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b00ed136-3352-4223-b636-58021431bded.aspx
  
3582Abatacept(Orencia®)forInjectionforIntravenousUseMA08.028gPharmacy (08)MA08.028gMA08.028b00ed136-3352-4223-b636-58021431bdedAbatacept (Orencia®) for Injection for Intravenous UseAbatacept (Orencia®) for Injection for Intravenous Use
{"3583": {"Id":3583,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":6282,"PolicyAttachmentPageName":"cf45094d-bd05-4d93-993e-aa5a18b82368"},}
5e7d70e9-cd59-4945-8fd8-e5552ecdbe7f.aspx
  
2507AbortionMA11.010aSurgery (11)MA11.010aMA11.0105e7d70e9-cd59-4945-8fd8-e5552ecdbe7fAbortionAbortion
ba6bd7ca-d349-4200-b14d-b89ece686f02.aspx
  
3752AcupunctureMA12.004cMiscellaneous (12)MA12.004cMA12.004ba6bd7ca-d349-4200-b14d-b89ece686f02AcupunctureAcupuncture
{"3753": {"Id":3753,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Acupuncture","MPPolicyAttachmentInternalSourceId":6538,"PolicyAttachmentPageName":"6f541d12-71dd-4931-ad62-8855a8184bf8"},}
534525a5-76f0-4bce-9bd9-d6dcff647b59.aspx
  
2689AcuteCareFacilityInpatientTransfersMA12.003aMiscellaneous (12)MA12.003aMA12.003534525a5-76f0-4bce-9bd9-d6dcff647b59Acute Care Facility Inpatient TransfersAcute Care Facility Inpatient Transfers
5f25974a-991e-490a-8a33-8d6a3fa71a7d.aspx
  
3182Ado-TrastuzumabEmtansine(Kadcyla®)MA08.066ePharmacy (08)MA08.066eMA08.0665f25974a-991e-490a-8a33-8d6a3fa71a7dAdo-Trastuzumab Emtansine (Kadcyla®)Ado-Trastuzumab Emtansine (Kadcyla®)
{"3183": {"Id":3183,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":5901,"PolicyAttachmentPageName":"a5920afd-efb8-4cba-a212-104df2b8fffa"},}
72b0047c-3b34-4685-ad68-a0a2b71933b1.aspx
  
3434Agalsidasebeta(Fabrazyme®)MA08.033cPharmacy (08)MA08.033cMA08.03372b0047c-3b34-4685-ad68-a0a2b71933b1Agalsidase beta (Fabrazyme®)Agalsidase beta (Fabrazyme®)
8e39da98-8d07-4c8a-bef5-02fa5b6a5006.aspx
  
2758AirAmbulanceServicesMA12.007aMiscellaneous (12)MA12.007aMA12.0078e39da98-8d07-4c8a-bef5-02fa5b6a5006Air Ambulance ServicesAir Ambulance Services
1f566b6c-8a94-4447-8e00-fe6c78c20462.aspx
  
3568Alemtuzumab(Lemtrada®)MA08.015dPharmacy (08)MA08.015dMA08.0151f566b6c-8a94-4447-8e00-fe6c78c20462Alemtuzumab (Lemtrada®)Alemtuzumab (Lemtrada®)
e5598147-140e-442f-b181-fb610293bd70.aspx
  
3525Alglucosidasealfa(e.g.,Lumizyme®),Avalglucosidasealfa-ngpt(Nexviazyme®)MA08.036fPharmacy (08)MA08.036fMA08.036e5598147-140e-442f-b181-fb610293bd70Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® )Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® )
719b74d6-420c-4235-bd9c-701076317da1.aspx
  
2592AllergyImmunotherapyMA07.055dMedicine (07)MA07.055dMA07.055719b74d6-420c-4235-bd9c-701076317da1Allergy ImmunotherapyAllergy Immunotherapy
1200bd89-d573-4716-a175-5c772b242da4.aspx
  
3569Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C,AralastNP,Glassia,Zemaira)MA08.050bPharmacy (08)MA08.050bMA08.0501200bd89-d573-4716-a175-5c772b242da4Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C, Aralast NP, Glassia, Zemaira)Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C, Aralast NP, Glassia, Zemaira)
c308d403-fa13-4dbf-9ff8-232d4a5cdeeb.aspx
  
