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c8843da7-d3aa-47c9-92f6-605aa648b496.aspx
  
2952Abatacept(Orencia®)forInjectionforIntravenousUseMA08.028fPharmacy (08)MA08.028fMA08.028c8843da7-d3aa-47c9-92f6-605aa648b496Abatacept (Orencia®) for Injection for Intravenous UseAbatacept (Orencia®) for Injection for Intravenous Use
{"2953": {"Id":2953,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":5705,"PolicyAttachmentPageName":"8d160c91-5b61-4e47-8d51-aeb4edf972df"},}
5e7d70e9-cd59-4945-8fd8-e5552ecdbe7f.aspx
  
2507AbortionMA11.010aSurgery (11)MA11.010aMA11.0105e7d70e9-cd59-4945-8fd8-e5552ecdbe7fAbortionAbortion
8d122c3d-9edc-4add-81d3-b1c65ff2de78.aspx
  
3023AcupunctureMA12.004cMiscellaneous (12)MA12.004cMA12.0048d122c3d-9edc-4add-81d3-b1c65ff2de78AcupunctureAcupuncture
{"3024": {"Id":3024,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Acupuncture","MPPolicyAttachmentInternalSourceId":5772,"PolicyAttachmentPageName":"c5403db5-1625-4eb7-b584-629290d58152"},}
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
90901d4f-1362-4821-9241-f9bed7689f50.aspx
  
2768Alemtuzumab(Lemtrada®)MA08.015dPharmacy (08)MA08.015dMA08.01590901d4f-1362-4821-9241-f9bed7689f50Alemtuzumab (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
1e16c2b1-95c7-45d6-9c02-05c6823a4816.aspx
  
3146Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C,AralastNP,Glassia,Zemaira)MA08.050bPharmacy (08)MA08.050bMA08.0501e16c2b1-95c7-45d6-9c02-05c6823a4816Alpha 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
461ba619-2fe9-42bd-8492-8bed8ec39944.aspx
  
3252AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)MonitoringMA07.026hMedicine (07)MA07.026hMA07.026461ba619-2fe9-42bd-8492-8bed8ec39944Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
3e940a7a-241b-4ffe-bc71-efda073f90f4.aspx
  
3443AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagementMA01.008Anesthesia (01)MA01.008MA01.0083e940a7a-241b-4ffe-bc71-efda073f90f4Anesthesia 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
{}
c8972418-fb77-4496-a360-272ec63eff5b.aspx
  
3431Anifrolumab-fnia(Saphnelo™)MA08.140bPharmacy (08)MA08.140bMA08.140c8972418-fb77-4496-a360-272ec63eff5bAnifrolumab-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"},}
8d7083aa-d91b-42cd-a9d2-2436df8015fd.aspx
  
3287AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucomaMA11.105hSurgery (11)MA11.105hMA11.1058d7083aa-d91b-42cd-a9d2-2436df8015fdAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
{"3288": {"Id":3288,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":6071,"PolicyAttachmentPageName":"88201f50-d557-44c7-ad4b-4e27db15c051"},}
db5c146e-b18a-4e6a-931c-33f744b37c96.aspx
  
3056ArtificialIntervertebralLumbarDiscInsertionMA11.114Surgery (11)MA11.114MA11.114db5c146e-b18a-4e6a-931c-33f744b37c96Artificial Intervertebral Lumbar Disc InsertionArtificial Intervertebral Lumbar Disc Insertion
cc37bdfd-4bcc-491d-8a01-26bac662db26.aspx
  
3310Asparaginaseerwiniachrysanthemi(Erwinaze®),asparaginaseerwiniachrysanthemi(recombinant)-rywn(Rylaze™)MA08.085ePharmacy (08)MA08.085eMA08.085cc37bdfd-4bcc-491d-8a01-26bac662db26Asparaginase 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"},}
5597ec50-4ed6-47ed-a1f6-ec70e871649a.aspx
  
