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07.00.14h​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Low-LevelLaserTherapy07.00.14hMedicine (07)​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Low-Level Laser Therapye0af15c1-d79a-4644-a497-85dee052f6235919​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Low-Level Laser Therapy07.00.14
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08.00.62pAbatacept(Orencia®)forInjectionforIntravenousUse08.00.62pPharmacy (08)Abatacept (Orencia®) for Injection for Intravenous Useb54e7ec4-dc44-418c-8fd0-1e1c2ad712f55543Abatacept (Orencia®) for Injection for Intravenous Use08.00.62
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12.00.01hAcupuncture12.00.01hMiscellaneous (12)Acupuncture06ffc3eb-f745-408c-ae63-cf0ba3ecbbdc6059Acupuncture12.00.01
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12.04.04bAcuteCareFacilityInpatientTransfers12.04.04bMiscellaneous (12)Acute Care Facility Inpatient Transfersad65734f-8c9d-4c0a-b362-9b3677e62f356190Acute Care Facility Inpatient Transfers12.04.04
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08.02.21ADAMTS13,recombinant-krhn(Adzynma)08.02.21Pharmacy (08)ADAMTS13, recombinant-krhn (Adzynma)d5e67f8a-f5e2-4997-8424-41e3b326d8b76515ADAMTS13, recombinant-krhn (Adzynma)08.02.21
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08.01.11iAdo-TrastuzumabEmtansine(Kadcyla®)08.01.11iPharmacy (08)Ado-Trastuzumab Emtansine (Kadcyla®)b2f741cb-d1fd-49a3-91e0-bf9f2d147f8d6105Ado-Trastuzumab Emtansine (Kadcyla®)08.01.11
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08.00.69cAgalsidasebeta(Fabrazyme®)08.00.69cPharmacy (08)Agalsidase beta (Fabrazyme®)62f7ab0b-f175-47c9-a8c3-1b9de01b65215088Agalsidase beta (Fabrazyme®)08.00.69
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12.04.03cAirAmbulanceServices12.04.03cMiscellaneous (12)Air Ambulance Services245ffd2b-6443-450c-854f-d6716f6c1f0c6418Air Ambulance Services12.04.03
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08.01.22dAlemtuzumab(Lemtrada®)08.01.22dPharmacy (08)Alemtuzumab (Lemtrada®)8ff701a8-0577-4eaa-be05-2bb2131430a66215Alemtuzumab (Lemtrada®)08.01.22
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08.00.72lAlglucosidasealfa(e.g.,Lumizyme®),Avalglucosidasealfa-ngpt(Nexviazyme®),Cipaglucosidasealfa-atga(Pombiliti™)08.00.72lPharmacy (08)Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® ), Cipaglucosidase alfa-atga (Pombiliti™ )acd08093-ff2e-4a25-bd88-d5bba19568616240Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® ), Cipaglucosidase alfa-atga (Pombiliti™ )08.00.72
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07.00.21jAllergyImmunotherapy07.00.21jMedicine (07)Allergy Immunotherapyf9143396-59dc-41c7-b0bd-3276abbd228c6262Allergy Immunotherapy07.00.21
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08.01.88AllogeneicProcessedThymusTissue-agdc(Rethymic®)08.01.88Pharmacy (08)Allogeneic Processed Thymus Tissue-agdc (Rethymic®)aacfb39b-5245-40ea-9144-83238a559ae36077Allogeneic Processed Thymus Tissue-agdc (Rethymic®)08.01.88
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06.02.29dAlloMap™MolecularExpressionTestingforHeartTransplantRejection(IndependenceAdministrators)06.02.29dPathology and Laboratory (06)AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators)5e8e88d4-c3f6-49aa-a4b4-8048806aaad26056AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators)06.02.29
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08.00.91eAlpha1-AntitrypsinTherapy(e.g.,Prolastin-C®,AralastNP®,Glassia®,Zemaira®)08.00.91ePharmacy (08)Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)d32eec72-479b-43a6-bdf3-cfe24dfa12b26266Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)08.00.91
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00.01.52vAlwaysBundledProcedureCodes00.01.52vAdministrative (00)Always Bundled Procedure Codesa87e8fab-e387-4910-a92c-f1b7616b55e56479Always Bundled Procedure Codes00.01.52
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07.02.09iAmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)Devices07.02.09iMedicine (07)Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices776d7278-6f90-453d-a8df-7cfdc81170446081Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices07.02.09
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07.02.21pAmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)Monitoring07.02.21pMedicine (07)Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoringde404cf7-22c0-4e3a-8f36-1c2c91d657456115Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring07.02.21
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08.01.90aAmivantamab-vmjw(Rybrevant®)08.01.90aPharmacy (08)Amivantamab-vmjw (Rybrevant®)22e3725e-1aab-4c4e-a86b-bd4cb90f60b26324Amivantamab-vmjw (Rybrevant®)08.01.90
5056252d-13e0-47ed-a32c-c0acd89b27c7.aspx
  