3460AlwaysBundledProcedureCodesMA00.026nAdministrative (00)MA00.026nMA00.026c308d403-fa13-4dbf-9ff8-232d4a5cdeebAlways Bundled Procedure CodesAlways Bundled Procedure Codes
{"3461": {"Id":3461,"MPAttachmentLetter":"B","Title":"Procedures/Services Not Eligible for Separate Reimbursement","MPPolicyAttachmentInternalSourceId":6313,"PolicyAttachmentPageName":"4c929de9-66d8-4c7e-bfc6-0aa7b60e83f5"},"3462": {"Id":3462,"MPAttachmentLetter":"A","Title":"Always Bundled Procedures (MPFSD Indicator B)","MPPolicyAttachmentInternalSourceId":6314,"PolicyAttachmentPageName":"bfe56c96-a3ed-4ee1-8564-21218c6b70eb"},"3463": {"Id":3463,"MPAttachmentLetter":"C","Title":"Procedures/Services Not Eligible for Reimbursement","MPPolicyAttachmentInternalSourceId":6315,"PolicyAttachmentPageName":"04778e62-489d-47c3-93ff-d4429e47d70e"},}
301346f4-5db6-4773-ade7-a8c8bddfe5fe.aspx
  
2460AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)DevicesMA07.005cMedicine (07)MA07.005cMA07.005301346f4-5db6-4773-ade7-a8c8bddfe5feAmbulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) DevicesAmbulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
d8076ce2-0412-4e39-861a-b11c14e55f16.aspx
  
3801AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)MonitoringMA07.026iMedicine (07)MA07.026iMA07.026d8076ce2-0412-4e39-861a-b11c14e55f16Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
6a1b55c5-5993-4f32-a0ed-4fd61d9d86ac.aspx
  
3813AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagementMA01.008aAnesthesia (01)MA01.008aMA01.0086a1b55c5-5993-4f32-a0ed-4fd61d9d86acAnesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint ManagementAnesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management
{}
2997254c-1be9-4fd5-9b6b-394b8f40bf96.aspx
  
3571Anifrolumab-fnia(Saphnelo™)MA08.140bPharmacy (08)MA08.140bMA08.1402997254c-1be9-4fd5-9b6b-394b8f40bf96Anifrolumab-fnia (Saphnelo™)Anifrolumab-fnia (Saphnelo™)
4381bbfc-9be4-4c1d-be48-104f3d74cddf.aspx
  
2830Ankle-Foot/Knee-Ankle-FootOrthosesMA05.010gDME (05)MA05.010gMA05.0104381bbfc-9be4-4c1d-be48-104f3d74cddfAnkle-Foot/Knee-Ankle-Foot OrthosesAnkle-Foot/Knee-Ankle-Foot Orthoses
{"2831": {"Id":2831,"MPAttachmentLetter":"A","Title":"HCPCS CODES FOR ANKLE-FOOT/ KNEE-ANKLE FOOT ORTHOSIS","MPPolicyAttachmentInternalSourceId":5438,"PolicyAttachmentPageName":"abe26858-dc87-4040-a463-5b67d4bafc0c"},}
6784e81c-0d85-46ea-8570-0305b1408593.aspx
  
3503AnorectalManometry,Electromyography(EMG)ofAnorectalorUrethralSphincters;BiofeedbackTrainingforPerinealMusclesandAnorectalorUrethralSphinctersMA07.018bMedicine (07)MA07.018bMA07.0186784e81c-0d85-46ea-8570-0305b1408593Anorectal Manometry, Electromyography (EMG) of Anorectal or Urethral Sphincters; Biofeedback Training for Perineal Muscles and Anorectal or Urethral SphinctersAnorectal Manometry, Electromyography (EMG) of Anorectal or Urethral Sphincters; Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters
a8e854f7-94e7-4833-a02c-b7fb4214ff25.aspx
  
2179ApheresisTherapyMA06.001ePathology and Laboratory (06)MA06.001eMA06.001a8e854f7-94e7-4833-a02c-b7fb4214ff25Apheresis TherapyApheresis Therapy
5e7b3431-7254-494b-91b5-f3edb685eb24.aspx
  
3515ApplicationandRemovalofTattoosMA11.072Surgery (11)MA11.072MA11.0725e7b3431-7254-494b-91b5-f3edb685eb24Application and Removal of TattoosApplication and Removal of Tattoos
2db5cb4d-4bc2-4894-b0b9-ff440fda15da.aspx
  
