Commercial
  
  
  
  
  
  
  
  
  
  
MPattachmentdataPub
85256AA800623D7A852584EB005E0702.aspx
  
08.00.62jAbatacept (Orencia®) for Injection for Intravenous UsePharmacy (08)Abatacept (Orencia®) for Injection for Intravenous Use85256AA800623D7A852584EB005E07022396Abatacept (Orencia®) for Injection for Intravenous Use08.00.62
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85256AA800623D7A8525850D004EBDA5.aspx
  
12.00.01fAcupuncture (Independence)Miscellaneous (12)Acupuncture (Independence)85256AA800623D7A8525850D004EBDA51773Acupuncture (Independence)12.00.01
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85256AA800623D7A85258596007CD987.aspx
  
12.04.04aAcute Care Facility Inpatient TransfersMiscellaneous (12)Acute Care Facility Inpatient Transfers85256AA800623D7A85258596007CD9871775Acute Care Facility Inpatient Transfers12.04.04
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08.01.11eAdo-Trastuzumab Emtansine (Kadcyla®)Pharmacy (08)Ado-Trastuzumab Emtansine (Kadcyla®)85256AA800623D7A852583C4005C46171846Ado-Trastuzumab Emtansine (Kadcyla®)08.01.11
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85256AA800623D7A852585420071736C.aspx
  
08.00.69bAgalsidase beta (Fabrazyme®)Pharmacy (08)Agalsidase beta (Fabrazyme®)85256AA800623D7A852585420071736C2031Agalsidase beta (Fabrazyme®)08.00.69
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12.04.03cAir Ambulance ServicesMiscellaneous (12)Air Ambulance Services85256AA800623D7A85258596007D3BA61776Air Ambulance Services12.04.03
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08.01.22dAlemtuzumab (Lemtrada®)Pharmacy (08)Alemtuzumab (Lemtrada®)85256AA800623D7A852584EB005B947D2054Alemtuzumab (Lemtrada®)08.01.22
85256AA800623D7A8525854200710D18.aspx
  
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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06.02.29dAlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators)Pathology and Laboratory (06)AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators)85256AA800623D7A8525852F00700D862005AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators)06.02.29
C0BF3216424958498525851F0065B493.aspx
  
08.00.91dAlpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)Pharmacy (08)Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)C0BF3216424958498525851F0065B4931993Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)08.00.91
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00.01.52iAlways Bundled Procedure CodesAdministrative (00)Always Bundled Procedure Codes85256AA800623D7A852584BE0061748B2158Always Bundled Procedure Codes00.01.52
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85256AA800623D7A8525852700657888.aspx
  
07.02.09gAmbulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) DevicesMedicine (07)Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices85256AA800623D7A85258527006578882041Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices07.02.09
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07.02.21eAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringMedicine (07)Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring85256AA800623D7A8525849B0072BC561962Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring07.02.21
85256AA800623D7A8525847900595D5D.aspx
  
05.00.39oAnkle-Foot/Knee-Ankle-Foot OrthosesDME (05)Ankle-Foot/Knee-Ankle-Foot Orthoses85256AA800623D7A8525847900595D5D1864Ankle-Foot/Knee-Ankle-Foot Orthoses05.00.39
{"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
85256AA800623D7A85258464005D7037.aspx
  
11.08.05gApplication and Removal of TattoosSurgery (11)Application and Removal of Tattoos85256AA800623D7A85258464005D70371866Application and Removal of Tattoos11.08.05
85256AA800623D7A8525853E004B8BDF.aspx
  
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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85256AA800623D7A85258397005A3BB6.aspx
  
11.05.16hAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaSurgery (11)Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma85256AA800623D7A85258397005A3BB61850Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma11.05.16
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A3A0632A8125CAEF85258588005C3C90.aspx
  
11.14.19oArtificial Intervertebral Disc InsertionSurgery (11)Artificial Intervertebral Disc InsertionA3A0632A8125CAEF85258588005C3C901733Artificial Intervertebral Disc Insertion11.14.19
85256AA800623D7A8525848D004D1680.aspx
  
08.01.35bAsparaginase Erwinia Chrysanthemi (Erwinaze®)Pharmacy (08)Asparaginase Erwinia Chrysanthemi (Erwinaze®)85256AA800623D7A8525848D004D16801929Asparaginase Erwinia Chrysanthemi (Erwinaze®)08.01.35
85256AA800623D7A852585A400652416.aspx
  
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
85256AA800623D7A852584C500591919.aspx
  
