|  | | 08.00.62l | Abatacept(Orencia®)forInjectionforIntravenousUse08.00.62l | Pharmacy (08) | Abatacept (Orencia®) for Injection for Intravenous Use | 394267e0-a5ab-4a65-b114-71b24fc55bd1 | 2725 | Abatacept (Orencia®) for Injection for Intravenous Use | 08.00.62 | {"2726": {"Id":2726,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":4966,"PolicyAttachmentPageName":"ab7d6c23-9f6b-4151-90ee-56ece05da01a"},} |
| | | 12.00.01f | Acupuncture (Independence) | Miscellaneous (12) | Acupuncture (Independence) | 85256AA800623D7A8525850D004EBDA5 | 1773 | Acupuncture (Independence) | 12.00.01 | {"2364": {"Id":2364,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Acupuncture","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525850D004EBDAD"},} |
| | | 12.04.04a | Acute Care Facility Inpatient Transfers | Miscellaneous (12) | Acute Care Facility Inpatient Transfers | 85256AA800623D7A85258596007CD987 | 1775 | Acute Care Facility Inpatient Transfers | 12.04.04 | |
| | | 08.01.11f | Ado-TrastuzumabEmtansine(Kadcyla®)08.01.11f | Pharmacy (08) | Ado-Trastuzumab Emtansine (Kadcyla®) | b1b70e6b-f0a4-4e8d-a402-c16710ec6422 | 2880 | Ado-Trastuzumab Emtansine (Kadcyla®) | 08.01.11 | {"2881": {"Id":2881,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes and Narratives","MPPolicyAttachmentInternalSourceId":4967,"PolicyAttachmentPageName":"93337778-48af-4f3e-8a67-96c5f917cbb1"},} |
| | | 08.00.69b | Agalsidase beta (Fabrazyme®) | Pharmacy (08) | Agalsidase beta (Fabrazyme®) | 85256AA800623D7A852585420071736C | 2031 | Agalsidase beta (Fabrazyme®) | 08.00.69 | |
| | | 12.04.03c | Air Ambulance Services | Miscellaneous (12) | Air Ambulance Services | 85256AA800623D7A85258596007D3BA6 | 1776 | Air Ambulance Services | 12.04.03 | |
| | | 08.01.22d | Alemtuzumab (Lemtrada®) | Pharmacy (08) | Alemtuzumab (Lemtrada®) | 85256AA800623D7A852584EB005B947D | 2054 | Alemtuzumab (Lemtrada®) | 08.01.22 | |
| | | 08.00.72h | Alglucosidase alfa (e.g., Lumizyme®) | Pharmacy (08) | Alglucosidase alfa (e.g., Lumizyme®) | 85256AA800623D7A8525854200710D18 | 2032 | Alglucosidase alfa (e.g., Lumizyme®) | 08.00.72 | |
| | | 07.00.21j | AllergyImmunotherapy07.00.21j | Medicine (07) | Allergy Immunotherapy | 9e3ab46c-3063-40f7-adf6-40bb1cc3c2a1 | 2826 | Allergy Immunotherapy | 07.00.21 | |
| | | 06.02.29d | AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators) | Pathology and Laboratory (06) | AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators) | 85256AA800623D7A8525852F00700D86 | 2005 | AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators) | 06.02.29 | |
| | | 08.00.91e | Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C®,AralastNP®,Glassia®,Zemaira®)08.00.91e | Pharmacy (08) | Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®) | 5382f61c-2acd-4417-831b-1daf8729bdbc | 2892 | Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®) | 08.00.91 | |
| | | 00.01.52k | AlwaysBundledProcedureCodes00.01.52k | Administrative (00) | Always Bundled Procedure Codes | 9d56cb78-4e98-4fc6-a682-bc21970fbc37 | 2978 | Always Bundled Procedure Codes | 00.01.52 | {"2979": {"Id":2979,"MPAttachmentLetter":"A","Title":"Always Bundled Procedures (Indicator B)","MPPolicyAttachmentInternalSourceId":4769,"PolicyAttachmentPageName":"b010ee1b-a974-423a-9266-d19e3a515b39"},"2980": {"Id":2980,"MPAttachmentLetter":"B","Title":"Procedures/Services Not Eligible for Separate Reimbursement","MPPolicyAttachmentInternalSourceId":4953,"PolicyAttachmentPageName":"0a1e0a3f-66b2-44db-8b28-b409bd6cf895"},"2981": {"Id":2981,"MPAttachmentLetter":"C","Title":"Procedures/Services Not Eligible for Reimbursement","MPPolicyAttachmentInternalSourceId":4954,"PolicyAttachmentPageName":"906e52cf-be51-40f7-b2c0-fa8e081165e1"},} |
| | | 07.02.09g | AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)Devices07.02.09g | Medicine (07) | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | fadd0242-f323-49fe-8ca7-2112b67a09c4 | 3006 | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | 07.02.09 | |
