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8f81b56b-8bfd-41e9-bdc9-ff93f72b87e5.aspx
  
eviCoreLabManagement(Independence)06.02.52y06.02.52yPathology and Laboratory (06)eviCore Lab Management (Independence)8f81b56b-8bfd-41e9-bdc9-ff93f72b87e54247eviCore Lab Management (Independence)06.02.526/1/2022 3:00 PM
{"4248": {"Id":4248,"MPAttachmentLetter":"B","Title":"Procedure Codes Requiring Prepayment Reviews","MPPolicyAttachmentInternalSourceId":6402,"PolicyAttachmentPageName":"ea309f96-d7ab-469b-b8f0-3c71e320e073"},"4249": {"Id":4249,"MPAttachmentLetter":"A","Title":"Procedure Codes Requiring Pre-service and Prepayment Reviews","MPPolicyAttachmentInternalSourceId":6403,"PolicyAttachmentPageName":"6253cf0f-3d55-418c-bccc-0da2ee6b8008"},}
7/1/2022
b7f456c6-6b96-4ed3-b4bc-033cdb28bee3.aspx
  
ProtonBeamRadiationTherapy09.00.49m09.00.49mRadiology (09)Proton Beam Radiation Therapyb7f456c6-6b96-4ed3-b4bc-033cdb28bee34327Proton Beam Radiation Therapy09.00.494/6/2022 10:00 AM
{"4328": {"Id":4328,"MPAttachmentLetter":"A","Title":"MEDICALLY NECESSARY ICD10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":6031,"PolicyAttachmentPageName":"1bd7a499-aa69-49d2-94c1-6b132afad338"},"4329": {"Id":4329,"MPAttachmentLetter":"B","Title":"NOT MEDICALLY NECESSARY ICD10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":6185,"PolicyAttachmentPageName":"38383021-3cac-473b-93b0-9888f2c7b082"},}
7/5/2022
ddbe5a52-031e-4ba7-bbb4-78f2b68fec8a.aspx
  
SelectivePhotothermolysisUsingPulsed-DyeLasers(PDL)11.08.04i11.08.04iSurgery (11)Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)ddbe5a52-031e-4ba7-bbb4-78f2b68fec8a4129Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)11.08.044/11/2022 10:00 AM
7/11/2022
2b6ece16-5f53-41de-84a9-f1260b9eb7ec.aspx
  
Stem-CellTherapy/Platelet-RichPlasmaforOrthopedicApplicationsand​Platelet-RichPlasma/Platelet-DerivedGrowthFactorforWoundHealingandOtherMiscellaneousNon-OrthopedicConditions07.07.09i07.07.09iMedicine (07)Stem-Cell Therapy/Platelet-Rich Plasma for Orthopedic Applications and ​Platelet-Rich Plasma/Platelet-Derived Growth Factor for Wound Healing and Other Miscellaneous Non-Orthopedic Conditions2b6ece16-5f53-41de-84a9-f1260b9eb7ec4131Stem-Cell Therapy/Platelet-Rich Plasma for Orthopedic Applications and ​Platelet-Rich Plasma/Platelet-Derived Growth Factor for Wound Healing and Other Miscellaneous Non-Orthopedic Conditions07.07.094/11/2022 12:00 PM
7/11/2022
c672e355-24d8-4c62-8af7-b16d9c58d3e2.aspx
  
WheelchairOptionsandAccessories05.00.67r05.00.67rDME (05)Wheelchair Options and Accessoriesc672e355-24d8-4c62-8af7-b16d9c58d3e24271Wheelchair Options and Accessories05.00.676/14/2022 9:00 AM
{"4272": {"Id":4272,"MPAttachmentLetter":"A","Title":"HCPCS Level II Codes For Wheelchair Options And Accessories","MPPolicyAttachmentInternalSourceId":6252,"PolicyAttachmentPageName":"02f5b747-781a-4dcb-a8d9-70bfb09c8616"},}
7/18/2022
157ba495-7eaf-4a85-9ea5-a099149e5b51.aspx
  
WheelchairOptionsandAccessories05.00.67r05.00.67rDME (05)Wheelchair Options and Accessories157ba495-7eaf-4a85-9ea5-a099149e5b514273Wheelchair Options and Accessories05.00.676/14/2022 12:00 PM
{"4274": {"Id":4274,"MPAttachmentLetter":"A","Title":"HCPCS Level II Codes For Wheelchair Options And Accessories","MPPolicyAttachmentInternalSourceId":6252,"PolicyAttachmentPageName":"f4ce3eab-b5a5-4f0f-b23d-7c2968bc664f"},}
7/18/2022
047f1a32-bacc-4506-8496-7ece45bb6911.aspx
  
PowerWheelchairs(PWCs),Power-OperatedVehicles(POVs),andPush-Rim-ActivatedPower-AssistDevices05.00.54i05.00.54iDME (05)Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim-Activated Power-Assist Devices047f1a32-bacc-4506-8496-7ece45bb69114303Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim-Activated Power-Assist Devices05.00.546/17/2022 10:00 AM
7/18/2022
1bacff46-edeb-4337-8a48-c111893afc26.aspx
  
AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucoma11.05.16k11.05.16kSurgery (11)Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma1bacff46-edeb-4337-8a48-c111893afc264319Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma11.05.166/20/2022 12:00 PM
{"4320": {"Id":4320,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":6349,"PolicyAttachmentPageName":"f009f5c5-51b1-4766-be30-06d476f98ea0"},}
9/19/2022
c53caf21-625e-421f-bca8-41cf258425ee.aspx
  
CornealPachymetryUsingUltrasound07.13.07l07.13.07lMedicine (07)Corneal Pachymetry Using Ultrasoundc53caf21-625e-421f-bca8-41cf258425ee4321Corneal Pachymetry Using Ultrasound07.13.076/20/2022 12:00 PM
{"4322": {"Id":4322,"MPAttachmentLetter":"A","Title":"ICD-10-CM codes","MPPolicyAttachmentInternalSourceId":6351,"PolicyAttachmentPageName":"0ebc36ca-6a69-4baa-98bd-dac5e5555384"},}
9/19/2022
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