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81aa888e-296c-422d-8ba8-e81243f8f744.aspx
  
4712Abatacept(Orencia®)forInjectionforIntravenousUseMA08.028iPharmacy (08)MA08.028iMA08.02881aa888e-296c-422d-8ba8-e81243f8f744Abatacept (Orencia®) for Injection for Intravenous UseAbatacept (Orencia®) for Injection for Intravenous Use
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5616AbortionMA11.010dSurgery (11)MA11.010dMA11.01008db9030-c311-4ab4-97df-cd3d713f2ee1AbortionAbortion
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5210AcupunctureMA12.004cMiscellaneous (12)MA12.004cMA12.00417d506eb-c5fb-4488-b959-a4e75880d2e0AcupunctureAcupuncture
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5388AcuteCareFacilityInpatientTransfersMA12.003bMiscellaneous (12)MA12.003bMA12.0030809d82e-8341-423b-aeed-cce7da5a3823Acute Care Facility Inpatient TransfersAcute Care Facility Inpatient Transfers
c3833256-3860-41e9-998a-3efc56e4c107.aspx
  
5652ADAMTS13,recombinant-krhn(Adzynma)MA08.171Pharmacy (08)MA08.171MA08.171c3833256-3860-41e9-998a-3efc56e4c107ADAMTS13, recombinant-krhn (Adzynma)ADAMTS13, recombinant-krhn (Adzynma)
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5272Ado-TrastuzumabEmtansine(Kadcyla®)MA08.066gPharmacy (08)MA08.066gMA08.066db6e085d-3e46-4bde-b37c-672c6dcdba72Ado-Trastuzumab Emtansine (Kadcyla®)Ado-Trastuzumab Emtansine (Kadcyla®)
{"5273": {"Id":5273,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":8440,"PolicyAttachmentPageName":"45854213-f098-424b-a721-2312eddd195d"},}
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4316Agalsidasebeta(Fabrazyme®)MA08.033cPharmacy (08)MA08.033cMA08.033899c9577-2cf3-4cf9-80dd-865bc7bd577dAgalsidase beta (Fabrazyme®)Agalsidase beta (Fabrazyme®)
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5566AirAmbulanceServicesMA12.007bMiscellaneous (12)MA12.007bMA12.007420ad8fb-7e35-42ef-bc80-342ad110b9c7Air Ambulance ServicesAir Ambulance Services
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5396Alemtuzumab(Lemtrada®)MA08.015dPharmacy (08)MA08.015dMA08.01522620808-80f2-4678-9d78-963135134c3fAlemtuzumab (Lemtrada®)Alemtuzumab (Lemtrada®)
3e58f2d7-3d82-4290-9777-c24b06b56b8b.aspx
  
5412Alglucosidasealfa(e.g.,Lumizyme®),Avalglucosidasealfa-ngpt(Nexviazyme®),Cipaglucosidasealfa-atga(Pombiliti™)MA08.036gPharmacy (08)MA08.036gMA08.0363e58f2d7-3d82-4290-9777-c24b06b56b8bAlglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® ), Cipaglucosidase alfa-atga (Pombiliti™ )Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® ), Cipaglucosidase alfa-atga (Pombiliti™ )
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5442AllergyImmunotherapyMA07.055dMedicine (07)MA07.055dMA07.055f13596c2-d792-4dd5-8c42-1aa95d5da992Allergy ImmunotherapyAllergy Immunotherapy
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5429Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C,AralastNP,Glassia,Zemaira)MA08.050bPharmacy (08)MA08.050bMA08.05004f53e63-b505-4577-a720-9cdd08902e6cAlpha 1-Antitrypsin Therapy (e.g., Prolastin-C, Aralast NP, Glassia, Zemaira)Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C, Aralast NP, Glassia, Zemaira)
e7057fa7-a6c3-4e0b-b705-d84867c49ee8.aspx
  