| | | 07.02.21f | AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)Monitoring07.02.21f | Medicine (07) | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | 792c202a-67b3-48a7-af0a-4840d602b361 | 2825 | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | 07.02.21 | |
| | | 05.00.39p | Ankle-Foot/Knee-Ankle-FootOrthoses05.00.39p | DME (05) | Ankle-Foot/Knee-Ankle-Foot Orthoses | 8e41f686-bc28-43fc-8d6e-6e17007ff41b | 2962 | Ankle-Foot/Knee-Ankle-Foot Orthoses | 05.00.39 | {"2963": {"Id":2963,"MPAttachmentLetter":"A","Title":"HCPCS Codes","MPPolicyAttachmentInternalSourceId":5037,"PolicyAttachmentPageName":"e9e48716-ca94-411b-9ec4-8057f8b30e92"},} |
| | | 06.03.04n | ApheresisTherapy06.03.04n | Pathology and Laboratory (06) | Apheresis Therapy | 36aee0bb-d271-4e94-8256-eafdfce45397 | 2774 | Apheresis Therapy | 06.03.04 | |
| | | 11.08.05g | ApplicationandRemovalofTattoos11.08.05g | Surgery (11) | Application and Removal of Tattoos | 877c1fd6-b369-4fc9-8864-59f82b761dc2 | 2642 | Application and Removal of Tattoos | 11.08.05 | |
| | | 08.01.41c | Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®) | Pharmacy (08) | Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®) | 85256AA800623D7A8525853E004B8BDF | 2033 | Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®) | 08.01.41 | {"2321": {"Id":2321,"MPAttachmentLetter":"A","Title":"Risk of Emesis Without Prophylaxis: Intravenous and Oral Antineoplastic Agents","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525853E004B8C13"},} |
| | | 11.05.16i | AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucoma11.05.16i | Surgery (11) | Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | f830ae35-762b-444b-8664-f5d039173ade | 2686 | Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | 11.05.16 | {"2687": {"Id":2687,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":4936,"PolicyAttachmentPageName":"75beb74b-5c50-4575-a3ca-4008184240ee"},} |
| | | 11.14.19p | ArtificialIntervertebralCervicalDiscInsertion(IndependenceAdministrators)11.14.19p | Surgery (11) | Artificial Intervertebral Cervical Disc Insertion (Independence Administrators) | e09699f1-6205-4c4f-b9b5-07035eacc229 | 2917 | Artificial Intervertebral Cervical Disc Insertion (Independence Administrators) | 11.14.19 | |
| | | 11.15.31 | ArtificialIntervertebralLumbarDiscInsertion11.15.31 | Surgery (11) | Artificial Intervertebral Lumbar Disc Insertion | a123b843-9dc4-4281-9614-0931a6c966d2 | 2916 | Artificial Intervertebral Lumbar Disc Insertion | 11.15.31 | |
| | | 08.01.35c | AsparaginaseErwiniaChrysanthemi(Erwinaze®)08.01.35c | Pharmacy (08) | Asparaginase Erwinia Chrysanthemi (Erwinaze®) | 71445744-0bb7-4616-86d4-6c1a231df3c6 | 2983 | Asparaginase Erwinia Chrysanthemi (Erwinaze®) | 08.01.35 | |
| | | 06.02.27l | Assays 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) | 85256AA800623D7A852585A400652416 | 1786 | Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (Independence Administrators) | 06.02.27 | |
| | | 07.10.06i | AssistedReproductiveTechnologyforInfertilityandOocyteCryopreservation07.10.06i | Medicine (07) | Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation | 964f2d08-cb46-4737-8a74-39b81deb6f6a | 2824 | Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation | 07.10.06 | |
| | | 08.01.69 | Atezolizumab(Tecentriq®)08.01.69 | Pharmacy (08) | Atezolizumab (Tecentriq®) | ae81a8ad-97c0-4dfd-8ce9-fe2532d6a43a | 2469 | Atezolizumab (Tecentriq®) | 08.01.69 | {"2470": {"Id":2470,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":4723,"PolicyAttachmentPageName":"ff1a9148-d750-4345-aece-2735ddef2f1b"},} |
| | | 11.14.06j | AutologousChondrocyteImplantation(ACI)andOtherCell-basedTreatmentsofFocalArticularCartilageLesions(IndependenceAdministrators)11.14.06j | Surgery (11) | Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions (Independence Administrators) | 70726fcf-404b-4ff9-9280-ac452ac48c19 | 2932 | Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions (Independence Administrators) | 11.14.06 | |