2904AutomaticExternalCardioverterDefibrillators(WearableandNonwearable)MA05.005dDME (05)MA05.005dMA05.0055597ec50-4ed6-47ed-a1f6-ec70e871649aAutomatic External Cardioverter Defibrillators (Wearable and Nonwearable)Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
{"2905": {"Id":2905,"MPAttachmentLetter":"B","Title":"ICD-10 codes used to represent the Nonwearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":5696,"PolicyAttachmentPageName":"ed6d8443-570b-4f46-8682-17aab3910728"},"2906": {"Id":2906,"MPAttachmentLetter":"A","Title":"ICD-10 codes used to represent the Wearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":5697,"PolicyAttachmentPageName":"8dd85c76-d455-4bef-bc25-e1327b353d7d"},}
88c7b6d9-8d91-43d3-abfa-cde96d8d500f.aspx
  
3273AutonomicNervousSystemTestingMA07.027eMedicine (07)MA07.027eMA07.02788c7b6d9-8d91-43d3-abfa-cde96d8d500fAutonomic 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"},}
96362b3e-c9dd-4016-ba9b-848e1daa84c4.aspx
  
3148BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitisMA11.100eSurgery (11)MA11.100eMA11.10096362b3e-c9dd-4016-ba9b-848e1daa84c4Balloon 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
41ad24ae-0026-45ae-8fc8-3b701c04bd70.aspx
  
3389Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUseMA08.072iPharmacy (08)MA08.072iMA08.07241ad24ae-0026-45ae-8fc8-3b701c04bd70Bevacizumab (Avastin®) and Related Biosimilars For Oncologic UseBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
{"3390": {"Id":3390,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":6053,"PolicyAttachmentPageName":"bb080a18-a681-45b6-8402-40e3647cb380"},}
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"},}
828edbc7-c517-4223-89ea-9740a68d2964.aspx
  
3055BiofeedbackTherapyMA07.010aMedicine (07)MA07.010aMA07.010828edbc7-c517-4223-89ea-9740a68d2964Biofeedback TherapyBiofeedback Therapy
c1e6aafa-0100-443d-9127-3883ac43bb26.aspx
  
2745BioimpedancefortheDetectionofLymphedemaMA07.052Medicine (07)MA07.052MA07.052c1e6aafa-0100-443d-9127-3883ac43bb26Bioimpedance 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"},}
2ee48daf-823a-407f-9a59-ee7b1644b7e5.aspx
  
2707Blinatumomab(Blincyto®)MA08.058dPharmacy (08)MA08.058dMA08.0582ee48daf-823a-407f-9a59-ee7b1644b7e5Blinatumomab (Blincyto®)Blinatumomab (Blincyto®)
436fa6c6-3279-4818-bdb6-e96b99bf1a19.aspx
  
3331Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAidsMA11.049dSurgery (11)MA11.049dMA11.049436fa6c6-3279-4818-bdb6-e96b99bf1a19Bone-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"},}
a4136f55-5f15-4b47-bae8-a1346b70b9aa.aspx
  
3516BotulinumToxinAgentsMA08.017gPharmacy (08)MA08.017gMA08.017a4136f55-5f15-4b47-bae8-a1346b70b9aaBotulinum Toxin AgentsBotulinum Toxin Agents
{"3517": {"Id":3517,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":6216,"PolicyAttachmentPageName":"da943c2f-3c65-4fcb-8a5f-35e5a824dd90"},}
d1c31d6f-4862-453e-89af-54d64ce7abc9.aspx
  
2971BrentuximabVedotin(Adcetris®)MA08.068fPharmacy (08)MA08.068fMA08.068d1c31d6f-4862-453e-89af-54d64ce7abc9Brentuximab Vedotin (Adcetris®)Brentuximab Vedotin (Adcetris®)
{"2972": {"Id":2972,"MPAttachmentLetter":"A","Title":"ICD 10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":5778,"PolicyAttachmentPageName":"893f6d02-ddff-4b9e-b122-6a5fb698f1b0"},}
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
c5973a63-e52f-43d8-a5df-3108449d0314.aspx
  
3059CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)ProgramsMA10.002bRehabilitation Services (10)MA10.002bMA10.002c5973a63-e52f-43d8-a5df-3108449d0314Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) ProgramsCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
{"3060": {"Id":3060,"MPAttachmentLetter":"A","Title":"Medically Necessary ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5730,"PolicyAttachmentPageName":"b8ba4853-8872-410a-840c-4a11647197aa"},}
8553b5bc-9382-43d1-941c-2ed398ea6963.aspx
  