5623AlwaysBundledProcedureCodesMA00.026uAdministrative (00)MA00.026uMA00.026e7057fa7-a6c3-4e0b-b705-d84867c49ee8Always Bundled Procedure CodesAlways Bundled Procedure Codes
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5245AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)DevicesMA07.005cMedicine (07)MA07.005cMA07.005f1e90256-36b5-4258-a55d-665e0ef0f39bAmbulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) DevicesAmbulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
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5289AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)MonitoringMA07.026pMedicine (07)MA07.026pMA07.02677c4cdba-df87-4083-92b0-4e82421168dfAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
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5499Amivantamab-vmjw(Rybrevant®)MA08.148aPharmacy (08)MA08.148aMA08.148ccc161f0-a85b-46c5-a2ce-d890adbb7140Amivantamab-vmjw (Rybrevant®)Amivantamab-vmjw (Rybrevant®)
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5541AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagementMA01.008bAnesthesia (01)MA01.008bMA01.0089e73fe4c-f5f6-4bf3-bb95-9ecc79f1871aAnesthesia 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
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5555Anifrolumab-fnia(Saphnelo®)MA08.140cPharmacy (08)MA08.140cMA08.1403c8f3bc9-2017-4dea-a268-406350e85081Anifrolumab-fnia (Saphnelo®)Anifrolumab-fnia (Saphnelo®)
b78c210c-e0d2-483d-ba9b-806a66a7dcfc.aspx
  
5347Ankle-Foot/Knee-Ankle-FootOrthosesMA05.010jDME (05)MA05.010jMA05.010b78c210c-e0d2-483d-ba9b-806a66a7dcfcAnkle-Foot/Knee-Ankle-Foot OrthosesAnkle-Foot/Knee-Ankle-Foot Orthoses
{"5348": {"Id":5348,"MPAttachmentLetter":"A","Title":"HCPCS CODES FOR ANKLE-FOOT/ KNEE-ANKLE FOOT ORTHOSIS","MPPolicyAttachmentInternalSourceId":8451,"PolicyAttachmentPageName":"903c0f97-12f3-401a-899d-2f07e36452bd"},}
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4981ApheresisTherapyMA06.001ePathology and Laboratory (06)MA06.001eMA06.00139dcf591-f9fc-44f7-bfc4-2d1736f2fd49Apheresis TherapyApheresis Therapy
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5036Apos®biomechanicalshoesystemMA05.070DME (05)MA05.070MA05.07003291464-9bff-4c1f-84d2-71221d6cc6bdApos® biomechanical shoe systemApos® biomechanical shoe system
2a27f7af-3e2a-4413-932d-11598d28a540.aspx
  
5214ApplicationandRemovalofTattoosMA11.072Surgery (11)MA11.072MA11.0722a27f7af-3e2a-4413-932d-11598d28a540Application and Removal of TattoosApplication and Removal of Tattoos
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5507AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucomaMA11.105jSurgery (11)MA11.105jMA11.1055d13769e-fdd0-4606-90f0-c33def059482Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
{"5508": {"Id":5508,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":8592,"PolicyAttachmentPageName":"3953fbb7-a495-4547-a7fa-21f7fef4d770"},}
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4884ArtificialIntervertebralLumbarDiscInsertionMA11.114bSurgery (11)MA11.114bMA11.1149772efeb-a7bd-4217-ac52-ea05bc5a3d31Artificial Intervertebral Lumbar Disc InsertionArtificial Intervertebral Lumbar Disc Insertion
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4558Asparaginaseerwiniachrysanthemi(Erwinaze®),asparaginaseerwiniachrysanthemi(recombinant)-rywn(Rylaze®)MA08.085gPharmacy (08)MA08.085gMA08.0857d0a7b7f-0ed5-4a94-ab38-982449843b7eAsparaginase erwinia chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze®)Asparaginase erwinia chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze®)
38d9e3e1-1b0d-4386-b60a-9b0787ca330f.aspx
  
