|  | | 08.00.62j | Abatacept (Orencia®) for Injection for Intravenous Use | Pharmacy (08) | Abatacept (Orencia®) for Injection for Intravenous Use | 85256AA800623D7A852584EB005E0702 | 2396 | Abatacept (Orencia®) for Injection for Intravenous Use | 08.00.62 | {"2339":{"Id":2339,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584EB005E070C"},} |
| | | 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 | |
| | | 08.01.11e | Ado-Trastuzumab Emtansine (Kadcyla®) | Pharmacy (08) | Ado-Trastuzumab Emtansine (Kadcyla®) | 85256AA800623D7A852583C4005C4617 | 1846 | Ado-Trastuzumab Emtansine (Kadcyla®) | 08.01.11 | {"2209": {"Id":2209,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes and Narratives","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852583C4005C461D"},} |
| | | 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 | |
| | | 07.00.21i | Allergy Immunotherapy | Medicine (07) | Allergy Immunotherapy | 85256AA800623D7A852584E900723F3A | 1980 | 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 | |
| | | 08.00.91d | Alpha 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™) | C0BF3216424958498525851F0065B493 | 1993 | Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™) | 08.00.91 | |
| | | 00.01.52i | Always Bundled Procedure Codes | Administrative (00) | Always Bundled Procedure Codes | 85256AA800623D7A852584BE0061748B | 2158 | Always Bundled Procedure Codes | 00.01.52 | {"2297": {"Id":2297,"MPAttachmentLetter":"A","Title":"CPT Codes and HCPCS Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584BE00617493"},} |
| | | 07.02.09g | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | Medicine (07) | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | 85256AA800623D7A8525852700657888 | 2041 | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | 07.02.09 | |
| | | 07.02.21e | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | Medicine (07) | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | 85256AA800623D7A8525849B0072BC56 | 1962 | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | 07.02.21 | |
| | | 05.00.39o | Ankle-Foot/Knee-Ankle-Foot Orthoses | DME (05) | Ankle-Foot/Knee-Ankle-Foot Orthoses | 85256AA800623D7A8525847900595D5D | 1864 | Ankle-Foot/Knee-Ankle-Foot Orthoses | 05.00.39 | {"2219": {"Id":2219,"MPAttachmentLetter":"A","Title":"HCPCS Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525847900595D63"},} |
| | | 06.03.04n | Apheresis Therapy | Pathology and Laboratory (06) | Apheresis Therapy | 85256AA800623D7A852581E800531E7B | 1795 | Apheresis Therapy | 06.03.04 | |
| | | 11.08.05g | Application and Removal of Tattoos | Surgery (11) | Application and Removal of Tattoos | 85256AA800623D7A85258464005D7037 | 1866 | 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"},} |
| | | 11.05.16h | Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | Surgery (11) | Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | 85256AA800623D7A85258397005A3BB6 | 1850 | Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | 11.05.16 | {"2211": {"Id":2211,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258397005A3BBF"},} |
| | | 11.14.19o | Artificial Intervertebral Disc Insertion | Surgery (11) | Artificial Intervertebral Disc Insertion | A3A0632A8125CAEF85258588005C3C90 | 1733 | Artificial Intervertebral Disc Insertion | 11.14.19 | |
| | | 08.01.35b | Asparaginase Erwinia Chrysanthemi (Erwinaze®) | Pharmacy (08) | Asparaginase Erwinia Chrysanthemi (Erwinaze®) | 85256AA800623D7A8525848D004D1680 | 1929 | 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 | |
| | | 07.10.06h | Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation | Medicine (07) | Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation | 85256AA800623D7A852584C500591919 | 1969 | Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation | 07.10.06 | |
| | | 11.14.06i | Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions | Surgery (11) | Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions | 85256AA800623D7A8525849B004313B6 | 1741 | Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions | 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 | Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis | Surgery (11) | Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis | 85256AA800623D7A852584C80048DC59 | 1958 | Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis | 11.16.06 | |
