, intractable, with status migrainosus G43.519   Persistent migraine aura without cerebral infarction, intractable, without status migrainosus G43.601   Persistent migraine aura with cerebral infarction, not intractable, with status migrainosus G43.609   Persistent migraine aura with cerebral infarction, not intractable, without status migrainosus G43.611   Persistent migraine aura with cerebral infarction, intractable, with status migrainosus G43.619   Persistent migraine aura with cerebral infarction, intractable, without status migrainosus G43.701   Chronic migraine without aura, not intractable, with status migrainosus G43.709   Chronic migraine without aura, not intractable, without status migrainosus G43.711   Chronic migraine without aura, intractable, with status migrainosus G43.719   Chronic migraine without aura, intractable, without status migrainosus G43.801   Other migraine, not intractable, with status migrainosus G43.809   Other migraine, not intractable, without status migrainosus G43.811   Other migraine, intractable, with status migrainosus G43.819   Other migraine, intractable, without status migrainosus G43.821   Menstrual migraine, not intractable, with status migrainosus G43.829   Menstrual migraine, not intractable, without status migrainosus G43.831   Menstrual migraine, intractable, with status migrainosus G43.839   Menstrual migraine, intractable, without status migrainosus G43.901   Migraine, unspecified, not intractable, with status migrainosus G43.909   Migraine, unspecified, not intractable, without status migrainosus G43.911   Migraine, unspecified, intractable, with status migrainosus G43.919   Migraine, unspecified, intractable, without status migrainosus ) to 08.00.45a Eptinezumab-jjmr (VYEPTI™)
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05.00.05l
Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
05.00.05l
Attachment A (ICD 10 Codes) to 05.00.05l Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
05.00.05l
Attachment B (HCPCS Codes) to 05.00.05l Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
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08.00.98e
Eribulin Mesylate (Halaven®)
08.00.98e
Attachment A (ICD-10 Codes and Narratives) to 08.00.98e Eribulin Mesylate (Halaven®)
08.00.75n
Erythropoiesis-Stimulating Agents (ESAs)
07.02.22a
Esophagogastroduodenoscopy (EGD) and Endoscopic Retrograde Cholangiopancreatography (ERCP)
07.03.07t
Evaluation and Management of Autism Spectrum Disorder (ASD)
07.03.15d
Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS)
11.11.01i
Evaluation and Treatment of Erectile Dysfunction (ED)
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06.02.52q
eviCore Lab Management Program (Independence)
06.02.52q
Attachment A (Procedure Codes Requiring Pre-service and Prepayment Reviews) to 06.02.52q eviCore Lab Management Program (Independence)
06.02.52q
Attachment B (Procedure Codes Requiring Prepayment Reviews) to 06.02.52q eviCore Lab Management Program (Independence)
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12.01.01av
Experimental/Investigational Services
12.01.01av
Attachment A (Experimental/Investigational Services Represented by a Specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code.) to 12.01.01av Experimental/Investigational Services
12.01.01av
Attachment B (Experimental/Investigational Services without a Specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code.) to 12.01.01av Experimental/Investigational Services
12.01.01av
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 12.01.01av Experimental/Investigational Services
07.02.05j
External Counterpulsation (ECP)
11.14.13g
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions
04.00.05d
Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth
00.01.19d
Facility Reporting of Observation Services
08.00.12a
Fam-trastuzumab deruxtecan-nxki (Enhertu®)
07.05.08a
Fecal Microbiota Transplantation (FMT)
06.02.04d
Fetal Fibronectin Enzyme (fFN) Immunoassay
11.00.03j
Fetal Surgery
09.00.36l
First-Trimester Prenatal Screening for Fetal Aneuploidy Using Fetal Ultrasound Markers
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05.00.35f
Foot Orthotics and Other Podiatric Appliances
05.00.35f
Attachment A (ICD-10 Codes) to 05.00.35f Foot Orthotics and Other Podiatric Appliances
11.03.05d
Frenectomy, Frenotomy, or Frenoplasty for Ankyloglossia (Tongue-Tie)
09.00.24c
Full-Body Computerized Tomography (CT) Scan Screening
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07.00.03n
Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy
07.00.03n
Attachment A (Utilization Guidelines) to 07.00.03n Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy
11.03.15h
Gastric Electrical Stimulation (Enterra™), Gastric Pacing
06.02.31f
Genetic Testing for Congenital Long QT Syndrome (Independence Administrators)
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06.02.06q
Genetic Testing for Inherited Breast Cancer 1 (BRCA1) and Breast Cancer 2 (BRCA2) Mutations (Independence Administrators)
06.02.06q
Attachment A (ICD-10 codes) to 06.02.06q Genetic Testing for Inherited Breast Cancer 1 (BRCA1) and Breast Cancer 2 (BRCA2) Mutations (Independence Administrators)
06.02.10q
Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome) (Independence Administrators)
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06.02.35y
Genetic Testing (Independence Administrators)
06.02.35y
Attachment A (Services that are Considered Medically Necessary) to 06.02.35y Genetic Testing (Independence Administrators)
06.02.35y
Attachment B (Services that are Considered Medically Necessary with Criteria) to 06.02.35y Genetic Testing (Independence Administrators)
06.02.35y
Attachment C (Services that are Considered Experimental/Investigational ) to 06.02.35y Genetic Testing (Independence Administrators)