2881Aprepitant(Cinvanti™),FosaprepitantDimeglumine(Emend®),Granisetron(Sustol®),andRolapitant(Varubi®)MA08.091cPharmacy (08)MA08.091cMA08.0912db5cb4d-4bc2-4894-b0b9-ff440fda15daAprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
{"2882": {"Id":2882,"MPAttachmentLetter":"A","Title":"Risk of Emesis Without Prophylaxis: Intravenous and Oral Antineoplastic Agents","MPPolicyAttachmentInternalSourceId":5661,"PolicyAttachmentPageName":"f1fed1fc-a936-48d8-8d28-4ada8844ac1e"},}
2313c755-a8c0-4d9c-8206-82caa054a320.aspx
  
3634AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucomaMA11.105iSurgery (11)MA11.105iMA11.1052313c755-a8c0-4d9c-8206-82caa054a320Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
{"3635": {"Id":3635,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":6350,"PolicyAttachmentPageName":"05b584a0-623a-4a99-97a9-d63d94ab24a2"},}
2cff6db4-e919-4ab2-ad56-761344c18f87.aspx
  
3695ArtificialIntervertebralLumbarDiscInsertionMA11.114aSurgery (11)MA11.114aMA11.1142cff6db4-e919-4ab2-ad56-761344c18f87Artificial Intervertebral Lumbar Disc InsertionArtificial Intervertebral Lumbar Disc Insertion
53bac0ed-9c15-45d1-a6eb-df0442a11e2a.aspx
  
3742Asparaginaseerwiniachrysanthemi(Erwinaze®),asparaginaseerwiniachrysanthemi(recombinant)-rywn(Rylaze™)MA08.085fPharmacy (08)MA08.085fMA08.08553bac0ed-9c15-45d1-a6eb-df0442a11e2aAsparaginase erwinia chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze™)Asparaginase erwinia chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze™)
cde82c5a-0a80-4bfb-9c2f-a6bec18e4a07.aspx
  
3391Atezolizumab(Tecentriq®)MA08.127bPharmacy (08)MA08.127bMA08.127cde82c5a-0a80-4bfb-9c2f-a6bec18e4a07Atezolizumab (Tecentriq®)Atezolizumab (Tecentriq®)
{"3392": {"Id":3392,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":6122,"PolicyAttachmentPageName":"1f3a7a81-eda4-44e7-a9a5-f6286558df75"},}
2c2947af-08f9-42aa-8f15-ab11b599d2fc.aspx
  
3802AutomaticExternalCardioverterDefibrillators(WearableandNonwearable)MA05.005eDME (05)MA05.005eMA05.0052c2947af-08f9-42aa-8f15-ab11b599d2fcAutomatic External Cardioverter Defibrillators (Wearable and Nonwearable)Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
{"3803": {"Id":3803,"MPAttachmentLetter":"B","Title":"ICD-10 codes used to represent the Nonwearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":6687,"PolicyAttachmentPageName":"903eea21-52a3-4476-a8a3-e7a9dd31808b"},"3804": {"Id":3804,"MPAttachmentLetter":"A","Title":"ICD-10 codes used to represent the Wearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":6688,"PolicyAttachmentPageName":"c336d160-a067-4713-960f-9bc06237edfa"},}
3af75148-49ba-4d1c-ba97-554d5699a376.aspx
  
3819AutonomicNervousSystemTestingMA07.027fMedicine (07)MA07.027fMA07.0273af75148-49ba-4d1c-ba97-554d5699a376Autonomic Nervous System TestingAutonomic Nervous System Testing
c806ce2a-769d-48f7-a30c-2cfeb52836f0.aspx
  
3304Avelumab(Bavencio®)MA08.122aPharmacy (08)MA08.122aMA08.122c806ce2a-769d-48f7-a30c-2cfeb52836f0Avelumab (Bavencio®)Avelumab (Bavencio®)
{"3305": {"Id":3305,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":6027,"PolicyAttachmentPageName":"990f7252-595d-48ad-bbee-e9b41d917538"},}
cabedfbf-0373-4c4a-92e4-36c05c25ded0.aspx
  
3619BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitisMA11.100eSurgery (11)MA11.100eMA11.100cabedfbf-0373-4c4a-92e4-36c05c25ded0Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic RhinosinusitisBalloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
cf4b9338-44d8-4be3-b8af-86f6920be908.aspx
  