4272Atezolizumab(Tecentriq®)MA08.127cPharmacy (08)MA08.127cMA08.12738d9e3e1-1b0d-4386-b60a-9b0787ca330fAtezolizumab (Tecentriq®)Atezolizumab (Tecentriq®)
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5496AuricularProsthesesMA05.068DME (05)MA05.068MA05.068b09c9dbd-b5a3-4d46-a5fa-27106de7f0e4Auricular ProsthesesAuricular Prostheses
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4759AutomaticExternalCardioverterDefibrillators(WearableandNonwearable)MA05.005gDME (05)MA05.005gMA05.00550cf8ab2-c1d7-4114-bf48-301031b97b42Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
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5389AutonomicNervousSystemTestingMA07.027fMedicine (07)MA07.027fMA07.027e33a8f30-42ec-4e35-b040-1f985ef5f41fAutonomic Nervous System TestingAutonomic Nervous System Testing
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5156Avelumab(Bavencio®)MA08.122cPharmacy (08)MA08.122cMA08.122214619b7-9453-46b2-8e3d-0e7843183edeAvelumab (Bavencio®)Avelumab (Bavencio®)
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4250BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitisMA11.100eSurgery (11)MA11.100eMA11.1006a0c5929-9fd0-40f2-8aee-a03e3c5d7160Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic RhinosinusitisBalloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
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5487Belimumab(Benlysta®)forIntravenousUseMA08.057dPharmacy (08)MA08.057dMA08.0573fc29fb9-fa26-4104-a1d4-e262c84ad84dBelimumab (Benlysta®) for Intravenous UseBelimumab (Benlysta®) for Intravenous Use
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4502Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUseMA08.072mPharmacy (08)MA08.072mMA08.07246cea12e-7050-4ace-8a7f-113e18bd0426Bevacizumab (Avastin®) and Related Biosimilars For Oncologic UseBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
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4964BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampusMA00.037lAdministrative (00)MA00.037lMA00.037df2725e5-51fc-4d42-95c9-22377801776dBilling 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
{"4965": {"Id":4965,"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":7909,"PolicyAttachmentPageName":"3471875c-7222-4749-bf82-8cc0c2280af2"},}
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5551BiofeedbackTherapyMA07.010cMedicine (07)MA07.010cMA07.01069860ba9-93b1-4ba2-b337-b349f00336c4Biofeedback TherapyBiofeedback Therapy
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4719BioimpedancefortheDetectionofLymphedemaMA07.052Medicine (07)MA07.052MA07.0521511575d-8683-46df-9aae-8fd9d97cc10dBioimpedance for the Detection of LymphedemaBioimpedance for the Detection of Lymphedema
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4004Blepharoplasty,RepairofBlepharoptosis,RepairofBrowPtosis,andCanthoplasty/CanthopexyMA11.047dSurgery (11)MA11.047dMA11.047471e433d-f780-4d16-882b-1406395273b3Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/CanthopexyBlepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
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4269Blinatumomab(Blincyto®)MA08.058fPharmacy (08)MA08.058fMA08.05803966d42-a58c-417b-ad2a-bd444959368aBlinatumomab (Blincyto®)Blinatumomab (Blincyto®)
1942af87-90e8-4c5d-b178-fbf39aafdedb.aspx
  
5408Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAidsMA11.049gSurgery (11)MA11.049gMA11.0491942af87-90e8-4c5d-b178-fbf39aafdedbBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing AidsBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
e88cddc6-75a0-4770-9147-d8832a0ba990.aspx
  
5470BotulinumToxinAgentsMA08.017kPharmacy (08)MA08.017kMA08.017e88cddc6-75a0-4770-9147-d8832a0ba990Botulinum Toxin AgentsBotulinum Toxin Agents
{"5471": {"Id":5471,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":8526,"PolicyAttachmentPageName":"61e7ac61-33bb-4c11-9ee1-7c92f0dc1a09"},}
dd70b2ce-1cc7-48f3-ad08-4bc652df61dc.aspx
  
5145BrentuximabVedotin(Adcetris®)MA08.068iPharmacy (08)MA08.068iMA08.068dd70b2ce-1cc7-48f3-ad08-4bc652df61dcBrentuximab Vedotin (Adcetris®)Brentuximab Vedotin (Adcetris®)
{"5146": {"Id":5146,"MPAttachmentLetter":"A","Title":"ICD 10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":7785,"PolicyAttachmentPageName":"0182b661-bf45-4c5d-a186-2e64765891a2"},}
2b139fc7-6fde-4f0a-88f2-8e6262cb2680.aspx
  
5485BronchialValvesMA11.020Surgery (11)MA11.020MA11.0202b139fc7-6fde-4f0a-88f2-8e6262cb2680Bronchial ValvesBronchial Valves
34ff3ea5-f3a5-44fa-a9c6-578d1fe08c02.aspx
  