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08.01.15d
Golimumab (Simponi Aria®) Intravenous (IV) Injection
08.01.15d
Attachment A (Medically Necessary ICD-10 Codes) to 08.01.15d Golimumab (Simponi Aria®) Intravenous (IV) Injection
08.01.33b
Gonadotropin-Releasing Hormone Agonist (Eligard®, Lupron Depot®)
06.02.50
GPS Cancer™ Testing by NantHealth
12.04.02i
Ground Ambulance Services (Emergency and Nonemergency) (Independence)
00.05.01f
Guidelines for Home Care Visits Following Inpatient Maternity Stay
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11.08.01g
Hair Transplants and Cranial Prostheses (Wigs)
11.08.01g
Attachment A (ICD-10-CM codes) to 11.08.01g Hair Transplants and Cranial Prostheses (Wigs)
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11.07.01t
Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant)
11.07.01t
Attachment A (References for the hematopoietic stem cell transplantation policy.) to 11.07.01t Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant)
05.00.14j
High-Frequency Chest Wall Oscillation Devices
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09.00.46ab
High-Technology Radiology Services (Independence)
09.00.46ab
Attachment A (High-Technology Radiology Services Code List ) to 09.00.46ab High-Technology Radiology Services (Independence)
09.00.13c
High Osmolar Contrast Agents
05.00.69b
Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD)
02.01.01d
Home Health Care Services
05.00.58l
Home Oxygen Therapy
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05.00.26i
Home Prothrombin Time Monitoring
05.00.26i
Attachment A (ICD-10-CODING) to 05.00.26i Home Prothrombin Time Monitoring
02.02.01g
Hospice Care
05.00.56i
Hospital Beds and Accessories
06.02.09g
Human Immunodeficiency Virus (HIV) Genotyping and Phenotyping (Independence Administrators)
08.01.00g
Hydroxyprogesterone Caproate Injection as a Technique to Reduce the Risk of Preterm Birth in High-Risk Pregnancies
11.00.13g
Hyperthermic Intraperitoneal Chemotherapy for Select Intra-abdominal and Pelvic Malignancies
08.01.46a
Ibalizumab-uiyk (Trogarzo™)
06.02.37a
Immune Cell Function Assay
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08.00.13w
Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
08.00.13w
Attachment A (Dosing and Frequency Requirements) to 08.00.13w Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
08.00.13w
Attachment B (ICD-10 DIAGNOSIS CODES) to 08.00.13w Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
08.00.22m
Immune Prophylaxis for Respiratory Syncytial Virus (RSV)
08.01.04v
Immunizations
11.15.03k
Implantable Infusion Pumps
11.16.08d
Implantable Steroid-Eluting Sinus Stents
11.05.11c
Implantation of Intrastromal Corneal Ring Segments (ICRS)
06.02.26d
In Vitro Allergy Testing
06.02.14i
In Vitro Chemosensitivity and Chemoresistance Assays
07.00.05g
In Vivo Allergy Sensitivity Testing
00.10.40d
Incident To and Non-Incident To Services Performed by Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs)
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08.00.34n
Infliximab and Related Biosimilars
08.00.34n
Attachment A (Dosing and Frequency Requirements for Infliximab and Related Biosimilars) to 08.00.34n Infliximab and Related Biosimilars
08.00.34n
Attachment B (ICD-10-CM Codes and Narratives) to 08.00.34n Infliximab and Related Biosimilars
05.00.62h
Injectable Dermal Fillers
00.01.47c
Inpatient Hospital Readmission
07.13.12d
Instrument-Based Vision Screening
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05.00.79b
Insulin Pumps and Long term Interstitial Continuous Glucose Monitoring Systems
05.00.79b
Attachment A (ICD-10 Diagnosis Codes for Insulin Pumps) to 05.00.79b Insulin Pumps and Long term Interstitial Continuous Glucose Monitoring Systems
05.00.79b
Attachment B (ICD-10 Diagnosis Codes for the CGM supplies used in conjunction with the threshold suspend (low glucose) device system ) to 05.00.79b Insulin Pumps and Long term Interstitial Continuous Glucose Monitoring Systems
09.00.17o
Intensity-Modulated Radiation Therapy (IMRT) (Independence Administrators)
08.01.23f
Interleukin-5 (IL-5) Antagonist (e.g., Cinqair®, Nucala®) and IL-5 Receptor Antagonist (e.g., Fasenra®)
11.14.07v
Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis
07.03.14o
Intraoperative Neurophysiological Monitoring (INM)
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07.00.02i
Intravenous Chelation Therapy
07.00.02i
Attachment A (ICD-10 Codes) to 07.00.02i Intravenous Chelation Therapy
00.01.45
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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08.00.74n
Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists and Related Biosimilars
08.00.74n
Attachment A (ICD-10 Codes and Narratives) to 08.00.74n Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists and Related Biosimilars
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08.01.01i
Ipilimumab (Yervoy®)
08.01.01i
Attachment A (Dosing and Frequency Requirements For Ipilimumab (Yervoy®)) to 08.01.01i Ipilimumab (Yervoy®)
08.01.01i
Attachment B (ICD-10 Diagnosis codes) to 08.01.01i Ipilimumab (Yervoy®)
08.00.46
Isatuximab-irfc (Sarclisa®)
11.04.01d
Islet Cell Transplantation
05.00.47n
Knee Orthoses
11.06.09d
Labiaplasty
07.03.24a
Laboratory-Based Vestibular Function Testing
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00.03.07y
Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
00.03.07y
Attachment A1 (CPT CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE) to 00.03.07y Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
00.03.07y
Attachment A2 (HCPCS CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE) to 00.03.07y Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
00.03.07y
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 00.03.07y Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