3423CareManagementandCarePlanningServicesMA00.006jAdministrative (00)MA00.006jMA00.0068553b5bc-9382-43d1-941c-2ed398ea6963Care 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™)
7a7e50a2-46a1-4673-b9d9-59a2fce39403.aspx
  
2236CastandSplintApplicationsandAssociatedSuppliesMA00.012cAdministrative (00)MA00.012cMA00.0127a7e50a2-46a1-4673-b9d9-59a2fce39403Cast and Splint Applications and Associated SuppliesCast and Splint Applications and Associated Supplies
{"2237": {"Id":2237,"MPAttachmentLetter":"A","Title":"Procedures Related to Cast and Splint Applications and Associated Supplies","MPPolicyAttachmentInternalSourceId":4985,"PolicyAttachmentPageName":"0a068e16-bb74-4ccb-9a5b-27b1dc464f75"},}
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"},}
9753416e-27fe-43ff-946d-2f4724fb3d68.aspx
  
3253CatheterAblationofCardiacArrhythmiasMA11.060dSurgery (11)MA11.060dMA11.0609753416e-27fe-43ff-946d-2f4724fb3d68Catheter Ablation of Cardiac ArrhythmiasCatheter Ablation of Cardiac Arrhythmias
b20eb9d7-1322-4095-b3fa-f8119ce79e16.aspx
  