| | | 05.00.29l | Automatic External Cardioverter Defibrillators (Wearable and Nonwearable) | DME (05) | Automatic External Cardioverter Defibrillators (Wearable and Nonwearable) | A0450B1CECA727FF852585AB00533565 | 2397 | Automatic External Cardioverter Defibrillators (Wearable and Nonwearable) | 05.00.29 | {"2405": {"Id":2405,"MPAttachmentLetter":"B","Title":"ICD-10 codes used to represent the Nonwearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"DE272CF959A83D46852585AB00533585"},"2406": {"Id":2406,"MPAttachmentLetter":"A","Title":"ICD-10 Codes used to represent the Wearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"5080E542121FA54B852585AB0053357F"},} |
| | | 07.03.23c | Autonomic Nervous System Testing | Medicine (07) | Autonomic Nervous System Testing | 85256AA800623D7A85258535005F4262 | 1751 | Autonomic Nervous System Testing | 07.03.23 | |
| | | 08.01.64 | Avelumab(Bavencio®)08.01.64 | Pharmacy (08) | Avelumab (Bavencio®) | 7e0e42f8-cf2c-4eb6-a9d8-4b172c1df27a | 2451 | Avelumab (Bavencio®) | 08.01.64 | {"2452": {"Id":2452,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":2486,"PolicyAttachmentPageName":"924afd68-e6b3-4c07-98e4-722d7e259554"},} |
| | | 11.16.06j | BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitis11.16.06j | Surgery (11) | Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis | b4850e37-c01a-4c04-aef2-7d9fed86e706 | 2695 | Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis | 11.16.06 | |
| | | 11.03.02t | BariatricSurgery11.03.02t | Surgery (11) | Bariatric Surgery | e2e22104-ada2-4d84-9c71-c600f1ea170e | 2791 | Bariatric Surgery | 11.03.02 | {"2792": {"Id":2792,"MPAttachmentLetter":"A","Title":"Body Mass Index (BMI) Charts","MPPolicyAttachmentInternalSourceId":4907,"PolicyAttachmentPageName":"292a20ba-ec48-442c-a624-40100880cb31"},"2793": {"Id":2793,"MPAttachmentLetter":"B","Title":"Tanner Staging System Criteria for Adolescents","MPPolicyAttachmentInternalSourceId":4908,"PolicyAttachmentPageName":"1b6da816-a2b6-4583-807a-5430c89f8392"},"2794": {"Id":2794,"MPAttachmentLetter":"C","Title":"ICD-10-CM codes","MPPolicyAttachmentInternalSourceId":4909,"PolicyAttachmentPageName":"b9184a36-7491-498e-aac9-ed1933abf92b"},} |
| | | 08.01.70a | Belantamabmafodotin-blmf(Blenrep)08.01.70a | Pharmacy (08) | Belantamab mafodotin-blmf (Blenrep) | b1ce9f69-3893-42af-b793-ced88bbdc1dc | 2911 | Belantamab mafodotin-blmf (Blenrep) | 08.01.70 | |
| | | 08.00.99c | Belimumab (Benlysta®) for Intravenous Use | Pharmacy (08) | Belimumab (Benlysta®) for Intravenous Use | 85256AA800623D7A852584EB005DFB48 | 1724 | Belimumab (Benlysta®) for Intravenous Use | 08.00.99 | |
| | | 08.00.66o | Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUse08.00.66o | Pharmacy (08) | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | 189b1146-8951-44d1-8e41-f3eb252918ec | 2984 | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | 08.00.66 | {"2985": {"Id":2985,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":5036,"PolicyAttachmentPageName":"98bfbb87-d5a2-44b4-a5ef-b1b180d98102"},} |
| | | 00.10.38a | Billing Requirements for Multiple Births for Professional Providers | Administrative (00) | Billing Requirements for Multiple Births for Professional Providers | 85256AA800623D7A852584B100666803 | 2156 | Billing Requirements for Multiple Births for Professional Providers | 00.10.38 | {"2286": {"Id":2286,"MPAttachmentLetter":"A","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ROUTINE OBSTETRIC (GLOBALE MATERNITY/OBSTETRIC [OB]) CARE WAS PROVIDED","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584B1006EAA44"},"2287": {"Id":2287,"MPAttachmentLetter":"B","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ANETEPARTUM CARE IS NOT PROVIDED","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584B1006EDFF6"},"2288": {"Id":2288,"MPAttachmentLetter":"C","Title":"CODING SCENARIOS FOR REPORTING HIGH-ORDER MULTIPLE (TRIPLETS, QUADRUPLETS, ETC) BIRTHS WHEN ROUTINE OBSTETRIC (GLOBAL MATERNITY/OBSTETRIC [OB]) CARE WAS PROVIDED","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584B1006F0E36"},"2289": {"Id":2289,"MPAttachmentLetter":"D","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF HIGH-ORDER MULTIPLES WHEN ANTEPARTUM CARE IS NOT PROVIDED","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584B1006F364A"},} |