00.03.07y
Attachment B2 (SERVICES ELIGIBLE FOR REIMBURSEMENT IN THE OUTPATIENT HOSPITAL LABORATORY) to 00.03.07y Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
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08.01.40b
Lanreotide (Somatuline® Depot)
08.01.40b
Attachment A (ICD-10 CODES AND NARRATIVES) to 08.01.40b Lanreotide (Somatuline® Depot)
11.08.03j
Lipectomy and Liposuction
07.00.14g
Low-level Laser Therapy (LLLT)
09.00.31d
Low Osmolar Contrast Agents
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05.00.59j
Lower Limb Prostheses
05.00.59j
Attachment A (HCPCS Level II Code Number(s) and Narrative(s)) to 05.00.59j Lower Limb Prostheses
08.00.10b
Luspatercept–aamt (Reblozyl®)
08.01.57
Lutathera® (Lutetium Lu 177 Dotatate) (Independence Administrators)
06.02.01j
Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic Therapy
11.15.13d
Lysis of Epidural Adhesions
11.06.06e
Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Ablation
09.00.45h
Magnetic Resonance Imaging (MRI) Contrast Agents
07.03.10e
Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI)
11.14.24b
Manipulation Under Anesthesia
05.00.12g
Manual Wheelchairs
00.01.48c
Marijuana for Medical Use
07.11.02f
Measurement of Exhaled Nitric Oxide and Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders
06.02.39d
Measurement of Serum Antibodies to and Measurement of Serum Levels of Biologics
05.00.70b
Mechanical Stretching Devices for the Treatment of Joint Stiffness or Contractures
07.08.03e
Medical and Surgical Treatment of Temporomandibular Joint Disorder
07.03.03g
Medical Evaluation and Management for Attention-Deficit Hyperactivity Disorder (ADHD)
12.01.02
Medical Necessity
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11.14.03g
Meniscal Allograft Transplantation and Meniscal Implants
11.14.03g
Attachment A (ICD-10-CM codes) to 11.14.03g Meniscal Allograft Transplantation and Meniscal Implants
11.14.01g
Mentoplasty or Genioplasty
11.14.21h
Microprocessor-Controlled Prostheses for Lower-Extremity Amputees
11.15.24a
Migraine Deactivation Surgery
03.00.15o
Modifier 24: Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period
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03.00.06s
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
03.00.06s
Attachment A (E&M codes appended with modifier 25 should be reimbursed at 50% 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 03.00.06s 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
03.00.06s
Attachment B (Problem-focused E&M Codes appended with modifier 25 should be reimbursed at 50% 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 03.00.06s 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
03.00.05k
Modifier 50: Bilateral Procedure
03.00.05l
Modifier 50: Bilateral Procedure
03.00.32a
Modifier 52 Reduced Services
03.00.16o
Modifier 57 Decision for Surgery
00.10.11m
Modifier 62: Two Surgeons
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00.10.17j
Modifier 66: Surgical Team
00.10.17j
Attachment A (Team Surgery Review Form) to 00.10.17j Modifier 66: Surgical Team
00.10.17j
Attachment B (Eligible Indicators 1 and 2 Procedure Codes) to 00.10.17j Modifier 66: Surgical Team
03.00.02b
Modifier 76: Repeat Procedure or Service by Same Physician or Qualified Health Professional
03.00.11b
Modifier 77: Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional
03.00.12f
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
03.00.28m
Modifier 79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
03.00.20j
Modifiers 26 (Professional Component) and TC (Technical Component)
00.10.18l
Modifiers for Assistant-at-Surgery Services: 80, 81, 82, and AS
03.00.31f
Modifiers for Split or Shared Surgical Services (Modifiers 54, 55, and 56)
03.00.08e
Modifiers XE, XS, XP, XU, and 59
08.01.52b
Mogamulizumab-kpkc (Poteligeo®)
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11.08.23j
Mohs' Micrographic Surgery
11.08.23j
Attachment A (ICD 10 Codes) to 11.08.23j Mohs' Micrographic Surgery
06.02.36c
Molecular Testing for the Management of Pancreatic Cysts or Barrett's Esophagus (Independence Administrators)
08.01.53b
Moxetumomab Pasudotox-tdfk (Lumoxiti™)
06.02.32d
Multigene Expression Assays for Predicting Recurrence in Colon Cancer (Independence Administrators)
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00.01.68
Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services
00.01.68
Attachment A (Multiple Reduction Always Therapy Procedure Codes) to 00.01.68 Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services
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00.01.60d
Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services
00.01.60d
Attachment A (Multiple Reduction Diagnostic Services) to 00.01.60d Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services
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11.00.10w
Multiple Surgery Payment Reduction
11.00.10w
Attachment A1 (Current Procedural Terminology (CPT) Codes To Which Multiple Surgery Payment Reduction Applies) to 11.00.10w Multiple Surgery Payment Reduction
11.00.10w
Attachment A2 (Current Procedural Terminology (CPT) Codes To Which Multiple Surgery Payment Reduction Applies) to 11.00.10w Multiple Surgery Payment Reduction
11.00.10w
Attachment B (Healthcare Common Procedure Coding System (HCPCS) Codes To Which Multiple Surgery Payment Reduction Applies) to 11.00.10w Multiple Surgery Payment Reduction
Hide details for
00.01.66b
Musculoskeletal Services (Independence)
00.01.66b
Attachment A (Procedure Codes for Spinal Surgery) to 00.01.66b Musculoskeletal Services (Independence)
00.01.66b
Attachment B (Procedure Codes for Joint Surgery) to 00.01.66b Musculoskeletal Services (Independence)
00.01.66b
Attachment C (Procedures Codes for Interventional Pain Management) to 00.01.66b Musculoskeletal Services (Independence)
