Commercial

Medical Policy

Name	MPDispTitle	MPPolicyNumber	Policy Category	Title	MPPolicyPageName	ID	MPTitle	MPPolicyNumberwithoutversion	MPNotificationIssuedDate	MPattachmentdataPub	MPEffectiveDate
cbbd8ae6-e131-4fe3-9e84-de1f8f219fbe	MedicalandSurgicalTreatmentofTemporomandibularJointDisorder07.08.03h	07.08.03h	Medicine (07)	Medical and Surgical Treatment of Temporomandibular Joint Disorder	cbbd8ae6-e131-4fe3-9e84-de1f8f219fbe	4519	Medical and Surgical Treatment of Temporomandibular Joint Disorder	07.08.03	9/9/2022 10:00 AM		10/10/2022
68152a97-778e-4552-94c8-4ca1732e6cfe	Eculizumab(Soliris®)andRelatedBiosimilars,Ravulizumab-cwvz(Ultomiris®)08.00.84i	08.00.84i	Pharmacy (08)	Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris®)	68152a97-778e-4552-94c8-4ca1732e6cfe	4528	Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris®)	08.00.84	9/19/2022 1:00 PM		10/17/2022
72b2ebd5-59d3-45c2-9c2a-a70a677b83ad	PneumaticCompressionTherapyDevices05.00.01n	05.00.01n	DME (05)	Pneumatic Compression Therapy Devices	72b2ebd5-59d3-45c2-9c2a-a70a677b83ad	4535	Pneumatic Compression Therapy Devices	05.00.01	9/23/2022 9:00 AM	{"4536": {"Id":4536,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":6546,"PolicyAttachmentPageName":"2338a55d-2484-46ce-b498-e9548c7c1308"},}	10/24/2022
74afbcd9-65f3-4d96-bd95-8995043065c0	ChimericAntigenReceptor(CAR)Therapy08.01.43k	08.01.43k	Pharmacy (08)	Chimeric Antigen Receptor (CAR) Therapy	74afbcd9-65f3-4d96-bd95-8995043065c0	4540	Chimeric Antigen Receptor (CAR) Therapy	08.01.43	9/28/2022 9:00 AM	{"4541": {"Id":4541,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":6560,"PolicyAttachmentPageName":"940358e1-043e-4889-b782-fe9a11c0ad48"},}	10/31/2022
11ab190d-19c9-4029-a919-4a64585eb231	Aprepitant(Cinvanti™),FosaprepitantDimeglumine(Emend®),Granisetron(Sustol®),andRolapitant(Varubi®)08.01.41d	08.01.41d	Pharmacy (08)	Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)	11ab190d-19c9-4029-a919-4a64585eb231	4510	Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)	08.01.41	8/30/2022 10:00 AM	{"4511": {"Id":4511,"MPAttachmentLetter":"A","Title":"Risk of Emesis Without Prophylaxis: Intravenous and Oral Antineoplastic Agents","MPPolicyAttachmentInternalSourceId":6528,"PolicyAttachmentPageName":"8aefe153-4e1e-42cc-af69-a7fb2e5bb80b"},}	11/29/2022
7d28d8ee-4fcf-48ac-aaee-cfd8b31c3bfb	ChemicalPeels11.08.08h	11.08.08h	Surgery (11)	Chemical Peels	7d28d8ee-4fcf-48ac-aaee-cfd8b31c3bfb	4537	Chemical Peels	11.08.08	9/26/2022 2:00 PM		12/26/2022

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