01.00.12bAnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagement01.00.12bAnesthesia (01)Anesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management5056252d-13e0-47ed-a32c-c0acd89b27c76370Anesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management01.00.12
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08.01.82cAnifrolumab-fnia(Saphnelo®)08.01.82cPharmacy (08)Anifrolumab-fnia (Saphnelo®)d76f0864-8820-4305-aef9-042ca7cef74f6388Anifrolumab-fnia (Saphnelo®)08.01.82
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05.00.39uAnkle-Foot/Knee-Ankle-FootOrthoses05.00.39uDME (05)Ankle-Foot/Knee-Ankle-Foot Orthosesfe722ca4-78d7-45f4-b87b-93327b0f1be16161Ankle-Foot/Knee-Ankle-Foot Orthoses05.00.39
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06.03.04nApheresisTherapy06.03.04nPathology and Laboratory (06)Apheresis Therapyfecd240a-368a-41a9-b5bd-3a444f0cf66d5811Apheresis Therapy06.03.04
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05.00.84Apos®biomechanicalshoesystem05.00.84DME (05)Apos® biomechanical shoe systemfa430b3c-36f7-432f-93c9-91524119145b5871Apos® biomechanical shoe system05.00.84
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11.08.05gApplicationandRemovalofTattoos11.08.05gSurgery (11)Application and Removal of Tattoos585fcd79-7a3a-47af-8791-80a5d1d213176047Application and Removal of Tattoos11.08.05
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14.00.03aAppliedBehaviorAnalysis(ABA)fortheTreatmentofAutismSpectrumDisorders(ASD)14.00.03aBehavioral Health (14)Applied Behavior Analysis (ABA) for the Treatment of Autism Spectrum Disorders (ASD)b0b7c940-7b0f-4b12-a290-55c6ca1442a25898Applied Behavior Analysis (ABA) for the Treatment of Autism Spectrum Disorders (ASD)14.00.03
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11.05.16lAqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucoma11.05.16lSurgery (11)Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma313650d2-3c00-43a3-ad1b-36d6fd45655e6331Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma11.05.16
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11.14.19pArtificialIntervertebralCervicalDiscInsertion(IndependenceAdministrators)11.14.19pSurgery (11)Artificial Intervertebral Cervical Disc Insertion (Independence Administrators)ec54656d-1d31-41b0-b458-e1a4358b0ed75233Artificial Intervertebral Cervical Disc Insertion (Independence Administrators)11.14.19
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11.15.31bArtificialIntervertebralLumbarDiscInsertion11.15.31bSurgery (11)Artificial Intervertebral Lumbar Disc Insertion5e7b1367-fc83-4e3e-b80b-d19ed56c3b375719Artificial Intervertebral Lumbar Disc Insertion11.15.31
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08.01.35gAsparaginaseErwiniaChrysanthemi(Erwinaze®),asparaginaseerwiniachrysanthemi(recombinant)-rywn(Rylaze®)08.01.35gPharmacy (08)Asparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze®)5caa8913-7c03-4a9a-a9df-9b90a880523a5371Asparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze®)08.01.35
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06.02.27nAssaysofGeneticExpressioninTumorTissueforBreastCancerPrognosis(IndependenceAdministrators)06.02.27nPathology and Laboratory (06)Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (Independence Administrators)07b6094a-2341-4bed-a1b8-841e3fe33dcc5474Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (Independence Administrators)06.02.27
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07.10.06jAssistedReproductiveTechnologyforInfertilityandOocyteCryopreservation07.10.06jMedicine (07)Assisted Reproductive Technology for Infertility and Oocyte Cryopreservationb753c112-cb1c-4a31-a437-b39ee728998e6522Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation07.10.06
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08.01.69cAtezolizumab(Tecentriq®)08.01.69cPharmacy (08)Atezolizumab (Tecentriq®)ab4a9746-3c0a-4512-bd38-0b178d74977d5045Atezolizumab (Tecentriq®)08.01.69
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05.00.82AuricularProstheses05.00.82DME (05)Auricular Prostheses854d35ec-1da5-4c9b-96c7-258cc052d5ff6321Auricular Prostheses05.00.82