08.00.64g
Natalizumab (Tysabri®)
00.01.56a
National Correct Coding Initiative (NCCI) Code Pair Edits
05.00.15q
Nebulizers and Inhalation Solutions
05.00.38j
Negative-Pressure Wound Therapy (NPWT) Systems
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07.03.18o
Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment A (Recommended Guidelines for Electrodiagnostic Studies) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment B (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment C (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment D (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment E (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment F (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment G (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment H (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment I (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment J (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment K (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
06.02.38d
Nerve Fiber Density Testing
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05.00.73c
Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES)
05.00.73c
Attachment A (ICD 10 Codes) to 05.00.73c Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES)
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07.03.08i
Neuropsychological Testing for Neurologically Based Conditions
07.03.08i
Attachment A (ICD-10 Codes) to 07.03.08i Neuropsychological Testing for Neurologically Based Conditions
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00.01.44h
Never Events and Preventable Adverse Events
00.01.44h
Attachment A (Appendix I Hospital Acquired Conditions (HACS) List ) to 00.01.44h Never Events and Preventable Adverse Events
00.01.44h
Attachment B (Pennsylvania House Bill No. 84 addressing Never Events and Preventable Adverse Events) to 00.01.44h Never Events and Preventable Adverse Events
00.01.44h
Attachment C ( New Jersey Act No. 2471 ) to 00.01.44h Never Events and Preventable Adverse Events
00.01.44h
Attachment D (Never Event or Preventable Adverse Event Reporting Form ) to 00.01.44h Never Events and Preventable Adverse Events
07.08.01f
Non-Surgical Spinal Decompression Therapy
07.10.05m
Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System
07.03.25a
Nonemergent Inpatient Video Electroencephalogram (EEG) Monitoring and Ambulatory EEG Monitoring in the Home
06.02.47d
Noninvasive Prenatal Screening for Fetal Aneuploidies Using Cell-Free Fetal DNA (Independence Administrators)
05.00.30m
Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) Devices and Bi-Level Devices (Independence Administrators)
06.02.56b
Noninvasive Techniques for the Evaluation and Monitoring of Individuals with Chronic Liver Disease
11.15.19e
Nucleoplasty
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08.00.18m
Nutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk
08.00.18m
Attachment A (PA Mandates) to 08.00.18m Nutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk
08.00.18m
Attachment B (NJ Mandates) to 08.00.18m Nutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk
08.00.18m
Attachment C (Caloric Requirements) to 08.00.18m Nutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk
00.01.24h
Obsolete or Unreliable Diagnostic Tests and Medical Services
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00.03.10e
Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
00.03.10e
Attachment A (High Risk Pregnancy) to 00.03.10e Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
00.03.10e
Attachment B (Rule out Ectopic Pregnancy) to 00.03.10e Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
00.03.10e
Attachment C (Rule out intrauterine pathology and Screening for Fetal abnormalities) to 00.03.10e Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
00.03.10e
Attachment D (First-trimester screening and Ovarian Dysfunction) to 00.03.10e Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
08.01.38c
Ocrelizumab (Ocrevus®)
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08.01.10f
Octreotide Acetate (Sandostatin® LAR Depot)
08.01.10f
Attachment A (ICD-10 CODES AND NARRATIVES) to 08.01.10f Octreotide Acetate (Sandostatin® LAR Depot)
08.00.88f
Ofatumumab (Arzerra®)
08.00.15f
Off-label Coverage for Prescription Drugs and/or Biologics
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08.00.55h
Omalizumab (Xolair®)
08.00.55h
Attachment A (Dosing and Frequency Requirements for Omalizumab (Xolair®)) to 08.00.55h Omalizumab (Xolair®)
11.14.08d
Orthognathic Surgery
07.13.01h
Orthoptic/Pleoptic Training
11.14.12e
Osteochondral Allograft Transplantation
11.14.09g
Osteochondral Autograft Transplantation (OAT) Procedure
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05.00.50k
Ostomy Supplies
05.00.50k
Attachment A (HCPCS Codes for Ostomy Supplies) to 05.00.50k Ostomy Supplies
11.01.01j
Otoplasty or Non-Surgical External Ear Molding
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12.05.01i
Outpatient Diabetes Education and Self-Management Training
12.05.01i
Attachment A (ICD-10 CM Codes Eligible to be Reported for Outpatient Diabetes Education and Self-Management Training (E08.00- E10.3491)) to 12.05.01i Outpatient Diabetes Education and Self-Management Training
12.05.01i
Attachment B (ICD-10 CM Codes Eligible to be Reported for Outpatient Diabetes Education and Self-Management Training (E10.3492- E13.37X2), Continued) to 12.05.01i Outpatient Diabetes Education and Self-Management Training
12.05.01i
Attachment C (ICD-10 CM Codes Eligible to be Reported for Outpatient Diabetes Education and Self-Management Training (E13.37X3- P70.2), Continued) to 12.05.01i Outpatient Diabetes Education and Self-Management Training
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00.03.03h