3532belantamabmafodotin-blmf(Blenrep)MA08.119bPharmacy (08)MA08.119bMA08.119cf4b9338-44d8-4be3-b8af-86f6920be908belantamab mafodotin-blmf (Blenrep) belantamab mafodotin-blmf (Blenrep)
16ac27d9-275a-45ac-9a62-6ed58a355d9f.aspx
  
3381Belimumab(Benlysta®)forIntravenousUseMA08.057cPharmacy (08)MA08.057cMA08.05716ac27d9-275a-45ac-9a62-6ed58a355d9fBelimumab (Benlysta®) for Intravenous UseBelimumab (Benlysta®) for Intravenous Use
7dce5b9d-95d2-4bd9-8393-6fbc8b93f084.aspx
  
3814Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUseMA08.072jPharmacy (08)MA08.072jMA08.0727dce5b9d-95d2-4bd9-8393-6fbc8b93f084Bevacizumab (Avastin®) and Related Biosimilars For Oncologic UseBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
{"3815": {"Id":3815,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":6759,"PolicyAttachmentPageName":"8f517e1f-a547-47f1-9234-0a8caa2ec1a5"},}
fa386a65-d740-4764-878d-b0c03ccee966.aspx
  
3321BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampusMA00.037kAdministrative (00)MA00.037kMA00.037fa386a65-d740-4764-878d-b0c03ccee966Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility CampusBilling for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
{"3322": {"Id":3322,"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 - CPT/HCPCS Codes","MPPolicyAttachmentInternalSourceId":6120,"PolicyAttachmentPageName":"59902f83-9042-435b-95fb-a2fc79a83db1"},}
cd3494a3-4f4f-4dc3-b0ae-c7e16e45d55f.aspx
  
3644BiofeedbackTherapyMA07.010aMedicine (07)MA07.010aMA07.010cd3494a3-4f4f-4dc3-b0ae-c7e16e45d55fBiofeedback TherapyBiofeedback Therapy
fc94fb44-a8a9-41f6-8fe6-687483a6ebc6.aspx
  
3618BioimpedancefortheDetectionofLymphedemaMA07.052Medicine (07)MA07.052MA07.052fc94fb44-a8a9-41f6-8fe6-687483a6ebc6Bioimpedance for the Detection of LymphedemaBioimpedance for the Detection of Lymphedema
2d373d81-6a26-4c58-ac15-91a4a9852ce4.aspx
  
3139Blepharoplasty,RepairofBlepharoptosis,RepairofBrowPtosis,andCanthoplasty/CanthopexyMA11.047dSurgery (11)MA11.047dMA11.0472d373d81-6a26-4c58-ac15-91a4a9852ce4Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/CanthopexyBlepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
{"3140": {"Id":3140,"MPAttachmentLetter":"A","Title":"ICD-10 Coding","MPPolicyAttachmentInternalSourceId":5957,"PolicyAttachmentPageName":"ded3956f-21da-4869-96e4-ea6aa23ba7a1"},}
9169d365-5d9b-44b4-a3f9-3fa88e9a4a1a.aspx
  
3631Blinatumomab(Blincyto®)MA08.058ePharmacy (08)MA08.058eMA08.0589169d365-5d9b-44b4-a3f9-3fa88e9a4a1aBlinatumomab (Blincyto®)Blinatumomab (Blincyto®)
66ab564f-29c9-49a4-b197-209795e269fe.aspx
  
3653Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAidsMA11.049dSurgery (11)MA11.049dMA11.04966ab564f-29c9-49a4-b197-209795e269feBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing AidsBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
9a2434d8-c271-4dea-a383-55f0c9886c7f.aspx
  
3446Bortezomib(BortezomibforInjection,Velcade®)MA08.037hPharmacy (08)MA08.037hMA08.0379a2434d8-c271-4dea-a383-55f0c9886c7fBortezomib (Bortezomib for Injection, Velcade®)Bortezomib (Bortezomib for Injection, Velcade®)
{"3447": {"Id":3447,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":6197,"PolicyAttachmentPageName":"f33ebea6-5963-4968-882c-4adac5474efb"},}
18450aea-5590-4c1c-93f7-b826767af30c.aspx
  
3855BotulinumToxinAgentsMA08.017hPharmacy (08)MA08.017hMA08.01718450aea-5590-4c1c-93f7-b826767af30cBotulinum Toxin AgentsBotulinum Toxin Agents
{"3856": {"Id":3856,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":6761,"PolicyAttachmentPageName":"c95eeb16-1e5d-46bb-8ec4-68f43aee9c3f"},}
5de87146-f5e7-4927-8264-ff5c323d17a9.aspx
  