07.10.06hAssisted Reproductive Technology for Infertility and Oocyte CryopreservationMedicine (07)Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation85256AA800623D7A852584C5005919191969Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation07.10.06
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11.14.06iAutologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage LesionsSurgery (11)Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions85256AA800623D7A8525849B004313B61741Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions11.14.06
A0450B1CECA727FF852585AB00533565.aspx
  
05.00.29lAutomatic External Cardioverter Defibrillators (Wearable and Nonwearable)DME (05)Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)A0450B1CECA727FF852585AB005335652397Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)05.00.29
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85256AA800623D7A85258535005F4262.aspx
  
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
{"2452": {"Id":2452,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":2486,"PolicyAttachmentPageName":"924afd68-e6b3-4c07-98e4-722d7e259554"},}
85256AA800623D7A852584C80048DC59.aspx
  
11.16.06jBalloon Catheter Dilation of Sinus Ostia for Treatment of Chronic RhinosinusitisSurgery (11)Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis85256AA800623D7A852584C80048DC591958Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis11.16.06
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11.03.02sBariatric SurgerySurgery (11)Bariatric Surgery85256AA800623D7A852584E0005DE5421972Bariatric Surgery11.03.02
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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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21B5108DBB59C30C8525854B0059E5B9.aspx
  
00.10.39lBilling for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility CampusAdministrative (00)Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus21B5108DBB59C30C8525854B0059E5B92171Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus00.10.39
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85256AA800623D7A852584B100666803.aspx
  
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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07.00.01iBiofeedback TherapyMedicine (07)Biofeedback Therapy85256AA800623D7A852584C800740AEF1952Biofeedback Therapy07.00.01
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07.06.03bBioimpedance for the Detection of LymphedemaMedicine (07)Bioimpedance for the Detection of Lymphedema85256AA800623D7A852585340044B9F12011Bioimpedance for the Detection of Lymphedema07.06.03
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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
  
08.01.21cBlinatumomab (Blincyto®)Pharmacy (08)Blinatumomab (Blincyto®)85256AA800623D7A85258401004A12A11826Blinatumomab (Blincyto®)08.01.21
85256AA800623D7A852584B80067B4E4.aspx
  
09.00.04kBone Mineral Density (BMD) TestingRadiology (09)Bone Mineral Density (BMD) Testing85256AA800623D7A852584B80067B4E41994Bone Mineral Density (BMD) Testing09.00.04
85256AA800623D7A852583F200496747.aspx
  
11.01.06eBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing AidsSurgery (11)Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids85256AA800623D7A852583F2004967471838Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids11.01.06
85256AA800623D7A8525838400606BF9.aspx
  
08.00.73lBortezomib (Bortezomib for Injection, Velcade®)Pharmacy (08)Bortezomib (Bortezomib for Injection, Velcade®)85256AA800623D7A8525838400606BF91816Bortezomib (Bortezomib for Injection, Velcade®)08.00.73
85256AA800623D7A8525853E005046D3.aspx
  
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
  
09.00.10zBrachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (Independence Administrators)Radiology (09)Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (Independence Administrators)85256AA800623D7A852583B60065D9531851Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (Independence Administrators)09.00.10
85256AA800623D7A852584C80074166B.aspx
  
05.00.76cBreast PumpsDME (05)Breast Pumps85256AA800623D7A852584C80074166B1947Breast Pumps05.00.76
85256AA800623D7A8525848D004D1008.aspx
  
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
85256AA800623D7A8525847E006E285B.aspx
  
08.01.49aBurosumab-twza (Crysvita®)Pharmacy (08)Burosumab-twza (Crysvita®)85256AA800623D7A8525847E006E285B1870Burosumab-twza (Crysvita®)08.01.49
85256AA800623D7A8525853D005A168F.aspx
  
08.00.96eCabazitaxel (Jevtana®)Pharmacy (08)Cabazitaxel (Jevtana®)85256AA800623D7A8525853D005A168F1780Cabazitaxel (Jevtana®)08.00.96
85256AA800623D7A852585660071B05C.aspx
  
08.01.51Canakinumab (Ilaris®)Pharmacy (08)Canakinumab (Ilaris®)85256AA800623D7A852585660071B05C2065Canakinumab (Ilaris®)08.01.51
85256AA800623D7A8525847E006A6590.aspx
  
10.01.01nCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) ProgramsRehabilitation Services (10)Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs85256AA800623D7A8525847E006A65901874Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs10.01.01
{"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
85256AA800623D7A852583E60043F347.aspx
  