Outpatient Short-Term Rehabilitation Services Included in Capitation
00.03.03h
Attachment A to 00.03.03h Outpatient Short-Term Rehabilitation Services Included in Capitation
11.06.07d
Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome
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08.00.90j
Paclitaxel Protein-bound Particles for Injectable Suspension (Albumin-bound)/(Abraxane® for Injectable Suspension)
08.00.90j
Attachment A (ICD-10 codes) to 08.00.90j Paclitaxel Protein-bound Particles for Injectable Suspension (Albumin-bound)/(Abraxane® for Injectable Suspension)
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11.08.06j
Panniculectomy, Abdominoplasty, and Other Excisions of Redundant Skin
11.08.06j
Attachment A (ICD-10 codes) to 11.08.06j Panniculectomy, Abdominoplasty, and Other Excisions of Redundant Skin
07.10.04c
Parenterally Administered Terbutaline Sulfate for the Prevention or Treatment of Pre-Term Labor
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07.13.08e
Partial Coherence Interferometry
07.13.08e
Attachment A (ICD-10 Codes) to 07.13.08e Partial Coherence Interferometry
05.00.42g
Patient Lifts
08.01.50b
Patisiran (Onpattro™)
10.00.03
Pediatric Intensive Day Feeding Program
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08.01.32c
Pegfilgrastim (Neulasta®) and Related Biosimilars
08.01.32c
Attachment A (EXAMPLES OF DISEASE SETTINGS AND CHEMOTHERAPY REGIMENS WITH A HIGH (>20%) OR INTERMEDIATE (10-20%) RISK FOR FEBRILE NEUTROPENIA) to 08.01.32c Pegfilgrastim (Neulasta®) and Related Biosimilars
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08.01.02e
Pegloticase (Krystexxa®)
08.01.02e
Attachment A (ICD-10 Codes and Narratives) to 08.01.02e Pegloticase (Krystexxa®)
07.12.01e
Pelvic Floor Stimulation as a Treatment of Incontinence
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08.00.87f
Pemetrexed (Alimta®)
08.00.87f
Attachment A (ICD-10 CODES AND NARRATIVES) to 08.00.87f Pemetrexed (Alimta®)
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11.02.27b
Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound (Independence)
11.02.27b
Attachment A (Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound Code List) to 11.02.27b Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound (Independence)
11.15.15g
Percutaneous Discectomy
05.00.75
Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)
11.15.22d
Percutaneous Image-Guided Lumbar Decompression (PILD) for Spinal Stenosis
11.14.14e
Percutaneous Intradiscal Annuloplasty (IDET/PIRFT)
11.02.26b
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
11.02.12i
Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery
11.14.10r
Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
08.00.95d
Personalized Vaccines (e.g. Provenge®)
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08.01.07f
Pertuzumab (Perjeta®)
08.01.07f
Attachment A (ICD-10-CM Codes and Narratives) to 08.01.07f Pertuzumab (Perjeta®)
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06.02.30e
Pharmacogenetic Testing to Determine Drug Sensitivity (Independence Administrators)
06.02.30e
Attachment A (Cytochrome p450 Genotyping for Assessment of Individuals Prior to Initiation of Clopidogrel Bisulfate (Plavix®)) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (Independence Administrators)
06.02.30e
Attachment B (Genetic Testing for Warfarin (Coumadin®) Dose) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (Independence Administrators)
06.02.30e
Attachment C (Genetic Testing for Helicobacter pylori treatment) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (Independence Administrators)
06.02.30e
Attachment D (Genetic Testing for Tamoxifen Treatment ) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (Independence Administrators)
06.02.30e
Attachment E (KRAS and BRAF Mutation Analysis in Metastatic Colorectal Cancer prior to use of cetuximab (Erbitux®) and pantiumumab (Vectibix®)) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (Independence Administrators)
06.02.30e
Attachment F (KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (Independence Administrators)
06.02.30e
Attachment G (KRAS mutation analylsis to predict treatment response to elotinib (Tarceva®) in non-small cell lung cancer (NSCLC)) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (Independence Administrators)
06.02.30e
Attachment H (Epidermal Growth Factor (EGFR) Mutation Analysis for individuals with non-small cell lung cancer) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (Independence Administrators)
06.02.30e
Attachment I (BRAF for melanoma) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (Independence Administrators)
06.02.30e
Attachment J (BCR-ABL Testing for Monitoring of Individuals with Chronic Myelogenous Leukemia or Acute Myelogenous Leukemia, who are Receiving Imatinib Mesylate (Gleevec®) Therapy) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (Independence Administrators)
06.02.18l
Pharmacogenetics and Metabolite Monitoring for Using Azathioprine (AZA)/6-Mercaptopurine (6-MP) Therapy (Independence Administrators)
11.05.08d
Photocoagulation of Macular Drusen
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07.07.03m
Photodynamic Therapy (PDT) Using Levulan® Kerastick® or Ameluz® (Aminolevulinic Acid HCl [ALA])
07.07.03m
Attachment A (ICD-10 Diagnosis Code Number(s) and Narrative(s)) to 07.07.03m Photodynamic Therapy (PDT) Using Levulan® Kerastick® or Ameluz® (Aminolevulinic Acid HCl [ALA])
07.00.10i
Photodynamic Therapy (PDT) Using Porfimer Sodium (Photofrin®)
07.13.05k
Photodynamic Therapy (PDT) Using Verteporfin (Visudyne®)
07.07.05b
Photography, Including Documentation and Record-Keeping Photography, Whole Body Integumentary Photography, Dermoscopy, and Dermatoscopy
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00.03.06f
Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