3792BrentuximabVedotin(Adcetris®)MA08.068hPharmacy (08)MA08.068hMA08.0685de87146-f5e7-4927-8264-ff5c323d17a9Brentuximab Vedotin (Adcetris®)Brentuximab Vedotin (Adcetris®)
{"3793": {"Id":3793,"MPAttachmentLetter":"A","Title":"ICD 10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":6763,"PolicyAttachmentPageName":"53f87106-7279-43a6-9fb7-e70e019e1292"},}
69c14601-19f4-4a22-869a-ce88af536766.aspx
  
3417BronchialValvesMA11.020Surgery (11)MA11.020MA11.02069c14601-19f4-4a22-869a-ce88af536766Bronchial ValvesBronchial Valves
6fab4e9d-5e32-4f2d-a48f-3b3b7d31608f.aspx
  
3524Burosumab-twza(Crysvita®)MA08.099bPharmacy (08)MA08.099bMA08.0996fab4e9d-5e32-4f2d-a48f-3b3b7d31608fBurosumab-twza (Crysvita®)Burosumab-twza (Crysvita®)
a9edc4ba-8e39-4e75-93f1-eccdd1d9391e.aspx
  
3402Canakinumab(Ilaris®)MA08.101aPharmacy (08)MA08.101aMA08.101a9edc4ba-8e39-4e75-93f1-eccdd1d9391eCanakinumab (Ilaris®)Canakinumab (Ilaris®)
9ed71d16-85d6-476c-9ed2-2e1a6fb65333.aspx
  
3401CanesandCrutchesMA05.052bDME (05)MA05.052bMA05.0529ed71d16-85d6-476c-9ed2-2e1a6fb65333Canes and CrutchesCanes and Crutches
d911f4fe-8fe3-42db-a33e-421e8b327cd9.aspx
  
3262CapsuleEndoscopyMA07.022dMedicine (07)MA07.022dMA07.022d911f4fe-8fe3-42db-a33e-421e8b327cd9Capsule EndoscopyCapsule Endoscopy
de73d54c-e82e-406d-a1d8-c94d36bf4fc5.aspx
  
3807CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)ProgramsMA10.002cRehabilitation Services (10)MA10.002cMA10.002de73d54c-e82e-406d-a1d8-c94d36bf4fc5Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) ProgramsCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
{"3808": {"Id":3808,"MPAttachmentLetter":"A","Title":"Medically Necessary ICD-10 Codes","MPPolicyAttachmentInternalSourceId":6702,"PolicyAttachmentPageName":"8a00fdd6-dd29-4596-b900-0e494b1c1ce9"},}
f825af05-94e9-4062-950b-87a69d2ad564.aspx
  
3567CareManagementandCarePlanningServicesMA00.006kAdministrative (00)MA00.006kMA00.006f825af05-94e9-4062-950b-87a69d2ad564Care Management and Care Planning ServicesCare Management and Care Planning Services
baf875dc-3289-463b-afc8-67f64e8ae11a.aspx
  
3181Carfilzomib(Kyprolis™)MA08.062fPharmacy (08)MA08.062fMA08.062baf875dc-3289-463b-afc8-67f64e8ae11aCarfilzomib (Kyprolis™)Carfilzomib (Kyprolis™)
b86099e5-ed74-4f52-9ab4-c534c779cb23.aspx
  
3612CastandSplintApplicationsandAssociatedSuppliesMA00.012cAdministrative (00)MA00.012cMA00.012b86099e5-ed74-4f52-9ab4-c534c779cb23Cast and Splint Applications and Associated SuppliesCast and Splint Applications and Associated Supplies
{"3613": {"Id":3613,"MPAttachmentLetter":"A","Title":"Procedures Related to Cast and Splint Applications and Associated Supplies","MPPolicyAttachmentInternalSourceId":6422,"PolicyAttachmentPageName":"eec4f404-030d-42ce-855c-d06522638dd4"},}
5095c829-369f-46c3-b691-0adf6863c45b.aspx
  