08.01.05fCarfilzomib (Kyprolis™)Pharmacy (08)Carfilzomib (Kyprolis™)85256AA800623D7A852583E60043F3471844Carfilzomib (Kyprolis™)08.01.05
82EF268AB3C7CA1E852581E9005653DB.aspx
  
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
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85256AA800623D7A8525847B00611B55.aspx
  
11.02.06mCatheter Ablation of Cardiac ArrhythmiasSurgery (11)Catheter Ablation of Cardiac Arrhythmias85256AA800623D7A8525847B00611B551885Catheter Ablation of Cardiac Arrhythmias11.02.06
85256AA800623D7A8525857A004FE849.aspx
  
08.01.66Cemiplimab-rwlc (LIBTAYO®)Pharmacy (08)Cemiplimab-rwlc (LIBTAYO®)85256AA800623D7A8525857A004FE8492398Cemiplimab-rwlc (LIBTAYO®)08.01.66
85256AA800623D7A8525852F006D7D15.aspx
  
08.01.39cCerliponase alfa (Brineura®)Pharmacy (08)Cerliponase alfa (Brineura®)85256AA800623D7A8525852F006D7D152014Cerliponase alfa (Brineura®)08.01.39
85256AA800623D7A852583CC0054CDD8.aspx
  
05.00.61fCervical Traction Devices for In-home UseDME (05)Cervical Traction Devices for In-home Use85256AA800623D7A852583CC0054CDD81830Cervical Traction Devices for In-home Use05.00.61
85256AA800623D7A8525846C00638C9B.aspx
  
08.00.67lCetuximab (Erbitux®)Pharmacy (08)Cetuximab (Erbitux®)85256AA800623D7A8525846C00638C9B1920Cetuximab (Erbitux®)08.00.67
{"2273": {"Id":2273,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525846C00638CAA"},"2274": {"Id":2274,"MPAttachmentLetter":"B","Title":"ICD-10 Codes for Cetuximab (Erbitux®)","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525846C00638CA4"},}
85256AA800623D7A85258464005D7623.aspx
  
11.08.08gChemical PeelsSurgery (11)Chemical Peels85256AA800623D7A85258464005D76231879Chemical Peels11.08.08
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{"2372": {"Id":2372,"MPAttachmentLetter":"A","Title":"MEDICALLY NECESSARY ICD 10 CODES FOR COBALAMIN (VITAMIN B12) AND/OR FOLIC ACID TESTING (CPT CODES 82607, 82608, 82746, AND 82747)","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852585A400662115"},}
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00.01.69Consultation ServicesAdministrative (00)Consultation ServicesF3BA7DB0E980312B8525854B005EE64C2172Consultation Services00.01.69
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10.00.02cDay RehabilitationRehabilitation Services (10)Day Rehabilitation85256AA800623D7A85258585004BD8851748Day Rehabilitation10.00.02
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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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08.01.37aDrugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Naltrexone Implants, Probuphine Implant, Sublocade Injection, Vivitrol Injection)Pharmacy (08)Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Naltrexone Implants, Probuphine Implant, Sublocade Injection, Vivitrol Injection)85256AA800623D7A8525820B004EC0DE1894Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Naltrexone Implants, Probuphine Implant, Sublocade Injection, Vivitrol Injection)08.01.37
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05.00.21uDurable Medical Equipment (DME) and Consumable Medical SuppliesDME (05)Durable Medical Equipment (DME) and Consumable Medical Supplies85256AA800623D7A852584D60053CD802162Durable Medical Equipment (DME) and Consumable Medical Supplies05.00.21
{"2300": {"Id":2300,"MPAttachmentLetter":"A1","Title":"Equipment that Meets the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584D60053CD90"},"2301": {"Id":2301,"MPAttachmentLetter":"A2","Title":"Equipment that Meets the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584D60053CD98"},"2302": {"Id":2302,"MPAttachmentLetter":"B","Title":"Items that Do Not Meet the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584D60053CD9E"},}
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{"2456": {"Id":2456,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":2495,"PolicyAttachmentPageName":"6fce0a1d-ee99-41d7-87e5-9c2b8620a774"},}
85256AA800623D7A852584C80066FE64.aspx
  
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08.01.42aEdaravone(Radicava™)08.01.42aPharmacy (08)Edaravone (Radicava™)c5d35afa-e005-41dd-9515-b27c07a2fcd32442Edaravone (Radicava™)08.01.42
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