5443Burosumab-twza(Crysvita®)MA08.099bPharmacy (08)MA08.099bMA08.09934ff3ea5-f3a5-44fa-a9c6-578d1fe08c02Burosumab-twza (Crysvita®)Burosumab-twza (Crysvita®)
e823b28a-58d2-4201-8b11-a1e4fd9480f8.aspx
  
4484Canakinumab(Ilaris®)MA08.101bPharmacy (08)MA08.101bMA08.101e823b28a-58d2-4201-8b11-a1e4fd9480f8Canakinumab (Ilaris®)Canakinumab (Ilaris®)
ce3cfd1e-4c67-4ca8-817e-690ac71d2f34.aspx
  
5185CanesandCrutchesMA05.052bDME (05)MA05.052bMA05.052ce3cfd1e-4c67-4ca8-817e-690ac71d2f34Canes and CrutchesCanes and Crutches
5fb9f4ac-c527-472a-b667-a78635412888.aspx
  
5204CapsuleEndoscopyMA07.022eMedicine (07)MA07.022eMA07.0225fb9f4ac-c527-472a-b667-a78635412888Capsule EndoscopyCapsule Endoscopy
0c9b7de9-21a0-4ad0-849c-9b58ef072e42.aspx
  
5267CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)ProgramsMA10.002fRehabilitation Services (10)MA10.002fMA10.0020c9b7de9-21a0-4ad0-849c-9b58ef072e42Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) ProgramsCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
{"5268": {"Id":5268,"MPAttachmentLetter":"A","Title":"Medically Necessary ICD-10 Codes","MPPolicyAttachmentInternalSourceId":8306,"PolicyAttachmentPageName":"77cc58cd-1a6f-4268-aee2-7d959cc428ab"},}
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5173CareManagementandCarePlanningServicesMA00.006nAdministrative (00)MA00.006nMA00.006ef7eca15-41e7-4d18-bb82-5e9138505093Care Management and Care Planning ServicesCare Management and Care Planning Services
9ae20d79-ba8d-4ced-abc5-527f69c7c997.aspx
  
5054Carfilzomib(Kyprolis)MA08.062hPharmacy (08)MA08.062hMA08.0629ae20d79-ba8d-4ced-abc5-527f69c7c997Carfilzomib (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"},}
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5556CataractSurgeryMA11.054eSurgery (11)MA11.054eMA11.054e5472b5f-bca0-453a-b369-550a15224d67Cataract SurgeryCataract Surgery
{"5557": {"Id":5557,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":8500,"PolicyAttachmentPageName":"8ef8ebd8-c48d-4da6-8a52-287b59e49e6a"},}
e18335ca-0588-4f80-a184-297223e33223.aspx
  
4768CatheterAblationofCardiacArrhythmiasMA11.060gSurgery (11)MA11.060gMA11.060e18335ca-0588-4f80-a184-297223e33223Catheter Ablation of Cardiac ArrhythmiasCatheter Ablation of Cardiac Arrhythmias
74f40bc4-a8ec-402a-a1f7-a1329d8a66c8.aspx
  
4653Cemiplimab-rwlc(Libtayo®)MA08.124cPharmacy (08)MA08.124cMA08.12474f40bc4-a8ec-402a-a1f7-a1329d8a66c8Cemiplimab-rwlc (Libtayo®)Cemiplimab-rwlc (Libtayo®)
cbcee004-59ba-4f3d-ace3-5dd2bb9e1992.aspx
  