3274CataractSurgeryMA11.054dSurgery (11)MA11.054dMA11.0545095c829-369f-46c3-b691-0adf6863c45bCataract SurgeryCataract Surgery
{"3275": {"Id":3275,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":6073,"PolicyAttachmentPageName":"78c40eb8-686a-4467-8e5c-92a9de5de2b3"},}
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3809CatheterAblationofCardiacArrhythmiasMA11.060eSurgery (11)MA11.060eMA11.060d64fed48-4aef-4817-967f-2e50017c1cb0Catheter Ablation of Cardiac ArrhythmiasCatheter Ablation of Cardiac Arrhythmias
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3308Cemiplimab-rwlc(Libtayo®)MA08.124aPharmacy (08)MA08.124aMA08.124b20eb9d7-1322-4095-b3fa-f8119ce79e16Cemiplimab-rwlc (Libtayo®)Cemiplimab-rwlc (Libtayo®)
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3526Cerliponasealfa(Brineura®)MA08.089cPharmacy (08)MA08.089cMA08.089af3e4f67-0660-4149-b715-205f07d43919Cerliponase alfa (Brineura®)Cerliponase alfa (Brineura®)
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3438CervicalTractionDevicesforIn-homeUseMA05.009aDME (05)MA05.009aMA05.009c98e6881-f694-4a4a-93e0-12285cfbf202Cervical Traction Devices for In-home UseCervical Traction Devices for In-home Use
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2912Cetuximab(Erbitux®)MA08.031ePharmacy (08)MA08.031eMA08.031c72d3dca-9d0d-4a60-8b91-7b43d611e591Cetuximab (Erbitux®)Cetuximab (Erbitux®)
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2927ChemicalPeelsMA11.103aSurgery (11)MA11.103aMA11.103a33f9f91-2a57-415b-85c9-2e9928af5618Chemical PeelsChemical Peels
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3267ChimericAntigenReceptor(CAR)TherapyMA08.093jPharmacy (08)MA08.093jMA08.093057ee391-bab8-4f1f-b406-27a9810e22e8Chimeric Antigen Receptor (CAR) TherapyChimeric Antigen Receptor (CAR) Therapy
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2960ChiropracticServicesMA10.004hRehabilitation Services (10)MA10.004hMA10.00482fa8d76-e28e-4d03-8e55-485c58416c4eChiropractic ServicesChiropractic Services
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1368Circulating Tumor Cell (CTC) AssayPathology and Laboratory (06)MA06.030MA06.030F371FB2E48AFB33885257DBE00723399Circulating Tumor Cell (CTC) AssayCirculating Tumor Cell (CTC) Assay
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3799CoagulationFactorsMA08.004tPharmacy (08)MA08.004tMA08.004321a9e47-fe03-4bf8-8925-0b6e0be9f2daCoagulation Factors Coagulation Factors
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3192Cobalamin(VitaminB12),FolicAcid,andHomocysteineTestingMA06.032Pathology and Laboratory (06)MA06.032MA06.0320e1034a1-44e6-4b1a-ba4a-5f9b439a5a18Cobalamin (Vitamin B12), Folic Acid, and Homocysteine TestingCobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
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2505CochlearImplantationMA11.039dSurgery (11)MA11.039dMA11.0392ff992d2-ca4a-42b9-b321-e387ed4804fdCochlear ImplantationCochlear Implantation
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3437Collagenaseclostridiumhistolyticum(Xiaflex®),collagenaseclostridiumhistolyticum-aaes(Qwo™)MA08.128Pharmacy (08)MA08.128MA08.128c4e07093-c912-4146-8bab-3e038ab4fbceCollagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™)Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™)
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3383CommodeChairsMA05.036bDME (05)MA05.036bMA05.036b54c4527-287c-44b4-ba99-2781f6ea0463Commode ChairsCommode Chairs
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3614ComplementaryandIntegrativeHealthServicesMA12.001dMiscellaneous (12)MA12.001dMA12.001a62fd0fa-8e7b-4ed1-bb67-fd235c1159f0Complementary and Integrative Health ServicesComplementary and Integrative Health Services
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3617CompleteDecongestiveTherapy(CDT)MA07.042Medicine (07)MA07.042MA07.04274c1970e-fa1e-40e5-91ce-bd5dd3e8a6f5Complete Decongestive Therapy (CDT)Complete Decongestive Therapy (CDT)
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3648CompositeTissueAllotransplantationoftheHand(s)andFaceMA11.112Surgery (11)MA11.112MA11.1121361257a-290f-4536-95f4-94e8c6ac325aComposite Tissue Allotransplantation of the Hand(s) and FaceComposite Tissue Allotransplantation of the Hand(s) and Face