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11.14.06jAutologousChondrocyteImplantation(ACI)andOtherCell-basedTreatmentsofFocalArticularCartilageLesions(IndependenceAdministrators)11.14.06jSurgery (11)Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions (Independence Administrators)561dc9ad-1c1e-407e-9e75-bd02a965bf105162Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions (Independence Administrators)11.14.06
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05.00.29oAutomaticExternalCardioverterDefibrillators(WearableandNonwearable)05.00.29oDME (05)Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)de68459f-cd9d-4108-a14e-398f4455f8a85596Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)05.00.29
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07.03.23fAutonomicNervousSystemTesting07.03.23fMedicine (07)Autonomic Nervous System Testingeee0b048-7dd4-4ed0-b156-650003b88cf46206Autonomic Nervous System Testing07.03.23
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08.01.64cAvelumab(Bavencio®)08.01.64cPharmacy (08)Avelumab (Bavencio®)9499af12-5287-4d71-85ef-b16bcb9e683a5994Avelumab (Bavencio®)08.01.64
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11.16.06jBalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitis11.16.06jSurgery (11)Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis24f38e25-4fbe-4329-b23f-2b507113624c5021Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis11.16.06
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11.03.02tBariatricSurgery11.03.02tSurgery (11)Bariatric Surgerye2e22104-ada2-4d84-9c71-c600f1ea170e2791Bariatric Surgery11.03.02
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08.00.99eBelimumab(Benlysta®)forIntravenousUse08.00.99ePharmacy (08)Belimumab (Benlysta®) for Intravenous Usee31a657f-48be-4a73-9792-130bfcdf2d6c6312Belimumab (Benlysta®) for Intravenous Use08.00.99
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08.02.10bBeremageneGeperpavec(Vyjuvek™)08.02.10bPharmacy (08)Beremagene Geperpavec (Vyjuvek™)e6dbad62-468b-468f-b299-699bc381c4b96516Beremagene Geperpavec (Vyjuvek™)08.02.10
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08.01.89aBetibeglogeneAutotemcel[Beti-Cel(ZYNTEGLO®)]08.01.89aPharmacy (08)Betibeglogene Autotemcel [Beti-Cel (ZYNTEGLO®)]eaeb3ab5-7cc1-47ad-b9ed-89caee51d73b6454Betibeglogene Autotemcel [Beti-Cel (ZYNTEGLO®)]08.01.89
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08.00.66uBevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUse08.00.66uPharmacy (08)Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use4f5fba6f-e0af-4ca7-ae67-ee9a82fff8e65313Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use08.00.66
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00.10.39pBillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampus00.10.39pAdministrative (00)Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus0c8d2564-3861-4119-a5ac-33bc514ae8ab5794Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus00.10.39
{"5795": {"Id":5795,"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":7908,"PolicyAttachmentPageName":"ea57ccb3-fc18-4495-8ca8-249692b39da8"},}
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00.10.38aBillingRequirementsforMultipleBirthsforProfessionalProviders00.10.38aAdministrative (00)Billing Requirements for Multiple Births for Professional Providers21ae79a9-3406-47c5-bb6d-1fae803679986302Billing Requirements for Multiple Births for Professional Providers00.10.38
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07.00.01nBiofeedbackTherapy07.00.01nMedicine (07)Biofeedback Therapy1b5502ef-edab-448d-a895-c6cb8b610cc96514Biofeedback Therapy07.00.01
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07.06.03bBioimpedancefortheDetectionofLymphedema07.06.03bMedicine (07)Bioimpedance for the Detection of Lymphedema22aac614-96fa-41c6-a170-e06cf45fb8765705Bioimpedance for the Detection of Lymphedema07.06.03
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a8bbd22a-8279-42e6-bce7-e23c36601e5f.aspx
  