| | | 00.10.39n | BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampus00.10.39n | Administrative (00) | Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus | 44d1f93e-e431-4e85-a65f-99ebd167ae49 | 2901 | Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus | 00.10.39 | {"2902": {"Id":2902,"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":5191,"PolicyAttachmentPageName":"4d997fc7-79b5-47d4-b004-59a1ff458993"},} |
| | | 07.00.01j | BiofeedbackTherapy07.00.01j | Medicine (07) | Biofeedback Therapy | 81ada7d5-27d5-4c0f-bc59-c401eefc836f | 2653 | Biofeedback Therapy | 07.00.01 | |
| | | 07.06.03b | Bioimpedance for the Detection of Lymphedema | Medicine (07) | Bioimpedance for the Detection of Lymphedema | 85256AA800623D7A852585340044B9F1 | 2011 | Bioimpedance for the Detection of Lymphedema | 07.06.03 | |
| | | 11.05.02j | Blepharoplasty,RepairofBlepharoptosis,RepairofBrowPtosis,andCanthoplasty/Canthopexy11.05.02j | Surgery (11) | Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy | 05af1ff1-9439-4274-90cd-c00835000c0e | 2975 | Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy | 11.05.02 | {"2976": {"Id":2976,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5006,"PolicyAttachmentPageName":"4cca31c1-c0b9-45fc-bfdb-e773e1b7116a"},} |
| | | 08.01.21c | Blinatumomab(Blincyto®)08.01.21c | Pharmacy (08) | Blinatumomab (Blincyto®) | 9063791b-e72d-4bef-aaf4-dd40df06bbe0 | 2711 | Blinatumomab (Blincyto®) | 08.01.21 | |
| | | 09.00.04k | Bone Mineral Density (BMD) Testing | Radiology (09) | Bone Mineral Density (BMD) Testing | 85256AA800623D7A852584B80067B4E4 | 1994 | Bone Mineral Density (BMD) Testing | 09.00.04 | |
| | | 11.01.06e | Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAids11.01.06e | Surgery (11) | Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids | 92e12e9d-2a7b-499b-bbe2-cbb276bc17ba | 2702 | Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids | 11.01.06 | |
| | | 08.00.73l | Bortezomib (Bortezomib for Injection, Velcade®) | Pharmacy (08) | Bortezomib (Bortezomib for Injection, Velcade®) | 85256AA800623D7A8525838400606BF9 | 1816 | Bortezomib (Bortezomib for Injection, Velcade®) | 08.00.73 | |
| | | 08.00.26w | Botulinum Toxin Agents | Pharmacy (08) | Botulinum Toxin Agents | 85256AA800623D7A8525853E005046D3 | 1727 | Botulinum Toxin Agents | 08.00.26 | {"2340": {"Id":2340,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525853E005046F5"},} |
| | | 09.00.10z | Brachytherapy 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) | 85256AA800623D7A852583B60065D953 | 1851 | Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (Independence Administrators) | 09.00.10 | |
| | | 05.00.76d | BreastPumps05.00.76d | DME (05) | Breast Pumps | 28248bd2-5b32-49ca-87b0-e1cfda1abbc7 | 2720 | Breast Pumps | 05.00.76 | |
| | | 08.01.13e | BrentuximabVedotin(Adcetris®)08.01.13e | Pharmacy (08) | Brentuximab Vedotin (Adcetris®) | 8b0960f6-d97d-43d8-b419-d94c9860ce8a | 3009 | Brentuximab Vedotin (Adcetris®) | 08.01.13 | {"3010": {"Id":3010,"MPAttachmentLetter":"A","Title":"ICD CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":5096,"PolicyAttachmentPageName":"b33e246d-9714-4e3c-91c0-e51c66859b8e"},} |
| | | 11.16.07b | Bronchial Thermoplasty | Surgery (11) | Bronchial Thermoplasty | 85256AA800623D7A852585A4005899AC | 1791 | Bronchial Thermoplasty | 11.16.07 | |