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3640CompressionGarmentsMA05.045aDME (05)MA05.045aMA05.04555f0dbf5-ae18-4373-b456-a221e9d39c1cCompression GarmentsCompression Garments
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3685Computer-AidedDetection(CAD)SystemforUsewithChestRadiographsMA09.014aRadiology (09)MA09.014aMA09.0140e3d12af-5a08-4b0c-8211-19ac349faf3bComputer-Aided Detection (CAD) System for Use with Chest RadiographsComputer-Aided Detection (CAD) System for Use with Chest Radiographs
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3605Computer-AssistedMusculoskeletalSurgicalNavigationalOrthopedicProcedureMA11.088cSurgery (11)MA11.088cMA11.0886c50e1d0-0b77-45d9-abd2-9c2633dc200eComputer-Assisted Musculoskeletal Surgical Navigational Orthopedic ProcedureComputer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
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3588ConsultationServicesMA00.049aAdministrative (00)MA00.049aMA00.04957649d5c-49aa-4216-9686-3c820b5d1237Consultation ServicesConsultation Services
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2931ContinuousGlucoseMonitorsandArtificialPancreasDeviceSystems(APDS)MA00.002hAdministrative (00)MA00.002hMA00.0025c1443e6-2913-42a5-8619-005a3242e93bContinuous Glucose Monitors and Artificial Pancreas Device Systems (APDS)Continuous Glucose Monitors and Artificial Pancreas Device Systems (APDS)
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2532ContrastAgentsUsedinConjunctionwithEchocardiographyMA09.004cRadiology (09)MA09.004cMA09.00416379ab5-1c4e-4ad3-9aa8-49dea5cd3d30Contrast Agents Used in Conjunction with EchocardiographyContrast Agents Used in Conjunction with Echocardiography
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3636CornealPachymetryUsingUltrasoundMA07.046gMedicine (07)MA07.046gMA07.0460d262908-e6ab-4ad9-a017-96491fb35ed8Corneal Pachymetry Using UltrasoundCorneal Pachymetry Using Ultrasound
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2751CosmeticProceduresMA12.009aMiscellaneous (12)MA12.009aMA12.0090853e101-4b8c-412e-a9e4-ebc95dc4ec4cCosmetic ProceduresCosmetic Procedures
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3048CoverageofMedicalDevicesMA05.040bDME (05)MA05.040bMA05.04069c3f8a1-1044-489c-869e-7e78dbb55b06Coverage of Medical DevicesCoverage of Medical Devices
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3850CranialElectrotherapyStimulationMA05.066bDME (05)MA05.066bMA05.0668272f5ab-b73f-497f-b763-57fbf79f2d1aCranial Electrotherapy StimulationCranial Electrotherapy Stimulation
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1616Criteria for Reimbursement of Emergency Room ServicesAdministrative (00)MA00.044bMA00.04485257D39006E7945852584FD00658A7ACriteria for Reimbursement of Emergency Room ServicesCriteria for Reimbursement of Emergency Room Services
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3387crizanlizumab-tmca(Adakveo®)MA08.109aPharmacy (08)MA08.109aMA08.1095c85f061-d9b8-458b-977b-a6d0470b0e1fcrizanlizumab-tmca (Adakveo®)crizanlizumab-tmca (Adakveo®)
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3623CryosurgicalAblationoftheProstateGlandMA11.022aSurgery (11)MA11.022aMA11.0224262ba16-e187-42a1-a358-5309ce6b6ea5Cryosurgical Ablation of the Prostate GlandCryosurgical Ablation of the Prostate Gland
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3746Daratumumab(Darzalex®),Daratumumab,andHyaluronidase-fihj(DarzalexFaspro®)MA08.079jPharmacy (08)MA08.079jMA08.079fc8bc0fe-8bb5-4590-830c-71eb68cd8fceDaratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®)Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®)
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3767DayRehabilitationMA10.005bRehabilitation Services (10)MA10.005bMA10.005c7e08d9f-c93b-4f1c-a093-ee818b303290Day RehabilitationDay Rehabilitation
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3688DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNailsMA11.014gSurgery (11)MA11.014gMA11.0145b93c7e1-f677-4375-922a-ca9531f9db6eDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe NailsDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
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3104DeepBrainStimulation(DBS)MA11.005dSurgery (11)MA11.005dMA11.0057275a229-55e1-4a18-bca7-047e1f28b32eDeep Brain Stimulation (DBS)Deep Brain Stimulation (DBS)