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10.02.02kChiropracticSpinalandExtraspinalManipulationTherapy10.02.02kRehabilitation Services (10)Chiropractic Spinal and Extraspinal Manipulation Therapya6a3818c-0215-4ef6-b633-abb5fd0d59246440Chiropractic Spinal and Extraspinal Manipulation Therapy10.02.02
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08.00.92agCoagulationFactors08.00.92agPharmacy (08)Coagulation Factors1bbe9c18-3706-4e0f-96f6-aab8d62484b65984Coagulation Factors08.00.92
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45899e80-2832-429f-8301-c238cda32dab.aspx
  
11.03.12tColorectalCancerScreening11.03.12tSurgery (11)Colorectal Cancer Screening45899e80-2832-429f-8301-c238cda32dab6216Colorectal Cancer Screening11.03.12
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12.00.03hComplementaryandIntegrativeHealthServices12.00.03hMiscellaneous (12)Complementary and Integrative Health Servicesbd65e1a4-f2f6-4bee-92f1-e5ace6a688d66308Complementary and Integrative Health Services12.00.03
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07.06.01bCompleteDecongestiveTherapy(CDT)07.06.01bMedicine (07)Complete Decongestive Therapy (CDT)df4be546-1954-4879-82ef-5b809efac6555402Complete Decongestive Therapy (CDT)07.06.01
2b5ef5e6-615c-4d34-8f9e-8e49c34dcdfb.aspx
  
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09.00.42cComputer-AidedDetection(CAD)SystemforUsewithChestRadiographs09.00.42cRadiology (09)Computer-Aided Detection (CAD) System for Use with Chest Radiographsddf4156a-01e2-4e9f-82fc-68aab25f027b5031Computer-Aided Detection (CAD) System for Use with Chest Radiographs09.00.42
34a2f226-750f-40db-a9d0-44decc11aea8.aspx
  
11.14.17eComputer-assistedMusculoskeletalSurgicalNavigationalOrthopedicProcedure11.14.17eSurgery (11)Computer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure34a2f226-750f-40db-a9d0-44decc11aea86080Computer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure11.14.17
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00.01.69bConsultationServices00.01.69bAdministrative (00)Consultation Services6b345f32-5fc3-4d8f-b455-be8e91900cb56315Consultation Services00.01.69
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09.00.11eContrastAgentsUsedinConjunctionwithEchocardiography09.00.11eRadiology (09)Contrast Agents Used in Conjunction with Echocardiography7c8e4bb0-6f66-4f72-84b4-1014281324975063Contrast Agents Used in Conjunction with Echocardiography09.00.11
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fb6694bb-0c14-4e23-a1d8-d9709f7ff567.aspx
  
12.01.03bCosmeticProcedures12.01.03bMiscellaneous (12)Cosmetic Proceduresfb6694bb-0c14-4e23-a1d8-d9709f7ff5676062Cosmetic Procedures12.01.03
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05.00.04eCoverageofMedicalDevices05.00.04eDME (05)Coverage of Medical Devices0e5a3246-799b-4df3-bc4a-9a5c0ec821663665Coverage of Medical Devices05.00.04
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1e846c90-26ad-42a3-a022-87051c882730.aspx
  
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00.10.03kCriteriaforReimbursementofEmergencyRoomServices00.10.03kAdministrative (00)Criteria for Reimbursement of Emergency Room Services1adfb9b5-6ec1-41a1-ab70-0ec7069d62d94962Criteria for Reimbursement of Emergency Room Services00.10.03
f3947580-94ff-4833-9972-eae6958cb8ca.aspx
  
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11.11.03dCryosurgicalAblationoftheProstateGland11.11.03dSurgery (11)Cryosurgical Ablation of the Prostate Gland7767bb97-a6be-4bcf-9f35-e36fc9a2e87a6526Cryosurgical Ablation of the Prostate Gland11.11.03
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08.01.29kDaratumumab(Darzalex®),DaratumumabandHyaluronidase-fihj(DarzalexFaspro®)08.01.29kPharmacy (08)Daratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®)1a6bddc6-a618-4287-8360-450516d7023b5514Daratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®)08.01.29
1381b984-d385-4d3d-91a9-8daa23bf024f.aspx
  
10.00.02cDayRehabilitation10.00.02cRehabilitation Services (10)Day Rehabilitation1381b984-d385-4d3d-91a9-8daa23bf024f5297Day Rehabilitation10.00.02
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11.08.17kDebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNails11.08.17kSurgery (11)Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nailsf8389c50-7373-416b-8e33-b719d614340c6255Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails11.08.17
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11.15.20tDeepBrainStimulation(DBS)11.15.20tSurgery (11)Deep Brain Stimulation (DBS)2a15c7db-3a42-453d-b606-3eb3ee680bde5957Deep Brain Stimulation (DBS)11.15.20
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08.02.13Delandistrogenemoxeparvovec(delandistrogenemoxeparvovec-rokl;Elevidys®)08.02.13Pharmacy (08)Delandistrogene moxeparvovec (delandistrogene moxeparvovec-rokl; Elevidys®) 95f895cc-90a8-4770-97e4-8c4cc31b20fd6431Delandistrogene moxeparvovec (delandistrogene moxeparvovec-rokl; Elevidys®) 08.02.13
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