Commercial

Medical Policy

Name	MPDispTitle	MPPolicyNumber	Policy Category	Title	MPPolicyPageName	ID	MPTitle	MPPolicyNumberwithoutversion	MPNotificationIssuedDate	MPattachmentdataPub	MPEffectiveDate
148f6df1-9bbb-4166-abb3-e5208095332a	ImplantationofIntrastromalCornealRingSegments(ICRS)11.05.11c	11.05.11c	Surgery (11)	Implantation of Intrastromal Corneal Ring Segments (ICRS)	148f6df1-9bbb-4166-abb3-e5208095332a	6608	Implantation of Intrastromal Corneal Ring Segments (ICRS)	11.05.11	9/6/2024 3:00 PM		10/7/2024
f804abbb-59d8-40aa-a484-522b74ccdcde	ArtificialIntervertebralLumbarDiscInsertion11.15.31b	11.15.31b	Surgery (11)	Artificial Intervertebral Lumbar Disc Insertion	f804abbb-59d8-40aa-a484-522b74ccdcde	6640	Artificial Intervertebral Lumbar Disc Insertion	11.15.31	9/20/2024 11:00 AM		10/20/2024
268ff50d-f83d-4de8-9e1b-42ae9304d5ab	ImmuneGlobulinIntravenous(IVIG),Subcutaneous(SCIG)08.00.13aj	08.00.13aj	Pharmacy (08)	Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)	268ff50d-f83d-4de8-9e1b-42ae9304d5ab	6646	Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)	08.00.13	7/16/2024 10:00 AM	{"6647": {"Id":6647,"MPAttachmentLetter":"B","Title":"ICD-10 DIAGNOSIS CODES","MPPolicyAttachmentInternalSourceId":7057,"PolicyAttachmentPageName":"f1dd9fc8-5245-456a-9aae-a81b4e7c3091"},"6648": {"Id":6648,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":7058,"PolicyAttachmentPageName":"c0b52725-2bca-4000-81c0-bc54e49af5f4"},}	10/14/2024
7216424e-dd02-482a-bc66-a47a4c296e25	ProtonBeamRadiationTherapy(IndependenceAdministrators)09.00.49n	09.00.49n	Radiology (09)	Proton Beam Radiation Therapy (Independence Administrators)	7216424e-dd02-482a-bc66-a47a4c296e25	6548	Proton Beam Radiation Therapy (Independence Administrators)	09.00.49	7/30/2024 3:00 PM	{"6549": {"Id":6549,"MPAttachmentLetter":"A","Title":"MEDICALLY NECESSARY ICD10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":8520,"PolicyAttachmentPageName":"7e4b0f11-5998-434a-a248-e349b3b46cfb"},"6550": {"Id":6550,"MPAttachmentLetter":"B","Title":"NOT MEDICALLY NECESSARY ICD10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":8521,"PolicyAttachmentPageName":"fd73ca31-1b3c-4ad4-b646-12ebe5a921b5"},}	10/28/2024
21874fac-26e1-4dad-b976-d7e95613351b	Microprocessor-ControlledProsthesesforLower-ExtremityAmputees11.14.21k	11.14.21k	Surgery (11)	Microprocessor-Controlled Prostheses for Lower-Extremity Amputees	21874fac-26e1-4dad-b976-d7e95613351b	6649	Microprocessor-Controlled Prostheses for Lower-Extremity Amputees	11.14.21	9/27/2024 5:00 PM		10/28/2024

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