4473Cerliponasealfa(Brineura®)MA08.089cPharmacy (08)MA08.089cMA08.089cbcee004-59ba-4f3d-ace3-5dd2bb9e1992Cerliponase alfa (Brineura®)Cerliponase alfa (Brineura®)
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4333CervicalTractionDevicesforIn-homeUseMA05.009aDME (05)MA05.009aMA05.009758792dc-b695-4e8f-8010-624a774b081bCervical Traction Devices for In-home UseCervical Traction Devices for In-home Use
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5235Cetuximab(Erbitux®)MA08.031gPharmacy (08)MA08.031gMA08.03138e8f5e0-eab4-421d-a5b3-807ff85010d8Cetuximab (Erbitux®)Cetuximab (Erbitux®)
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4980ChemicalPeelsMA11.103bSurgery (11)MA11.103bMA11.10368af371b-fdac-4133-a97a-bf73d8c4b158Chemical PeelsChemical Peels
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5617ChimericAntigenReceptor(CAR)TherapyMA08.093mPharmacy (08)MA08.093mMA08.09362d4dadc-02a2-4ec2-a1b0-eb8246eb5b2aChimeric Antigen Receptor (CAR) TherapyChimeric Antigen Receptor (CAR) Therapy
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5383ChiropracticServicesMA10.004iRehabilitation Services (10)MA10.004iMA10.0048ed9bb88-f1ab-4f7d-9a40-cc3b70b96714Chiropractic 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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5149CoagulationFactorsMA08.004vPharmacy (08)MA08.004vMA08.004f447005e-abcc-475f-aa45-41bbaa0db95bCoagulation FactorsCoagulation Factors
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5630Cobalamin(VitaminB12),FolicAcid,andHomocysteineTestingMA06.032aPathology and Laboratory (06)MA06.032aMA06.0323043586c-7729-4aee-af43-8223b5080cb1Cobalamin (Vitamin B12), Folic Acid, and Homocysteine TestingCobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
{"5631": {"Id":5631,"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":8881,"PolicyAttachmentPageName":"52256419-fadb-4f99-a259-45f33eddac58"},}
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5337CochlearImplantationMA11.039eSurgery (11)MA11.039eMA11.039130ca20c-4804-4ab4-be8c-780650f5b2c4Cochlear ImplantationCochlear Implantation
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5216Collagenaseclostridiumhistolyticum(Xiaflex®),collagenaseclostridiumhistolyticum-aaes(Qwo®)MA08.128Pharmacy (08)MA08.128MA08.128a7b81ecf-cefa-42a8-aa7c-f728507035baCollagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo®)Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo®)
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5199CommodeChairsMA05.036bDME (05)MA05.036bMA05.0366536528d-3a29-42cc-a5ba-3bdca5c484ebCommode ChairsCommode Chairs
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5483ComplementaryandIntegrativeHealthServicesMA12.001eMiscellaneous (12)MA12.001eMA12.0010ebbc2e0-fe75-4e98-bc5c-e967fbbc79bcComplementary and Integrative Health ServicesComplementary and Integrative Health Services
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4584CompleteDecongestiveTherapy(CDT)MA07.042Medicine (07)MA07.042MA07.042b4e4e763-9995-4651-935b-e382cd5fb5beComplete Decongestive Therapy (CDT)Complete Decongestive Therapy (CDT)
f88af933-9425-4295-b8c3-5209c77615f8.aspx
  
5339CompositeTissueAllotransplantationoftheHand(s)andFaceMA11.112Surgery (11)MA11.112MA11.112f88af933-9425-4295-b8c3-5209c77615f8Composite Tissue Allotransplantation of the Hand(s) and FaceComposite Tissue Allotransplantation of the Hand(s) and Face
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5537CompressionGarmentsMA05.045eDME (05)MA05.045eMA05.045662fec0d-e490-4359-95ee-4825a1f1d5d7Compression GarmentsCompression Garments
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4261Computer-AidedDetection(CAD)SystemforUsewithChestRadiographsMA09.014aRadiology (09)MA09.014aMA09.0145280f42d-aefd-4364-b335-f20bb8471cffComputer-Aided Detection (CAD) System for Use with Chest RadiographsComputer-Aided Detection (CAD) System for Use with Chest Radiographs
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5244Computer-AssistedMusculoskeletalSurgicalNavigationalOrthopedicProcedureMA11.088cSurgery (11)MA11.088cMA11.088bba5081d-4c80-4f43-bdfa-e81babdc9b90Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic ProcedureComputer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
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5490ConsultationServicesMA00.049bAdministrative (00)MA00.049bMA00.04969d6946a-3b6c-4b70-aa82-23b993e2e391Consultation ServicesConsultation Services
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5619ContinuousGlucoseMonitorsandHomeBloodGlucoseMonitorsandSuppliesMA00.002nAdministrative (00)MA00.002nMA00.0023ead32ac-94f7-4ce2-b60a-98f51d09d858Continuous Glucose Monitors and Home Blood Glucose Monitors and SuppliesContinuous Glucose Monitors and Home Blood Glucose Monitors and Supplies
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4293ContrastAgentsUsedinConjunctionwithEchocardiographyMA09.004cRadiology (09)MA09.004cMA09.004d647b737-a9b2-45c6-8d24-5a6b333db1e7Contrast Agents Used in Conjunction with EchocardiographyContrast Agents Used in Conjunction with Echocardiography
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5581CornealPachymetryUsingUltrasoundMA07.046gMedicine (07)MA07.046gMA07.0463b3366a5-93c9-473f-a7c6-e4e5c014d21cCorneal Pachymetry Using UltrasoundCorneal Pachymetry Using Ultrasound
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3d6b55b7-1271-45c2-a667-be77db0458a9.aspx
  