| | | 08.01.49a | Burosumab-twza (Crysvita®) | Pharmacy (08) | Burosumab-twza (Crysvita®) | 85256AA800623D7A8525847E006E285B | 1870 | Burosumab-twza (Crysvita®) | 08.01.49 | |
| | | 08.01.51a | Canakinumab(Ilaris®)08.01.51a | Miscellaneous (12) | Canakinumab (Ilaris®) | 38d30b81-d6e8-498c-bccd-3c3f2baa02a4 | 3000 | Canakinumab (Ilaris®) | 08.01.51 | |
| | | 10.01.01n | CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)Programs10.01.01n | Rehabilitation Services (10) | Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs | 4f1e0439-21a8-49d2-bc90-7a39d70677e5 | 2717 | Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs | 10.01.01 | {"2718": {"Id":2718,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":4998,"PolicyAttachmentPageName":"48fe8723-3060-4b73-8f7f-30d46dc317cf"},} |
| | | 00.01.59h | CareManagementandCarePlanningServices00.01.59h | Administrative (00) | Care Management and Care Planning Services | 8e339ceb-45a8-4a58-a802-6e0d86f524a5 | 2893 | Care Management and Care Planning Services | 00.01.59 | |
| | | 08.01.05g | Carfilzomib(Kyprolis®)08.01.05g | Pharmacy (08) | Carfilzomib (Kyprolis®) | 26a9c1aa-7bed-41e2-a468-178e8e009f8c | 2645 | Carfilzomib (Kyprolis®) | 08.01.05 | |
| | | 00.10.15d | CastandSplintApplicationsandAssociatedSupplies00.10.15d | Administrative (00) | Cast and Splint Applications and Associated Supplies | 9a58b2c2-ac51-4f36-b633-45311f346cea | 2782 | Cast and Splint Applications and Associated Supplies | 00.10.15 | {"2783": {"Id":2783,"MPAttachmentLetter":"A","Title":"Procedure Codes Related to Cast and Splint Applications and Associated Supplies","MPPolicyAttachmentInternalSourceId":4979,"PolicyAttachmentPageName":"0e216c08-2117-49fb-87c3-6ff39b233cd3"},} |
| | | 11.01.07e | Cataract Surgery | Surgery (11) | Cataract Surgery | 85256AA800623D7A85258574006D0BB6 | 1721 | Cataract Surgery | 11.01.07 | {"2336": {"Id":2336,"MPAttachmentLetter":"A","Title":"ICD 10 codes for policy 11.01.07d, Cataract Surgery","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258574006D0BFE"},} |
| | | 11.02.06m | CatheterAblationofCardiacArrhythmias11.02.06m | Surgery (11) | Catheter Ablation of Cardiac Arrhythmias | 5bc8fc6f-5bd5-4370-ab9e-ce20a42e10fe | 2659 | Catheter Ablation of Cardiac Arrhythmias | 11.02.06 | |
| | | 08.01.66 | Cemiplimab-rwlc (LIBTAYO®) | Pharmacy (08) | Cemiplimab-rwlc (LIBTAYO®) | 85256AA800623D7A8525857A004FE849 | 2398 | Cemiplimab-rwlc (LIBTAYO®) | 08.01.66 | |
| | | 08.01.39c | Cerliponase alfa (Brineura®) | Pharmacy (08) | Cerliponase alfa (Brineura®) | 85256AA800623D7A8525852F006D7D15 | 2014 | Cerliponase alfa (Brineura®) | 08.01.39 | |
| | | 05.00.61g | CervicalTractionDevicesforIn-homeUse05.00.61g | DME (05) | Cervical Traction Devices for In-home Use | a11f7cc3-9d42-42f0-8f28-deb4b0380548 | 2640 | Cervical Traction Devices for In-home Use | 05.00.61 | |
| | | 08.00.67l | Cetuximab (Erbitux®) | Pharmacy (08) | Cetuximab (Erbitux®) | 85256AA800623D7A8525846C00638C9B | 1920 | Cetuximab (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"},} |
| | | 11.08.08g | ChemicalPeels11.08.08g | Surgery (11) | Chemical Peels | 7bbf486e-20bb-4661-a6b8-817953106101 | 2662 | Chemical Peels | 11.08.08 | |
| | | 08.01.43f | ChimericAntigenReceptor(CAR)Therapy08.01.43f | Pharmacy (08) | Chimeric Antigen Receptor (CAR) Therapy | 61f2d16e-5693-4749-8603-5eebc5e588d5 | 2803 | Chimeric Antigen Receptor (CAR) Therapy | 08.01.43 | {"2804": {"Id":2804,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":4713,"PolicyAttachmentPageName":"5d1b9c5a-f759-403f-8c97-b7565e2fcce1"},} |
| | | 10.02.02j | Chiropractic Spinal and Extraspinal Manipulation Therapy | Rehabilitation Services (10) | Chiropractic Spinal and Extraspinal Manipulation Therapy | CD5255F2AD53803E8525856C006F1209 | 2059 | Chiropractic Spinal and Extraspinal Manipulation Therapy | 10.02.02 | |
| | | 08.00.92ac | CoagulationFactors08.00.92ac | Pharmacy (08) | Coagulation Factors | 465ad1f4-30bc-45ac-8114-468e0f652a26 | 2736 | Coagulation Factors | 08.00.92 | |