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3522Denosumab(Prolia®,Xgeva®),Romosozumab-aqqg(Evenity®)MA08.052jPharmacy (08)MA08.052jMA08.052116bf5f6-59fe-4c5b-b271-9a90bf62beb6Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)
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3271DermabrasionforRhinophyma,Septoplasty,Rhinoplasty,andSeptorhinoplastyMA11.099bSurgery (11)MA11.099bMA11.099fc1b8cfd-8564-48f4-95e2-35079b441983Dermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and SeptorhinoplastyDermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and Septorhinoplasty
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3346DirectAccesstoObstetrics/Gynecology(OB/GYN)ServicesMA00.032dAdministrative (00)MA00.032dMA00.0323cc570f5-3a08-4974-a65d-e95d42146963Direct Access to Obstetrics/Gynecology (OB/GYN) ServicesDirect Access to Obstetrics/Gynecology (OB/GYN) Services
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3575Dofetilide(Tikosyn®)UseintheInpatientSettingMA08.021bPharmacy (08)MA08.021bMA08.021062b48a0-26a9-4077-805d-713072908f88Dofetilide (Tikosyn®) Use in the Inpatient SettingDofetilide (Tikosyn®) Use in the Inpatient Setting
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3413Dostarlimab-gxly(Jemperli)MA08.136cPharmacy (08)MA08.136cMA08.136c37d9c69-6413-4a3b-872a-d26735e8bd34Dostarlimab-gxly (Jemperli)Dostarlimab-gxly (Jemperli)
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3085Drug-ElutingBeadsandBlandEmbolizationfortheTreatmentofHepaticMalignanciesMA07.041bMedicine (07)MA07.041bMA07.041ae95d034-1aa3-4388-8961-5b98f504ad3eDrug-Eluting Beads and Bland Embolization for the Treatment of Hepatic MalignanciesDrug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
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3734DurableMedicalEquipment(DME)MA05.044lDME (05)MA05.044lMA05.0448ca43202-8ef1-4013-b9af-92fd11a9ccc6Durable Medical Equipment (DME)Durable Medical Equipment (DME)
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2423DurableMedicalEquipment(DME)NotSubjecttoaRentaltoPurchaseMaximumMA05.028eDME (05)MA05.028eMA05.02881644841-0f55-4dc1-9476-5ab8d631fd3aDurable Medical Equipment (DME) Not Subject to a Rental to Purchase MaximumDurable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
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3306Durvalumab(Imfinzi®)MA08.123aPharmacy (08)MA08.123aMA08.12308bdcc51-41f8-4c2d-a5e2-addbc9e3f053Durvalumab (Imfinzi®)Durvalumab (Imfinzi®)
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3816Eculizumab(Soliris®)andRelatedBiosimilars,Ravulizumab-cwvz(Ultomiris™)MA08.044hPharmacy (08)MA08.044hMA08.04413726d35-3661-4825-a4a4-6dd5c8fc297cEculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™)Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™)
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3578Edaravone(Radicava®)MA08.092aPharmacy (08)MA08.092aMA08.09293ee35b6-d0d3-4c1a-b0e0-152e9dd153e8Edaravone (Radicava®)Edaravone (Radicava®)
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3675Efgartigimod-alfa(VyvgartTM)MA08.142aPharmacy (08)MA08.142aMA08.1428c9b2f4f-e061-48c5-8b0c-6da861903805Efgartigimod-alfa (VyvgartTM)Efgartigimod-alfa (VyvgartTM)
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3511ElectricalStimulationandElectromagneticStimulationfortheTreatmentofWoundsMA07.013dMedicine (07)MA07.013dMA07.0139c10b787-7936-43dc-85af-d1b5f8b51d28Electrical Stimulation and Electromagnetic Stimulation for the Treatment of WoundsElectrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
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3822Electromyography(EMG)Studies:NeedleEMG,SurfaceEMG(SEMG)MA07.050jMedicine (07)MA07.050jMA07.050cb418482-3e52-441f-9345-a3e2330a6c83Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
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3749ElectronBeamComputedTomography(EBCT)forScreeningEvaluationsMA09.011bRadiology (09)MA09.011bMA09.0116366b7e5-d8ba-4377-927a-40fa07e33fd0Electron Beam Computed Tomography (EBCT) for Screening EvaluationsElectron Beam Computed Tomography (EBCT) for Screening Evaluations
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