| | | 11.03.02s | Bariatric Surgery | Surgery (11) | Bariatric Surgery | 85256AA800623D7A852584E0005DE542 | 1972 | Bariatric Surgery | 11.03.02 | {"2303": {"Id":2303,"MPAttachmentLetter":"A","Title":"Body Mass Index (BMI) Charts","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584E0005DE54F"},"2304": {"Id":2304,"MPAttachmentLetter":"B","Title":"Tanner Staging System Criteria for Adolescents","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584E0005DE554"},"2305": {"Id":2305,"MPAttachmentLetter":"C","Title":"ICD-10-CM codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584E0005DE558"},} |
| | | 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 | |
| | | 08.00.66n | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | Pharmacy (08) | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | 6566BD92D37238AE8525856900675D9F | 2057 | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | 08.00.66 | {"2328": {"Id":2328,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"22FCB0309FA06CF48525856900675DB5"},} |
| | | 00.10.39l | Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus | Administrative (00) | Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus | 21B5108DBB59C30C8525854B0059E5B9 | 2171 | 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 | {"2323": {"Id":2323,"MPAttachmentLetter":"A","Title":"No Title","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"9640A916A3C2C7C98525854B0059E5C9"},} |
| | | 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"},} |
| | | 07.00.01i | Biofeedback Therapy | Medicine (07) | Biofeedback Therapy | 85256AA800623D7A852584C800740AEF | 1952 | 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 | |
| | | 11.05.02i | Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy | Surgery (11) | Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy | 85256AA800623D7A85258336004611B0 | 1801 | Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy | 11.05.02 | {"2194": {"Id":2194,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258336004611BB"},} |
| | | 08.01.21c | Blinatumomab (Blincyto®) | Pharmacy (08) | Blinatumomab (Blincyto®) | 85256AA800623D7A85258401004A12A1 | 1826 | 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) Hearing Aids and Implantable Middle Ear Hearing Aids | Surgery (11) | Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids | 85256AA800623D7A852583F200496747 | 1838 | 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 | |
| | | 05.00.76c | Breast Pumps | DME (05) | Breast Pumps | 85256AA800623D7A852584C80074166B | 1947 | Breast Pumps | 05.00.76 | |
| | | 08.01.13d | Brentuximab Vedotin (Adcetris®) | Pharmacy (08) | Brentuximab Vedotin (Adcetris®) | 85256AA800623D7A8525848D004D1008 | 1945 | Brentuximab Vedotin (Adcetris®) | 08.01.13 | {"2285": {"Id":2285,"MPAttachmentLetter":"A","Title":"ICD CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525848D004D1011"},} |
| | | 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 | |
| | | 08.00.96e | Cabazitaxel (Jevtana®) | Pharmacy (08) | Cabazitaxel (Jevtana®) | 85256AA800623D7A8525853D005A168F | 1780 | Cabazitaxel (Jevtana®) | 08.00.96 | |
| | | 08.01.51 | Canakinumab (Ilaris®) | Pharmacy (08) | Canakinumab (Ilaris®) | 85256AA800623D7A852585660071B05C | 2065 | Canakinumab (Ilaris®) | 08.01.51 | |
| | | 10.01.01n | Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs | Rehabilitation Services (10) | Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs | 85256AA800623D7A8525847E006A6590 | 1874 | Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs | 10.01.01 | {"2221": {"Id":2221,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525847E006A6597"},} |
| | | 00.01.59f | Care Management and Care Planning Services | Administrative (00) | Care Management and Care Planning Services | 85256AA800623D7A8525847F0061D443 | 2161 | Care Management and Care Planning Services | 00.01.59 | |
| | | 08.01.05f | Carfilzomib (Kyprolis™) | Pharmacy (08) | Carfilzomib (Kyprolis™) | 85256AA800623D7A852583E60043F347 | 1844 | Carfilzomib (Kyprolis™) | 08.01.05 | |
| | | 00.10.15c | Cast and Splint Applications and Associated Supplies Provided in the Office Setting | Administrative (00) | Cast and Splint Applications and Associated Supplies Provided in the Office Setting | 82EF268AB3C7CA1E852581E9005653DB | 2119 | Cast and Splint Applications and Associated Supplies Provided in the Office Setting | 00.10.15 | {"2184": {"Id":2184,"MPAttachmentLetter":"A","Title":"No Title","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"4D63E2E2E70A4FA4852581E9005653EC"},} |
