|  | | Pegfilgrastim(Neulasta®)andrelatedbiosimilars08.01.32g | 08.01.32g | Pharmacy (08) | Pegfilgrastim (Neulasta®) and related biosimilars | ad72e765-70b2-46fc-a65d-4160b459de88 | 3839 | Pegfilgrastim (Neulasta®) and related biosimilars | 08.01.32 | 11/9/2021 11:00 AM | {"3840": {"Id":3840,"MPAttachmentLetter":"A","Title":"EXAMPLES OF DISEASE SETTINGS AND CHEMOTHERAPY REGIMENS WITH A HIGH (>20%) OR INTERMEDIATE (10-20%) RISK FOR FEBRILE NEUTROPENIA","MPPolicyAttachmentInternalSourceId":5725,"PolicyAttachmentPageName":"a6eab59d-f351-4044-901f-06658faafb6c"},} | 2/7/2022 | | | | ModifiersforAssistant-at-SurgeryServices:80,81,82,andAS00.10.18r | 00.10.18r | Administrative (00) | Modifiers for Assistant-at-Surgery Services: 80, 81, 82, and AS | 85f3b0fc-77f5-4f84-a19c-04db9cba2fcc | 3745 | Modifiers for Assistant-at-Surgery Services: 80, 81, 82, and AS | 00.10.18 | 11/5/2021 2:00 PM | | 2/14/2022 | | | | InfliximabandRelatedBiosimilars08.00.34q | 08.00.34q | Pharmacy (08) | Infliximab and Related Biosimilars | baf8fae0-2c70-43bc-85b9-3caed8246664 | 3988 | Infliximab and Related Biosimilars | 08.00.34 | 1/14/2022 10:00 AM | {"3989": {"Id":3989,"MPAttachmentLetter":"B","Title":"ICD-10-CM Codes and Narratives","MPPolicyAttachmentInternalSourceId":6112,"PolicyAttachmentPageName":"46fd6a28-b3cf-44ad-82cf-9061009eff15"},"3990": {"Id":3990,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements for Infliximab and Related Biosimilars","MPPolicyAttachmentInternalSourceId":6113,"PolicyAttachmentPageName":"82850786-a2d6-4e91-a92d-380f3ed7931b"},} | 2/15/2022 | | | | Electromyography(EMG)Studies:NeedleEMG,SurfaceEMG(SEMG)07.03.09s | 07.03.09s | Medicine (07) | Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG) | f8f6a0ce-087c-4425-a851-754fae5336e5 | 3857 | Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG) | 07.03.09 | 12/20/2021 12:00 PM | {"3858": {"Id":3858,"MPAttachmentLetter":"A","Title":"Recommended Guidelines for Electrodiagnostic Studies","MPPolicyAttachmentInternalSourceId":5970,"PolicyAttachmentPageName":"aa854370-b52c-4e87-97a8-685372ba3cdb"},"3859": {"Id":3859,"MPAttachmentLetter":"D","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5971,"PolicyAttachmentPageName":"112acff1-3121-4d19-a59f-a6f773864a9b"},"3860": {"Id":3860,"MPAttachmentLetter":"F","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5972,"PolicyAttachmentPageName":"e7389844-1cab-4a41-ac14-b8e4545f9f35"},"3861": {"Id":3861,"MPAttachmentLetter":"B","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5973,"PolicyAttachmentPageName":"27c85dd3-ce1f-4a03-b845-569ee604353d"},"3862": {"Id":3862,"MPAttachmentLetter":"G","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5974,"PolicyAttachmentPageName":"e8d48a98-d055-403b-b6fe-f20e639301e3"},"3863": {"Id":3863,"MPAttachmentLetter":"C","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5975,"PolicyAttachmentPageName":"2f1e6486-4094-4f62-84e8-bfcb088c96d2"},"3864": {"Id":3864,"MPAttachmentLetter":"K","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5976,"PolicyAttachmentPageName":"3d74a3c8-2c52-422d-9f07-abd3d140f080"},"3865": {"Id":3865,"MPAttachmentLetter":"I","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5977,"PolicyAttachmentPageName":"a5e54d8e-eb55-4f45-88f2-e8d2a557d805"},"3866": {"Id":3866,"MPAttachmentLetter":"E","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5978,"PolicyAttachmentPageName":"8c6b1ba8-6dce-4abb-ac20-f75244a211c8"},"3867": {"Id":3867,"MPAttachmentLetter":"J","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5979,"PolicyAttachmentPageName":"b5b97d86-425d-4f9f-9474-ebf9e5cd0b92"},"3868": {"Id":3868,"MPAttachmentLetter":"H","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5980,"PolicyAttachmentPageName":"3c716980-ab5b-44e4-bd23-890f66b171bc"},} | 3/21/2022 | | | | NerveConductionStudies(NCS)andRelatedElectrodiagnosticStudies07.03.18r | 07.03.18r | Medicine (07) | Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies | 1c1f7a5f-3dfa-4f7c-a7c5-3ac09e9faae4 | 3869 | Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies | 07.03.18 | 12/20/2021 12:00 PM | {"3870": {"Id":3870,"MPAttachmentLetter":"A","Title":"Recommended Guidelines for Electrodiagnostic Studies","MPPolicyAttachmentInternalSourceId":5992,"PolicyAttachmentPageName":"c37d72b4-40ea-4ef0-8b6c-b6ad537a90d4"},"3871": {"Id":3871,"MPAttachmentLetter":"F","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5993,"PolicyAttachmentPageName":"44c8b4ac-dce6-4468-bafe-5b71875a8860"},"3872": {"Id":3872,"MPAttachmentLetter":"C","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5994,"PolicyAttachmentPageName":"f2dd47b8-e2c9-48d1-b59c-3c8760788cd2"},"3873": {"Id":3873,"MPAttachmentLetter":"D","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5995,"PolicyAttachmentPageName":"209b6952-b9bb-485f-b2a1-ec4bf1e7cba0"},"3874": {"Id":3874,"MPAttachmentLetter":"E","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5996,"PolicyAttachmentPageName":"458f1874-517a-48a2-8c4e-a37f0e3f92e4"},"3875": {"Id":3875,"MPAttachmentLetter":"B","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5997,"PolicyAttachmentPageName":"5d534d1b-869e-4b73-9d7e-75e6aa5070e6"},"3876": {"Id":3876,"MPAttachmentLetter":"K","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5998,"PolicyAttachmentPageName":"dd576c53-c9bc-4b64-a727-6ca50b7c05df"},"3877": {"Id":3877,"MPAttachmentLetter":"J","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5999,"PolicyAttachmentPageName":"2bfcbd0c-9363-45f2-ba90-72f72de06116"},"3878": {"Id":3878,"MPAttachmentLetter":"I","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":6000,"PolicyAttachmentPageName":"5092dc07-7e00-4cf2-a6a5-dc19dfa91643"},"3879": {"Id":3879,"MPAttachmentLetter":"H","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":6001,"PolicyAttachmentPageName":"ab013d66-308d-487f-b1e2-021e15abb979"},"3880": {"Id":3880,"MPAttachmentLetter":"G","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":6002,"PolicyAttachmentPageName":"5a668dcd-c2c9-4d7a-9106-ed1ce4ec5f4c"},} | 3/21/2022 | | | | Pertuzumab,Trastuzumab,andHyaluronidase-zzxf(Phesgo®)08.01.72a | 08.01.72a | Pharmacy (08) | Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo®) | aeeb63b5-3df0-48f6-88b1-34200c4ebdc8 | 3887 | Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo®) | 08.01.72 | 12/21/2021 7:00 AM | | 3/21/2022 | | | | pegfilgrastim(Neulasta®)andrelatedbiosimilars08.01.32h | 08.01.32h | Pharmacy (08) | pegfilgrastim (Neulasta®) and related biosimilars | 5f331758-7796-43ae-a766-3d54fe77664a | 3897 | pegfilgrastim (Neulasta®) and related biosimilars | 08.01.32 | 12/31/2021 9:00 AM | {"3898": {"Id":3898,"MPAttachmentLetter":"A","Title":"EXAMPLES OF DISEASE SETTINGS AND CHEMOTHERAPY REGIMENS WITH A HIGH (>20%) OR INTERMEDIATE (10-20%) RISK FOR FEBRILE NEUTROPENIA","MPPolicyAttachmentInternalSourceId":6058,"PolicyAttachmentPageName":"9151992b-8300-4f11-a49e-444181230040"},} | 4/1/2022 | | | | Rituximab(Rituxan®)InfusionandRelatedBiosimilars,andRituximab/HyaluronidaseHumanforSubcutaneousInjection(RituxanHycela®)08.00.50z | 08.00.50z | Pharmacy (08) | Rituximab (Rituxan®) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela®) | 07dd187e-4940-4468-a4e4-c23707a35f67 | 3899 | Rituximab (Rituxan®) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela®) | 08.00.50 | 12/31/2021 9:00 AM | {"3900": {"Id":3900,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements For Rituximab (Rituxan®) infusion and related biosimilars, and rituximab/hyaluronidase human for subcutaneous injection (Rituxan Hycela®)","MPPolicyAttachmentInternalSourceId":6060,"PolicyAttachmentPageName":"3ce263eb-7f76-4457-8e5a-df47d9fff133"},"3901": {"Id":3901,"MPAttachmentLetter":"B","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":6061,"PolicyAttachmentPageName":"b6443242-52e8-4c8b-b76e-87c393f173a1"},} | 4/1/2022 | | | | IntravenousKetamine(Ketalar®)andIntranasalEsketamine(Spravato®)08.01.80 | 08.01.80 | Pharmacy (08) | Intravenous Ketamine (Ketalar®) and Intranasal Esketamine (Spravato®) | 30aa5c8c-3774-4f2f-81c6-7b02c2d236e4 | 3971 | Intravenous Ketamine (Ketalar®) and Intranasal Esketamine (Spravato®) | 08.01.80 | 1/4/2022 2:00 PM | | 4/4/2022 |
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