Commercial
  
  
  
  
  
  
  
  
  
  
MPattachmentdataPub
c81a12e0-fec5-45c0-af8f-18ad49d2e379.aspx
  
08.00.62kAbatacept(Orencia®)forInjectionforIntravenousUse08.00.62kPharmacy (08)Abatacept (Orencia®) for Injection for Intravenous Usec81a12e0-fec5-45c0-af8f-18ad49d2e3792509Abatacept (Orencia®) for Injection for Intravenous Use08.00.62
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12.00.01fAcupuncture (Independence)Miscellaneous (12)Acupuncture (Independence)85256AA800623D7A8525850D004EBDA51773Acupuncture (Independence)12.00.01
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85256AA800623D7A85258596007CD987.aspx
  
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85256AA800623D7A852585420071736C.aspx
  
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08.00.72hAlglucosidase alfa (e.g., Lumizyme®)Pharmacy (08)Alglucosidase alfa (e.g., Lumizyme®)85256AA800623D7A8525854200710D182032Alglucosidase alfa (e.g., Lumizyme®)08.00.72
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07.00.21iAllergy ImmunotherapyMedicine (07)Allergy Immunotherapy85256AA800623D7A852584E900723F3A1980Allergy Immunotherapy07.00.21
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00.01.52jAlwaysBundledProcedureCodes00.01.52jAdministrative (00)Always Bundled Procedure Codes060363dc-3ab0-430f-b750-5b8e7a077c8d2567Always Bundled Procedure Codes00.01.52
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{"2219": {"Id":2219,"MPAttachmentLetter":"A","Title":"HCPCS Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525847900595D63"},}
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06.03.04nApheresis TherapyPathology and Laboratory (06)Apheresis Therapy85256AA800623D7A852581E800531E7B1795Apheresis Therapy06.03.04
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08.01.41cAprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)Pharmacy (08)Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)85256AA800623D7A8525853E004B8BDF2033Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)08.01.41
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f830ae35-762b-444b-8664-f5d039173ade.aspx
  
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A3A0632A8125CAEF85258588005C3C90.aspx
  
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08.01.35bAsparaginase Erwinia Chrysanthemi (Erwinaze®)Pharmacy (08)Asparaginase Erwinia Chrysanthemi (Erwinaze®)85256AA800623D7A8525848D004D16801929Asparaginase Erwinia Chrysanthemi (Erwinaze®)08.01.35
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06.02.27lAssays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (Independence Administrators)Pathology and Laboratory (06)Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (Independence Administrators)85256AA800623D7A852585A4006524161786Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (Independence Administrators)06.02.27
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07.10.06hAssistedReproductiveTechnologyforInfertilityandOocyteCryopreservation07.10.06hMedicine (07)Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation0b226d39-c2e8-4ebc-88e7-fc1f0d6537062582Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation07.10.06
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{"2470": {"Id":2470,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":4723,"PolicyAttachmentPageName":"ff1a9148-d750-4345-aece-2735ddef2f1b"},}
85256AA800623D7A8525849B004313B6.aspx
  
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07.03.23cAutonomic Nervous System TestingMedicine (07)Autonomic Nervous System Testing85256AA800623D7A85258535005F42621751Autonomic Nervous System Testing07.03.23
7e0e42f8-cf2c-4eb6-a9d8-4b172c1df27a.aspx
  
08.01.64Avelumab(Bavencio®)08.01.64Pharmacy (08)Avelumab (Bavencio®)7e0e42f8-cf2c-4eb6-a9d8-4b172c1df27a2451Avelumab (Bavencio®)08.01.64
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11.03.02sBariatric SurgerySurgery (11)Bariatric Surgery85256AA800623D7A852584E0005DE5421972Bariatric Surgery11.03.02
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08.01.70Belantamabmafodotin-blmf(Blenrep)08.01.70Pharmacy (08)Belantamab mafodotin-blmf (Blenrep)18cb9a65-0274-49ff-8d52-ce2e50e5137d2589Belantamab mafodotin-blmf (Blenrep)08.01.70
85256AA800623D7A852584EB005DFB48.aspx
  
08.00.99cBelimumab (Benlysta®) for Intravenous UsePharmacy (08)Belimumab (Benlysta®) for Intravenous Use85256AA800623D7A852584EB005DFB481724Belimumab (Benlysta®) for Intravenous Use08.00.99
6566BD92D37238AE8525856900675D9F.aspx
  