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
{"2961": {"Id":2961,"MPAttachmentLetter":"A","Title":"Medically neessary ICD-10 diagnosis codes","MPPolicyAttachmentInternalSourceId":5875,"PolicyAttachmentPageName":"834cf659-9228-46b9-8755-7241a7d8da3f"},}
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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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3097CoagulationFactorsMA08.004sPharmacy (08)MA08.004sMA08.004eb5f10f4-c8a1-4b10-aba1-7ba53b4e822cCoagulation 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
{"3193": {"Id":3193,"MPAttachmentLetter":"A","Title":"ICD 10 CODES FOR MEDICALLY NECESSARY COBALAMIN (VITAMIN B12), FOLIC ACID, AND/OR HOMOCYSTEINE TESTING (CPT CODES 82607, 82746, AND 83090)","MPPolicyAttachmentInternalSourceId":6107,"PolicyAttachmentPageName":"8816a85c-bf20-467e-906a-584a77f59ef8"},}
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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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1668Complementary and Integrative Health ServicesMiscellaneous (12)MA12.001dMA12.00185257D39006E7945852585040068A7CDComplementary and Integrative Health ServicesComplementary and Integrative Health Services
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2752CompleteDecongestiveTherapy(CDT)MA07.042Medicine (07)MA07.042MA07.042af3a51ad-e178-4ab8-87d6-c5f616db4abeComplete Decongestive Therapy (CDT)Complete Decongestive Therapy (CDT)
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2659CompositeTissueAllotransplantationoftheHand(s)andFaceMA11.112Surgery (11)MA11.112MA11.112c751b663-969e-44e9-9ed3-333584162b51Composite Tissue Allotransplantation of the Hand(s) and FaceComposite Tissue Allotransplantation of the Hand(s) and Face
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2637CompressionGarmentsMA05.045aDME (05)MA05.045aMA05.045ab1071fd-1c46-4266-a71c-6dd8cea5c750Compression GarmentsCompression Garments
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2935Computer-AidedDetection(CAD)SystemforUsewithChestRadiographsMA09.014aRadiology (09)MA09.014aMA09.014935f4c28-cc58-44c2-a6d0-984f28a62422Computer-Aided Detection (CAD) System for Use with Chest RadiographsComputer-Aided Detection (CAD) System for Use with Chest Radiographs
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2640Computer-AssistedMusculoskeletalSurgicalNavigationalOrthopedicProcedureMA11.088cSurgery (11)MA11.088cMA11.0887eccc322-fc2c-4c32-97f5-d2792e48497bComputer-Assisted Musculoskeletal Surgical Navigational Orthopedic ProcedureComputer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
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2041ConsultationServicesMA00.049Administrative (00)MA00.049MA00.0491a75604c-5542-4601-b256-9e702f9428baConsultation 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)
{"2932": {"Id":2932,"MPAttachmentLetter":"A","Title":"ICD-10: Short term CGM","MPPolicyAttachmentInternalSourceId":5562,"PolicyAttachmentPageName":"113e4f62-516f-4439-b0f6-296f308fbef4"},"2933": {"Id":2933,"MPAttachmentLetter":"B","Title":"THERAPEUTIC LONG-TERM INTERSTITIAL CGMS","MPPolicyAttachmentInternalSourceId":5563,"PolicyAttachmentPageName":"1f15e1a5-4dcb-4ec2-8523-4e24b8cbfa04"},}
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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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3141CornealPachymetryUsingUltrasoundMA07.046fMedicine (07)MA07.046fMA07.046f646cf51-1c38-4c6d-a854-bbe8c3717e5fCorneal Pachymetry Using UltrasoundCorneal Pachymetry Using Ultrasound
{"3142": {"Id":3142,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes Eligible to be Reported for Corneal Pachymetry Using Ultrasound","MPPolicyAttachmentInternalSourceId":5965,"PolicyAttachmentPageName":"2d1de0fa-418e-4379-925d-d0fffd121b24"},}
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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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3163CranialElectrotherapyStimulationMA05.066aDME (05)MA05.066aMA05.066926424cb-d449-475a-bffd-e766248d6937Cranial 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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2645CryosurgicalAblationoftheProstateGlandMA11.022aSurgery (11)MA11.022aMA11.022f949b8ee-ae93-49e4-af37-675e06be8bd2Cryosurgical Ablation of the Prostate GlandCryosurgical Ablation of the Prostate Gland
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2709Daratumumab(Darzalex®),Daratumumab,andHyaluronidase-fihj(DarzalexFaspro®)MA08.079iPharmacy (08)MA08.079iMA08.079eeda51c3-f345-4c9c-b1e8-4383e943ae09Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®)Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®)
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2769DayRehabilitationMA10.005bRehabilitation Services (10)MA10.005bMA10.005ebab4b51-cc41-4866-9d3e-f134b810965bDay RehabilitationDay Rehabilitation
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3009DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNailsMA11.014gSurgery (11)MA11.014gMA11.014b3040a13-2215-4c0c-8fe1-616dc7e9e953Debridement 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®)
{"3523": {"Id":3523,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes","MPPolicyAttachmentInternalSourceId":6189,"PolicyAttachmentPageName":"dd04c740-d70b-48c8-b128-cde0f0c0b1f9"},}
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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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2651Dofetilide(Tikosyn®)UseintheInpatientSettingMA08.021bPharmacy (08)MA08.021bMA08.021fb045038-630a-438d-b076-241198fe9b0cDofetilide (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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3049DurableMedicalEquipment(DME)MA05.044kDME (05)MA05.044kMA05.044ddf91086-b3c9-4100-98a0-12059f037016Durable 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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3412Eculizumab(Soliris®)andRelatedBiosimilars,Ravulizumab-cwvz(Ultomiris™)MA08.044gPharmacy (08)MA08.044gMA08.0446d08baf9-f663-4f12-8766-b2e89901736aEculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™)Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™)
3e6b4d1a-b289-45f9-938b-9b8c37e853d4.aspx
  
2652Edaravone(Radicava®)MA08.092aPharmacy (08)MA08.092aMA08.0923e6b4d1a-b289-45f9-938b-9b8c37e853d4Edaravone (Radicava®)Edaravone (Radicava®)
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3397Efgartigimod-alfa(VyvgartTM)MA08.142Pharmacy (08)MA08.142MA08.142546b89d6-0da3-422a-9ab4-74ccbba33c94Efgartigimod-alfa (VyvgartTM)Efgartigimod-alfa (VyvgartTM)
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2454ElectricalContinenceAidMA05.059DME (05)MA05.059MA05.059d0ed73a0-1d77-4f22-9d58-a33008362521Electrical Continence AidElectrical Continence Aid
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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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3207Electromyography(EMG)Studies:NeedleEMG,SurfaceEMG(SEMG)MA07.050iMedicine (07)MA07.050iMA07.05093ee1465-f44b-4c23-89d8-b92cdb22194cElectromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
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