00.03.06f
Attachment A1 (HAND THERAPY SERVICES) to 00.03.06f Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
00.03.06f
Attachment A2 (HAND THERAPY SERVICES) to 00.03.06f Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
00.03.06f
Attachment B (LYMPHEDEMA THERAPY SERVICES) to 00.03.06f Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
00.03.06f
Attachment C (PELVIC FLOOR THERAPY SERVICES) to 00.03.06f Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
00.03.06f
Attachment D (VESTIBULAR REHABILIATION SERVICES) to 00.03.06f Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
10.03.01l
Physical Medicine, Rehabilitation, and Habilitation Services
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05.00.01m
Pneumatic Compression Therapy Devices
05.00.01m
Attachment A (ICD-10 Codes) to 05.00.01m Pneumatic Compression Therapy Devices
08.01.59b
Polatuzumab Vedotin-Piiq (Polivy™)
09.00.51a
Positron Emission Mammography (PEM)
05.00.54g
Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices
Hide details for
00.01.25ax
PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
00.01.25ax
Attachment A1 (DME Network Rules and Limited Circumstances) to 00.01.25ax PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
00.01.25ax
Attachment A2 (DME Network Rules and Limited Circumstances cont'd.) to 00.01.25ax PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
00.01.25ax
Attachment A3 (DME Network Rules and Limited Circumstances) to 00.01.25ax PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
00.01.25ax
Attachment B1 (Laboratory Network Rules and Limited Circumstances) to 00.01.25ax PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
00.01.25ax
Attachment B2 (Laboratory Network Rules and Limited Circumstances cont'd.) to 00.01.25ax PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
00.01.25ax
Attachment B3 (Laboratory Network Rules and Limited Circumstances cont'd.) to 00.01.25ax PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
00.01.25ax
Attachment C1 (Radiology Network Rules and Limited Circumstances) to 00.01.25ax PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
00.01.25ax
Attachment C2 (Radiology Network Rules and Limited Circumstances cont'd.) to 00.01.25ax PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
00.01.25ax
Attachment D (Physical Medicine & Rehabilitation Network Rules and Limited Circumstances) to 00.01.25ax PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
06.02.24j
Preimplantation Genetic Testing (Independence Administrators)
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07.13.13c
Prescription Lenses and Visual Devices
07.13.13c
Attachment A (Contains the applicable codes for prescription lenses and visual devices for Commercial (non-Medicare Advantage) members) to 07.13.13c Prescription Lenses and Visual Devices
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05.00.60h
Pressure-Reducing Support Surfaces
05.00.60h
Attachment A (ICD-10 Codes) to 05.00.60h Pressure-Reducing Support Surfaces
06.02.44m
Presumptive and Definitive Drug Testing in Substance Abuse and Pain Management Treatments
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00.06.02ac
Preventive Care Services (Independence)
00.06.02ac
Attachment A (Adult Preventive Services) to 00.06.02ac Preventive Care Services (Independence)
00.06.02ac
Attachment B (Female Preventive Care Services) to 00.06.02ac Preventive Care Services (Independence)
00.06.02ac
Attachment C (Pediatric Preventive Care Services) to 00.06.02ac Preventive Care Services (Independence)
02.01.02c
Private Duty Nursing
11.08.29e
Procedures for the Treatment of Acne
11.03.11n
Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD)
Hide details for
08.01.20j
Programmed Death Receptor-1 (PD-1) Antagonists (e.g., Keytruda®, Opdivo®) and Programmed Death-Ligand 1 (PD-L1) Antagonists (e.g., Tecentriq®, Bavencio®, Imfinzi™)
08.01.20j
Attachment A (ICD-10 Codes and Narratives) to 08.01.20j Programmed Death Receptor-1 (PD-1) Antagonists (e.g., Keytruda®, Opdivo®) and Programmed Death-Ligand 1 (PD-L1) Antagonists (e.g., Tecentriq®, Bavencio®, Imfinzi™)
11.08.19o
Prophylactic Mastectomy, Oophorectomy/Salpingo-Oophorectomy, and Hysterectomy
06.02.43b
Proteomic (Protein)-Based Testing for the Evaluation of Ovarian (Adnexal) Masses Using OVA1® Test and Risk of Ovarian Malignancy Algorithm (ROMA™)
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09.00.49l
Proton Beam Radiation Therapy
09.00.49l
Attachment A (ICD-10 Diagnosis Codes) to 09.00.49l Proton Beam Radiation Therapy
10.04.01l
Pulmonary Rehabilitation
05.00.31e
Pulse Oximetry Devices in the Home Setting
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09.00.56j
Radiation Therapy Services (Independence)
09.00.56j
Attachment A (CPT, HCPCS and Revenue Codes) to 09.00.56j Radiation Therapy Services (Independence)
09.00.48g
Radioembolization for Primary and Metastatic Tumors of the Liver (Independence Administrators)
11.00.16g
Radiofrequency Ablation and Cryosurgical Ablation of Lung Tumors
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08.00.08j
Radioimmunotherapy with Ibritumomab Tiuxetan (Zevalin®) (Independence Administrators)
08.00.08j
Attachment A (ICD-10 Codes) to 08.00.08j Radioimmunotherapy with Ibritumomab Tiuxetan (Zevalin®) (Independence Administrators)
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00.10.36q
Radiologic Guidance of a Procedure
00.10.36q
Attachment A (Radiologic Guidance and Supervision and Interpretation Procedure Codes) to 00.10.36q Radiologic Guidance of a Procedure
08.01.14e
Radium Ra 223 dichloride (Xofigo®) Injection (Independence Administrators)
08.01.25d
Ramucirumab (Cyramza®)
11.08.15x
Reconstructive Breast Surgery
11.08.02h
Reduction Mammoplasty
11.05.01f
Refractive Keratoplasty
11.05.10b
Reimbursement for a Presbyopia- or Astigmatism-Correcting Intraocular Lens