08.00.66nBevacizumab (Avastin®) and Related Biosimilars For Oncologic UsePharmacy (08)Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use6566BD92D37238AE8525856900675D9F2057Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use08.00.66
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00.10.38aBilling Requirements for Multiple Births for Professional ProvidersAdministrative (00)Billing Requirements for Multiple Births for Professional Providers85256AA800623D7A852584B1006668032156Billing Requirements for Multiple Births for Professional Providers00.10.38
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00.10.39mBillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampus00.10.39mAdministrative (00)Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campuse8885830-5459-4bdb-98c8-17101e36961f2597Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus00.10.39
{"2598": {"Id":2598,"MPAttachmentLetter":"A","Title":"Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus","MPPolicyAttachmentInternalSourceId":4894,"PolicyAttachmentPageName":"a9902f96-9b03-4f9d-a232-2bc8f5d59ad1"},}
81ada7d5-27d5-4c0f-bc59-c401eefc836f.aspx
  
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11.05.02iBlepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/CanthopexySurgery (11)Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy85256AA800623D7A85258336004611B01801Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy11.05.02
{"2194": {"Id":2194,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258336004611BB"},}
85256AA800623D7A85258401004A12A1.aspx
  
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08.00.73lBortezomib (Bortezomib for Injection, Velcade®)Pharmacy (08)Bortezomib (Bortezomib for Injection, Velcade®)85256AA800623D7A8525838400606BF91816Bortezomib (Bortezomib for Injection, Velcade®)08.00.73
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08.00.26wBotulinum Toxin AgentsPharmacy (08)Botulinum Toxin Agents85256AA800623D7A8525853E005046D31727Botulinum Toxin Agents08.00.26
{"2340": {"Id":2340,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525853E005046F5"},}
85256AA800623D7A852583B60065D953.aspx
  
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05.00.76cBreast PumpsDME (05)Breast Pumps85256AA800623D7A852584C80074166B1947Breast Pumps05.00.76
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08.01.13dBrentuximab Vedotin (Adcetris®)Pharmacy (08)Brentuximab Vedotin (Adcetris®)85256AA800623D7A8525848D004D10081945Brentuximab Vedotin (Adcetris®)08.01.13
{"2285": {"Id":2285,"MPAttachmentLetter":"A","Title":"ICD CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525848D004D1011"},}
85256AA800623D7A852585A4005899AC.aspx
  
11.16.07bBronchial ThermoplastySurgery (11)Bronchial Thermoplasty85256AA800623D7A852585A4005899AC1791Bronchial Thermoplasty11.16.07
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08.01.51Canakinumab (Ilaris®)Pharmacy (08)Canakinumab (Ilaris®)85256AA800623D7A852585660071B05C2065Canakinumab (Ilaris®)08.01.51
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{"2221": {"Id":2221,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525847E006A6597"},}
85256AA800623D7A8525847F0061D443.aspx
  
00.01.59fCare Management and Care Planning ServicesAdministrative (00)Care Management and Care Planning Services85256AA800623D7A8525847F0061D4432161Care Management and Care Planning Services00.01.59
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08.01.05gCarfilzomib(Kyprolis®)08.01.05gPharmacy (08)Carfilzomib (Kyprolis®)26a9c1aa-7bed-41e2-a468-178e8e009f8c2645Carfilzomib (Kyprolis®)08.01.05
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00.10.15cCast and Splint Applications and Associated Supplies Provided in the Office SettingAdministrative (00)Cast and Splint Applications and Associated Supplies Provided in the Office Setting82EF268AB3C7CA1E852581E9005653DB2119Cast and Splint Applications and Associated Supplies Provided in the Office Setting00.10.15
{"2184": {"Id":2184,"MPAttachmentLetter":"A","Title":"No Title","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"4D63E2E2E70A4FA4852581E9005653EC"},}
85256AA800623D7A85258574006D0BB6.aspx
  
11.01.07eCataract SurgerySurgery (11)Cataract Surgery85256AA800623D7A85258574006D0BB61721Cataract Surgery11.01.07
{"2336": {"Id":2336,"MPAttachmentLetter":"A","Title":"ICD 10 codes for policy 11.01.07d, Cataract Surgery","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258574006D0BFE"},}
5bc8fc6f-5bd5-4370-ab9e-ce20a42e10fe.aspx
  
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10.00.02cDay RehabilitationRehabilitation Services (10)Day Rehabilitation85256AA800623D7A85258585004BD8851748Day Rehabilitation10.00.02
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85256AA800623D7A8525842B006B6CC3.aspx
  
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11.15.09nDenervation of the Spinal Nerves for Chronic PainSurgery (11)Denervation of the Spinal Nerves for Chronic Pain6E54370B49975A5A85258588005CDCC01737Denervation of the Spinal Nerves for Chronic Pain11.15.09
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00.03.02aaDiagnostic Radiology Services Included in CapitationAdministrative (00)Diagnostic Radiology Services Included in Capitation85256AA800623D7A85258513005AF2AB2170Diagnostic Radiology Services Included in Capitation00.03.02
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05.00.48jDurable Medical Equipment (DME) Not Subject to a Rental to Purchase MaximumDME (05)Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum85256AA800623D7A85258360004DAB8C2128Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum05.00.48
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