| | | 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 | Catheter Ablation of Cardiac Arrhythmias | Surgery (11) | Catheter Ablation of Cardiac Arrhythmias | 85256AA800623D7A8525847B00611B55 | 1885 | 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 | |
| | | 05.00.61f | Cervical Traction Devices for In-home Use | DME (05) | Cervical Traction Devices for In-home Use | 85256AA800623D7A852583CC0054CDD8 | 1830 | 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 | Chemical Peels | Surgery (11) | Chemical Peels | 85256AA800623D7A85258464005D7623 | 1879 | Chemical Peels | 11.08.08 | |
| | | 08.01.43e | Chimeric Antigen Receptor (CAR) Therapy | Pharmacy (08) | Chimeric Antigen Receptor (CAR) Therapy | 85256AA800623D7A852583E500468BCA | 1925 | Chimeric Antigen Receptor (CAR) Therapy | 08.01.43 | {"2276": {"Id":2276,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852583E500468BD0"},} |
| | | 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 | |
| | | 08.00.92ab | Coagulation Factors | Pharmacy (08) | Coagulation Factors | 85256AA800623D7A85258583006910C4 | 1765 | Coagulation Factors | 08.00.92 | |
| | | 06.02.54 | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | Pathology and Laboratory (06) | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | 85256AA800623D7A852585A4006620E8 | 1789 | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | 06.02.54 | {"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"},} |
| | | 11.01.02o | Cochlear Implant | Surgery (11) | Cochlear Implant | 85256AA800623D7A852584C500591E9D | 1968 | Cochlear Implant | 11.01.02 | |
| | | 11.03.12s | Colorectal Cancer Screening | Surgery (11) | Colorectal Cancer Screening | 85256AA800623D7A85258538004FBB12 | 2024 | 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 | |
| | | 11.14.17d | Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures | Surgery (11) | Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures | 85256AA800623D7A852584E90067043F | 2049 | Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures | 11.14.17 | |
| | | 00.01.69 | Consultation Services | Administrative (00) | Consultation Services | F3BA7DB0E980312B8525854B005EE64C | 2172 | Consultation Services | 00.01.69 | |
| | | 07.13.11i | Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects | Medicine (07) | Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects | 85256AA800623D7A852584B600729006 | 1914 | Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects | 07.13.11 | {"2272": {"Id":2272,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584B60072900D"},} |
| | | 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 | |
| | | 07.13.07j | Corneal Pachymetry Using Ultrasound | Medicine (07) | Corneal Pachymetry Using Ultrasound | 85256AA800623D7A852584B6006FCA09 | 1911 | Corneal Pachymetry Using Ultrasound | 07.13.07 | {"2269": {"Id":2269,"MPAttachmentLetter":"A","Title":"ICD-10-CM codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584B6006FCA0F"},} |
| | | 12.01.03 | Cosmetic Procedures | Miscellaneous (12) | Cosmetic Procedures | 85256AA800623D7A852583CC0054C214 | 1821 | 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 | Cranial Electrotherapy Stimulation | DME (05) | Cranial Electrotherapy Stimulation | 85256AA800623D7A852584C80048E9C1 | 1953 | Cranial Electrotherapy Stimulation | 05.00.80 | |
| | | 05.00.25i | Cranial Remolding Orthoses (Helmets) | DME (05) | Cranial Remolding Orthoses (Helmets) | B359B93517FDEAD385258550007A8C53 | 2043 | 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 | |
| | | 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 | |
| | | 08.01.29f | Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro™) | Pharmacy (08) | Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro™) | 85256AA800623D7A8525856F00681F27 | 2399 | 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 | |