| | | 06.02.54a | Cobalamin(VitaminB12),FolicAcid,andHomocysteineTesting06.02.54a | Pathology and Laboratory (06) | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | 7cb2da95-c713-46c9-ad44-10da7132a337 | 2795 | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | 06.02.54 | {"2796": {"Id":2796,"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":4910,"PolicyAttachmentPageName":"3f38e38f-1a5e-4b0a-933d-2b46ca742a4d"},} |
| | | 11.01.02o | Cochlear Implant | Surgery (11) | Cochlear Implant | 85256AA800623D7A852584C500591E9D | 1968 | Cochlear Implant | 11.01.02 | |
| | | 08.01.71 | Collagenaseclostridiumhistolyticum(Xiaflex®),collagenaseclostridiumhistolyticum-aaes(Qwo™)08.01.71 | Pharmacy (08) | Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™) | 519fdc48-27be-4644-8075-53b91ac2863d | 2689 | Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™) | 08.01.71 | |
| | | 11.03.12s | ColorectalCancerScreening11.03.12s | Surgery (11) | Colorectal Cancer Screening | 60f8b449-b0dd-41bc-a76d-e67a8d129d3a | 2648 | Colorectal Cancer Screening | 11.03.12 | |
| | | 12.00.03g | Complementary and Integrative Health Services | Miscellaneous (12) | Complementary and Integrative Health Services | B55889244594F1F085258574005DA579 | 2104 | Complementary and Integrative Health Services | 12.00.03 | |
| | | 07.06.01b | Complete Decongestive Therapy (CDT) | Medicine (07) | Complete Decongestive Therapy (CDT) | 85256AA800623D7A852585340042F9F6 | 2010 | Complete Decongestive Therapy (CDT) | 07.06.01 | |
| | | 11.14.30 | Composite Tissue Allotransplantation of the Hand(s) and Face | Surgery (11) | Composite Tissue Allotransplantation of the Hand(s) and Face | 85256AA800623D7A852585380063AE75 | 1716 | Composite Tissue Allotransplantation of the Hand(s) and Face | 11.14.30 | |
| | | 05.00.37f | Compression Garments | DME (05) | Compression Garments | 85256AA800623D7A8525855100776BC6 | 1772 | Compression Garments | 05.00.37 | |
| | | 09.00.42c | Computer-Aided Detection (CAD) System for Use with Chest Radiographs | Radiology (09) | Computer-Aided Detection (CAD) System for Use with Chest Radiographs | 85256AA800623D7A852584F2004C9E48 | 1988 | Computer-Aided Detection (CAD) System for Use with Chest Radiographs | 09.00.42 | |
| | | 11.14.17e | Computer-assistedMusculoskeletalSurgicalNavigationalOrthopedicProcedure11.14.17e | Surgery (11) | Computer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure | bdbfbb63-502f-4867-826b-25ce7bbe89b8 | 2823 | Computer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure | 11.14.17 | |
| | | 00.01.69 | Consultation Services | Administrative (00) | Consultation Services | F3BA7DB0E980312B8525854B005EE64C | 2172 | Consultation Services | 00.01.69 | |
| | | 07.13.11j | ContactLensesfortheTreatmentofPersistent(Corneal)EpithelialDefects07.13.11j | Medicine (07) | Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects | 7e953cdf-6f32-49a8-b2df-1f780a7d242d | 2649 | Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects | 07.13.11 | {"2650": {"Id":2650,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":4947,"PolicyAttachmentPageName":"ac05b158-f2de-4614-81cc-945829898efa"},} |
| | | 01.00.09c | Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump | Anesthesia (01) | Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump | 85256AA800623D7A852584E900724249 | 1977 | Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump | 01.00.09 | |
| | | 09.00.11d | Contrast Agents Used in Conjunction with Echocardiography | Radiology (09) | Contrast Agents Used in Conjunction with Echocardiography | 85256AA800623D7A8525851B005C0BC6 | 2165 | Contrast Agents Used in Conjunction with Echocardiography | 09.00.11 | |