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00.01.18d
Reimbursement for Associated Services Performed in Conjunction with Dental Care
00.01.18d
Attachment A (Diagnosis Codes) to 00.01.18d Reimbursement for Associated Services Performed in Conjunction with Dental Care
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00.01.61a
Reimbursement for Components of Comprehensive Laboratory Panels
00.01.61a
Attachment A (CPT Codes) to 00.01.61a Reimbursement for Components of Comprehensive Laboratory Panels
09.00.32u
Reimbursement for Radiopharmaceutical Agents for Professional Providers
07.00.15l
Reimbursement for the Administration of Immunizations
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11.08.14k
Removal of Breast Implants
11.08.14k
Attachment A (ICD-10-CM codes) to 11.08.14k Removal of Breast Implants
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05.00.44k
Repair and Replacement of Durable Medical Equipment (DME)
05.00.44k
Attachment A (HCPCS Codes For Repair and Replacment DME) to 05.00.44k Repair and Replacement of Durable Medical Equipment (DME)
11.03.01e
Repair of Cleft Lip, Cleft Nose, and/or Cleft Palate
05.00.45k
Repair or Replacement of an External Prosthetic Device
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00.01.14r
Reporting and Documentation Requirements for Anesthesia Services
00.01.14r
Attachment A (ASA Anesthesia Procedure Codes) to 00.01.14r Reporting and Documentation Requirements for Anesthesia Services
00.01.49c
Reporting Requirements for Drugs and Biologics
08.01.12b
Repository Corticotropin (H.P. Acthar® Gel Injection)
11.08.13g
Rhytidectomy and/or Cervicoplasty With or Without Liposuction and/or Platysmaplasty
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08.00.50v
Rituximab (Rituxan®) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela®)
08.00.50v
Attachment A (Dosing and Frequency Requirements For Rituximab (Rituxan®) infusion and related biosimilars, and rituximab/hyaluronidase human for subcutaneous injection (Rituxan Hycela®)) to 08.00.50v Rituximab (Rituxan®) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela®)
08.00.50v
Attachment B (ICD-10 CODES AND NARRATIVES) to 08.00.50v Rituximab (Rituxan®) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela®)
07.00.20f
Routine Costs Associated with Qualifying Clinical Trials
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07.07.01o
Routine Foot Care for Certain Medical Conditions
07.07.01o
Attachment A (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (A30.0 -E10.21)) to 07.07.01o Routine Foot Care for Certain Medical Conditions
07.07.01o
Attachment B (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (E10.22 - E13.3512), Continued) to 07.07.01o Routine Foot Care for Certain Medical Conditions
07.07.01o
Attachment C (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (E13.3513 - I87.093), Continued ) to 07.07.01o Routine Foot Care for Certain Medical Conditions
07.07.01o
Attachment D (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (I87.099 - S86.891S), Continued) to 07.07.01o Routine Foot Care for Certain Medical Conditions
07.07.01o
Attachment E (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (S86.892A - Z79.01), Continued) to 07.07.01o Routine Foot Care for Certain Medical Conditions
Hide details for
08.01.60
Sacituzumab govitecan-hziy (TrodelvyTM)
08.01.60
Attachment A ( Diagnosis list ) to 08.01.60 Sacituzumab govitecan-hziy (TrodelvyTM)
11.17.04s
Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence
11.11.06h
Saturation Needle Biopsy of the Prostate
07.13.06k
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
11.08.25m
Scar Revision
09.00.40d
Screening for Vertebral Fracture with Dual-Energy X-ray Absorptiometry (DEXA/DXA)
05.00.43f
Seat Lift Mechanisms
08.01.28d
Sebelipase alfa (Kanuma®)
11.08.04h
Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)
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08.00.78ae
Self-Administered Drugs
08.00.78ae
Attachment A (Prescription drugs that are considered by the Company to be self-administered.) to 08.00.78ae Self-Administered Drugs
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11.07.02j
Sentinel Lymph Node Biopsy and Mapping
11.07.02j
Attachment A (ICD-10 Codes) to 11.07.02j Sentinel Lymph Node Biopsy and Mapping
11.16.01h
Septoplasty, Rhinoplasty, and Septorhinoplasty
06.02.17h
Serodiagnosis of Inflammatory Bowel Disease (IBD) and the Prometheus® IBD sgi Diagnostic™ Test
Hide details for
00.10.01ab
Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
00.10.01ab
Attachment A (Pennsylvania Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers ) to 00.10.01ab Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
00.10.01ab
Attachment B (New Jersey Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers) to 00.10.01ab Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
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05.00.24q
Short-term Interstitial Continuous Glucose Monitoring Systems (CGMSs)
05.00.24q
Attachment A (ICD-10 Diagnosis Codes for Short-term Interstitial Continuous Glucose Monitoring System) to 05.00.24q Short-term Interstitial Continuous Glucose Monitoring Systems (CGMSs)
08.01.19f
Siltuximab (Sylvant®)
07.03.05w
Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies (Independence)
07.11.01c
Smell and Taste Dysfunction Testing
11.00.09f
Solid Organ Transplantation and Procurement Cost of Organs and Tissues
05.00.32j
Speech and Non-Speech Generating Devices
Hide details for
10.06.01l
Speech Therapy
10.06.01l
Attachment A (NJ mandate for biologically-based mental illness (BBMI) regulations in regard to outpatient speech therapy) to 10.06.01l Speech Therapy
11.15.01w
Spinal Cord and Dorsal Root Ganglion Stimulation
11.14.22d
Spinal Decompression with Interspinous and Interlaminar Devices