| | | 11.08.17i | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | Surgery (11) | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | 85256AA800623D7A85258527006587B4 | 2027 | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | 11.08.17 | {"2315": {"Id":2315,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (A30.0 -E10.21)","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258527006587BF"},"2316": {"Id":2316,"MPAttachmentLetter":"B","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E10.22 - E13.3512), Continued","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258527006587C7"},"2317": {"Id":2317,"MPAttachmentLetter":"C","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E13.3513 - I87.093), Continued","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258527006587CD"},"2318": {"Id":2318,"MPAttachmentLetter":"D","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (I87.099 - S86.891S), Continued","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258527006587D3"},"2319": {"Id":2319,"MPAttachmentLetter":"E","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (S86.892A - Z79.01), Continued","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258527006587DB"},} |
| | | 11.15.20o | Deep Brain Stimulation (DBS) | Surgery (11) | Deep Brain Stimulation (DBS) | 85256AA800623D7A8525842B006B6CC3 | 1857 | Deep Brain Stimulation (DBS) | 11.15.20 | |
| | | 11.15.09n | Denervation of the Spinal Nerves for Chronic Pain | Surgery (11) | Denervation of the Spinal Nerves for Chronic Pain | 6E54370B49975A5A85258588005CDCC0 | 1737 | Denervation of the Spinal Nerves for Chronic Pain | 11.15.09 | |
| | | 08.00.94m | Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™) | Pharmacy (08) | Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™) | 85256AA800623D7A8525847A0047A1F9 | 1883 | Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™) | 08.00.94 | {"2227": {"Id":2227,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525847A0047A20C"},} |
| | | 08.01.24a | Deoxycholic Acid (Kybella™) | Pharmacy (08) | Deoxycholic Acid (Kybella™) | 85256AA800623D7A852585880062FEBF | 1762 | Deoxycholic Acid (Kybella™) | 08.01.24 | |
| | | 00.03.02aa | Diagnostic Radiology Services Included in Capitation | Administrative (00) | Diagnostic Radiology Services Included in Capitation | 85256AA800623D7A85258513005AF2AB | 2170 | Diagnostic Radiology Services Included in Capitation | 00.03.02 | {"2314": {"Id":2314,"MPAttachmentLetter":"A","Title":"Diagnostic Radiology Procedure Codes Included in Capitation for Pennsylvania (PA) Health Maintenance Organization (HMO) Members","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258513005AF2BC"},} |
| | | 00.09.01f | Direct Access to Obstetrics/Gynecology (OB/GYN) Services | Administrative (00) | Direct Access to Obstetrics/Gynecology (OB/GYN) Services | 85256AA800623D7A852582CD00532104 | 2133 | Direct Access to Obstetrics/Gynecology (OB/GYN) Services | 00.09.01 | |
| | | 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-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies | Medicine (07) | Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies | 85256AA800623D7A852584A300472C57 | 1927 | 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 | |
| | | 05.00.21u | Durable Medical Equipment (DME) and Consumable Medical Supplies | DME (05) | Durable Medical Equipment (DME) and Consumable Medical Supplies | 85256AA800623D7A852584D60053CD80 | 2162 | Durable Medical Equipment (DME) and Consumable Medical Supplies | 05.00.21 | {"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"},} |
| | | 05.00.48j | Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum | DME (05) | Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum | 85256AA800623D7A85258360004DAB8C | 2128 | Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum | 05.00.48 | |
| | | 08.01.65 | Durvalumab(Imfinzi™)08.01.65 | Pharmacy (08) | Durvalumab (Imfinzi™) | 0482613c-8013-4037-b66f-4be91e7362cf | 2455 | Durvalumab (Imfinzi™) | 08.01.65 | {"2456": {"Id":2456,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":2495,"PolicyAttachmentPageName":"6fce0a1d-ee99-41d7-87e5-9c2b8620a774"},} |
| | | 08.00.84g | Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris®) | Pharmacy (08) | Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris®) | 85256AA800623D7A852584C80066FE64 | 2044 | Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris®) | 08.00.84 | |
| | | 08.01.42a | Edaravone(Radicava™)08.01.42a | Pharmacy (08) | Edaravone (Radicava™) | c5d35afa-e005-41dd-9515-b27c07a2fcd3 | 2442 | Edaravone (Radicava™) | 08.01.42 | |