| | | 07.13.07k | CornealPachymetryUsingUltrasound07.13.07k | Medicine (07) | Corneal Pachymetry Using Ultrasound | 985d887d-5350-4c1c-ba1d-4dd28827fdc5 | 2651 | Corneal Pachymetry Using Ultrasound | 07.13.07 | {"2652": {"Id":2652,"MPAttachmentLetter":"A","Title":"ICD-10-CM codes","MPPolicyAttachmentInternalSourceId":4969,"PolicyAttachmentPageName":"eb3a5e1b-6833-42ae-88c0-4bc890ca50cb"},} |
| | | 12.01.03a | CosmeticProcedures12.01.03a | Miscellaneous (12) | Cosmetic Procedures | 47697caf-68a0-4d8d-9831-dac0ce68e860 | 2666 | Cosmetic Procedures | 12.01.03 | |
| | | 05.00.04e | Coverage of Medical Devices | DME (05) | Coverage of Medical Devices | 85256AA800623D7A852583F900647246 | 2140 | Coverage of Medical Devices | 05.00.04 | |
| | | 08.01.08d | Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical Benefit | Pharmacy (08) | Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical Benefit | 85256AA800623D7A8525855000697D90 | 2048 | Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical Benefit | 08.01.08 | |
| | | 05.00.80A | CranialElectrotherapyStimulation05.00.80A | DME (05) | Cranial Electrotherapy Stimulation | 57d5d404-40e8-4bca-b4b5-39fe907e8b06 | 2612 | Cranial Electrotherapy Stimulation | 05.00.80 | |
| | | 05.00.25i | CranialRemoldingOrthoses(Helmets)05.00.25i | DME (05) | Cranial Remolding Orthoses (Helmets) | 81e6e200-2094-43e9-804d-25c02aa5f8bf | 2998 | Cranial Remolding Orthoses (Helmets) | 05.00.25 | |
| | | 00.10.03j | Criteria for Reimbursement of Emergency Room Services | Administrative (00) | Criteria for Reimbursement of Emergency Room Services | 85256AA800623D7A852584710058EC0E | 2001 | Criteria for Reimbursement of Emergency Room Services | 00.10.03 | |
| | | 08.00.04 | crizanlizumab-tmca(Adakveo®)08.00.04 | Pharmacy (08) | crizanlizumab-tmca (Adakveo®) | c808513e-ccf8-465c-ab4d-9abcee7be5e1 | 2424 | crizanlizumab-tmca (Adakveo®) | 08.00.04 | |
| | | 11.11.03d | Cryosurgical Ablation of the Prostate Gland | Surgery (11) | Cryosurgical Ablation of the Prostate Gland | 85256AA800623D7A8525853000775E5F | 2017 | Cryosurgical Ablation of the Prostate Gland | 11.11.03 | |
| | | 08.01.29h | Daratumumab(Darzalex®),Daratumumab,andHyaluronidase-fihj(DarzalexFaspro™)08.01.29h | Pharmacy (08) | Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro™) | 0b7f187d-9fcc-4638-954b-0fd49ac02dd1 | 2894 | Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro™) | 08.01.29 | |
| | | 10.00.02c | Day Rehabilitation | Rehabilitation Services (10) | Day Rehabilitation | 85256AA800623D7A85258585004BD885 | 1748 | Day Rehabilitation | 10.00.02 | |
| | | 11.08.17j | DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNails11.08.17j | Surgery (11) | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | f64bdcce-8c4e-430e-92e5-d4e14eb3ce24 | 2514 | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | 11.08.17 | {"2515": {"Id":2515,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (A30.0 -E10.21)","MPPolicyAttachmentInternalSourceId":4872,"PolicyAttachmentPageName":"9857e79f-1d2b-4283-9a68-6dd9866f1748"},"2516": {"Id":2516,"MPAttachmentLetter":"B","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E10.22 - E13.3512), Continued","MPPolicyAttachmentInternalSourceId":4873,"PolicyAttachmentPageName":"24df6cce-58eb-45d4-8797-9fc68e44951a"},"2517": {"Id":2517,"MPAttachmentLetter":"C","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E13.3513 - I87.093), Continued","MPPolicyAttachmentInternalSourceId":4874,"PolicyAttachmentPageName":"aeaec271-9d3e-4d03-bc0a-5a5098af561e"},"2518": {"Id":2518,"MPAttachmentLetter":"E","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (S86.892A - Z79.01), Continued","MPPolicyAttachmentInternalSourceId":4875,"PolicyAttachmentPageName":"0c0b972a-20c3-4175-8806-fb3bb99e8bab"},"2519": {"Id":2519,"MPAttachmentLetter":"D","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (I87.099 - S86.891S), Continued","MPPolicyAttachmentInternalSourceId":4876,"PolicyAttachmentPageName":"a68dbcea-d9ef-4f6d-9323-fc5467df0203"},} |
| | | 11.15.20p | DeepBrainStimulation(DBS)11.15.20p | Surgery (11) | Deep Brain Stimulation (DBS) | 3ecc3555-70b4-4662-ae43-bfa5024ef24e | 2629 | Deep Brain Stimulation (DBS) | 11.15.20 | |