11.14.29f
Spinal Discectomy
11.14.27d
Spinal Fusion
11.14.28c
Spinal Laminectomy
05.00.71c
Standing Frames
Hide details for
00.01.41b
STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point of Service (POS) Products
00.01.41b
Attachment A to 00.01.41b STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point of Service (POS) Products
07.07.09g
Stem-Cell Therapy for Orthopedic Applications and Autologous Platelet-Derived Growth Factors (PDGFs)/Platelet-Rich Plasmas (PRPs) for Acute or Chronic Wound Healing and Other Miscellaneous Conditions
05.00.77a
Subcutaneous Implantable Cardioverter Defibrillator (S-ICD) for Treating Life-threatening Ventricular Tachyarrhythmia
11.08.12h
Surgery for Gynecomastia
11.17.06n
Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
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11.05.07d
Surgical Correction of Strabismus
11.05.07d
Attachment A (ICD-10 Diagnosis Code Numbers and Narratives) to 11.05.07d Surgical Correction of Strabismus
11.14.23c
Surgical Treatment of Femoroacetabular Impingement
11.14.26a
Surgical Treatments of Athletic Pubalgia
08.01.55c
Tagraxofusp-erzs (Elzonris™)
06.02.51c
Testing Serum Vitamin D Levels
06.02.55
Therapeutic Drug Monitoring for Antidepressants, Antipsychotics, or Antiepileptics
Hide details for
05.00.11i
Therapeutic Shoes and Orthopedic Shoes
05.00.11i
Attachment A (ICD-10 Coding) to 05.00.11i Therapeutic Shoes and Orthopedic Shoes
08.01.36e
Therapies for Spinal Muscular Atrophy Nusinersen (Spinraza®) and Onasemnogene abeparvovec-xioi (Zolgensma®)
08.01.48b
Tildrakizumab-asmn (Ilumya™)
Hide details for
08.00.85i
Tocilizumab (Actemra®) for Intravenous Infusion
08.00.85i
Attachment A (ICD-10 CODES AND NARRATIVES) to 08.00.85i Tocilizumab (Actemra®) for Intravenous Infusion
07.00.09d
Topical Oxygenation
11.02.19f
Total Artificial Hearts (TAHs)
08.00.17h
Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Parenteral Nutrition (IPN)
07.05.06g
Transcatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies
11.02.25g
Transcatheter Cardiac Valve Procedures
11.02.11g
Transcatheter Closure of Cardiac Septal Defects
07.03.22d
Transcranial Magnetic Stimulation (TMS)
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05.00.74d
Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies
05.00.74d
Attachment A (ICD 10 Codes) to 05.00.74d Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies
05.00.78
Transtympanic Micropressure Device as a Treatment of Meniere's Disease
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08.00.33o
Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
08.00.33o
Attachment A (Dosing & Frequency Requirements for Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and hyaluronidase-oysk (Herceptin Hylecta)) to 08.00.33o Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
08.00.33o
Attachment B (ICD-10 CM Codes and Narratives) to 08.00.33o Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
11.09.02h
Treatment of Gender Dysphoria
11.00.02f
Treatment of Medical and Surgical Complications
11.00.06k
Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring
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08.00.25l
Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents
08.00.25l
Attachment A (Dosing and Frequency Requirements) to 08.00.25l Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents
11.00.14f
Treatment of Twin-Twin Transfusion Syndrome (TTTS)
11.02.01s
Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence
08.00.57n
Treatments for Complex Regional Pain Syndrome (CRPS)
08.01.47a
Triamcinolone Acetonide Extended-Release Injectable (Zilretta™)
11.14.02o
Trigger Point Injections
07.03.26a
Tumor Treating Fields
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07.07.02j
Ultraviolet Light Therapy for the Treatment of Dermatological Conditions
07.07.02j
Attachment A (ICD-10-CM codes ) to 07.07.02j Ultraviolet Light Therapy for the Treatment of Dermatological Conditions
Hide details for
05.00.72f
Upper Limb Prostheses
05.00.72f
Attachment A (HCPCS Codes) to 05.00.72f Upper Limb Prostheses
11.00.18a
Use of a Robotic-Assisted Surgical System
08.00.82k
Ustekinumab (Stelara®)
11.06.04k
Uterine Artery Embolization
11.15.16n
Vagus Nerve Stimulation (VNS)
06.02.45
Vectra® DA Blood Test for Rheumatoid Arthritis
Hide details for
08.01.18e
Vedolizumab (Entyvio®)
08.01.18e
Attachment A (ICD-10 CODES AND NARRATIVES) to 08.01.18e Vedolizumab (Entyvio®)
11.02.16r
Ventricular Assist Devices (VADs)
06.02.49b
VeriStrat® Testing for Targeted Therapy in Non-Small Cell Lung Cancer
08.01.44c
Voretigene Neparvovec-rzyl (Luxturna™)
05.00.55i
Wheelchair Cushions and Seating
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05.00.67p
Wheelchair Options and Accessories
05.00.67p
Attachment A (HCPCS Level II Codes For Wheelchair Options And Accessories) to 05.00.67p Wheelchair Options and Accessories
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07.05.02n
Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon
07.05.02n
Attachment A (ICD-10-CM Codes) to 07.05.02n Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon
Hide details for
11.08.20v
Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds
11.08.20v
Attachment A (Skin substitutes and their approved indications.) to 11.08.20v Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds
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00.03.09d
X-rays Associated with Fractures in the Office Setting
00.03.09d
Attachment A (Codes Eligible for Reimbursement by Hand Surgeons, Orthopedic Surgeons, or Sports Medicine Specialists) to 00.03.09d X-rays Associated with Fractures in the Office Setting
00.03.09d
Attachment B (Codes Eligible for Reimbursement by Podiatrists) to 00.03.09d X-rays Associated with Fractures in the Office Setting

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