| | | 11.15.09o | DenervationoftheSpinalNervesforChronicPain(IndependenceAdministrators)11.15.09o | Surgery (11) | Denervation of the Spinal Nerves for Chronic Pain (Independence Administrators) | b05afb73-aba6-464c-9acf-1d4e934cc883 | 2928 | Denervation of the Spinal Nerves for Chronic Pain (Independence Administrators) | 11.15.09 | |
| | | 08.00.94n | Denosumab(Prolia®,Xgeva®),Romosozumab-aqqg(Evenity™)08.00.94n | Pharmacy (08) | Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™) | 8d9d870a-9cef-4e53-a799-1cf04b959223 | 2575 | Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™) | 08.00.94 | {"2576": {"Id":2576,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes","MPPolicyAttachmentInternalSourceId":4828,"PolicyAttachmentPageName":"6b69ad4a-cf8a-48c3-be05-4d1ae940beb8"},} |
| | | 00.03.02ab | DiagnosticRadiologyServicesIncludedinCapitation00.03.02ab | Administrative (00) | Diagnostic Radiology Services Included in Capitation | ef37cab5-6501-4d87-acad-5bf9060d23d4 | 2960 | Diagnostic Radiology Services Included in Capitation | 00.03.02 | {"2961": {"Id":2961,"MPAttachmentLetter":"A","Title":"Diagnostic Radiology Procedure Codes Included in Capitation for Pennsylvania (PA) Health Maintenance Organization (HMO) Members","MPPolicyAttachmentInternalSourceId":5246,"PolicyAttachmentPageName":"1a071f00-e2c4-47cb-9af9-e77692b0d24c"},} |
| | | 00.09.01h | DirectAccesstoObstetrics/Gynecology(OB/GYN)Services00.09.01h | Administrative (00) | Direct Access to Obstetrics/Gynecology (OB/GYN) Services | 9c981601-10cc-4167-a854-9da704832694 | 2912 | Direct Access to Obstetrics/Gynecology (OB/GYN) Services | 00.09.01 | {"2913": {"Id":2913,"MPAttachmentLetter":"A","Title":"Procedure Codes for Direct Access OB/GYN","MPPolicyAttachmentInternalSourceId":5193,"PolicyAttachmentPageName":"06aff05f-ffda-49be-930f-087f93089d77"},} |
| | | 08.00.49e | Dofetilide (Tikosyn®) Use in the Inpatient Setting | Pharmacy (08) | Dofetilide (Tikosyn®) Use in the Inpatient Setting | 85256AA800623D7A852585A40063C332 | 1790 | Dofetilide (Tikosyn®) Use in the Inpatient Setting | 08.00.49 | |
| | | 07.05.07d | Drug-ElutingBeadsandBlandEmbolizationfortheTreatmentofHepaticMalignancies07.05.07d | Medicine (07) | Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies | e6e62a11-5776-4052-ab2f-c0631761df82 | 2637 | Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies | 07.05.07 | |
| | | 08.01.37a | Drugs 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) | 85256AA800623D7A8525820B004EC0DE | 1894 | Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Naltrexone Implants, Probuphine Implant, Sublocade Injection, Vivitrol Injection) | 08.01.37 | |
| | | 05.00.21w | DurableMedicalEquipment(DME)andConsumableMedicalSupplies05.00.21w | DME (05) | Durable Medical Equipment (DME) and Consumable Medical Supplies | 4e3f43f8-2319-4e2b-a904-b5f1da2cfc84 | 2859 | Durable Medical Equipment (DME) and Consumable Medical Supplies | 05.00.21 | {"2860": {"Id":2860,"MPAttachmentLetter":"A2","Title":"Equipment that Meets the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":5039,"PolicyAttachmentPageName":"c68f84be-777b-47ea-b7c2-e7a984368366"},"2861": {"Id":2861,"MPAttachmentLetter":"B","Title":"Items that Do Not Meet the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":5040,"PolicyAttachmentPageName":"aa69befa-d39d-407c-900d-7194651ae237"},"2862": {"Id":2862,"MPAttachmentLetter":"A1","Title":"Equipment that Meets the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":5041,"PolicyAttachmentPageName":"a282b700-00ee-413b-a130-198f8c698cf3"},} |
| | | 05.00.48k | DurableMedicalEquipment(DME)NotSubjecttoaRentaltoPurchaseMaximum05.00.48k | DME (05) | Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum | 7cae1a28-f168-4966-b786-0320a4fa96d4 | 2986 | Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum | 05.00.48 | |