5218CosmeticProceduresMA12.009aMiscellaneous (12)MA12.009aMA12.0093d6b55b7-1271-45c2-a667-be77db0458a9Cosmetic 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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5548CranialElectrotherapyStimulationMA05.066dDME (05)MA05.066dMA05.066006edde1-4274-4bea-be2e-c0a7902bdcf7Cranial Electrotherapy StimulationCranial Electrotherapy Stimulation
bd8724e2-053c-46e0-ad5a-4e5dbf9cf587.aspx
  
4169CriteriaforReimbursementofEmergencyRoomServicesMA00.044cAdministrative (00)MA00.044cMA00.044bd8724e2-053c-46e0-ad5a-4e5dbf9cf587Criteria for Reimbursement of Emergency Room ServicesCriteria for Reimbursement of Emergency Room Services
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5513crizanlizumab-tmca(Adakveo®) MA08.109bPharmacy (08)MA08.109bMA08.1095b7afd00-4a72-4163-9941-435cca4c8a55crizanlizumab-tmca (Adakveo®) crizanlizumab-tmca (Adakveo®)
1a8c950f-4326-43c3-afed-3275e0913c24.aspx
  
5655CryosurgicalAblationoftheProstateGlandMA11.022aSurgery (11)MA11.022aMA11.0221a8c950f-4326-43c3-afed-3275e0913c24Cryosurgical Ablation of the Prostate GlandCryosurgical Ablation of the Prostate Gland
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4683Daratumumab(Darzalex®),Daratumumab,andHyaluronidase-fihj(DarzalexFaspro®)MA08.079kPharmacy (08)MA08.079kMA08.079143087a4-01b2-4afb-a001-eb8ba9423773Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®)Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®)
ee92c759-ee9f-4de2-8688-6082eef33136.aspx
  
4493DayRehabilitationMA10.005bRehabilitation Services (10)MA10.005bMA10.005ee92c759-ee9f-4de2-8688-6082eef33136Day RehabilitationDay Rehabilitation
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5435DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNailsMA11.014gSurgery (11)MA11.014gMA11.01419d79bbc-4ec2-432d-8e9f-52e59010ccd8Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe NailsDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
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5448DeepBrainStimulation(DBS)MA11.005hSurgery (11)MA11.005hMA11.005b49ab836-c598-40c4-a5a4-3ddcfd7c2788Deep Brain Stimulation (DBS)Deep Brain Stimulation (DBS)
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5154Denosumab(Prolia®,Xgeva®),Romosozumab-aqqg(Evenity®)MA08.052lPharmacy (08)MA08.052lMA08.052f02a318c-a818-47ab-a614-46aa61d61896Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)
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5434DermabrasionforRhinophyma,Septoplasty,Rhinoplasty,andSeptorhinoplastyMA11.099dSurgery (11)MA11.099dMA11.0996cd757ab-ff32-4497-8438-e00b0b988753Dermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and SeptorhinoplastyDermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and Septorhinoplasty
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5004DirectAccesstoObstetrics/Gynecology(OB/GYN)ServicesMA00.032fAdministrative (00)MA00.032fMA00.0327393357c-6383-4146-9971-34e92357c526Direct Access to Obstetrics/Gynecology (OB/GYN) ServicesDirect Access to Obstetrics/Gynecology (OB/GYN) Services
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5263Dofetilide(Tikosyn®)UseintheInpatientSettingMA08.021cPharmacy (08)MA08.021cMA08.02101e34de8-b7d9-453b-970c-f5e26b7b36d9Dofetilide (Tikosyn®) Use in the Inpatient SettingDofetilide (Tikosyn®) Use in the Inpatient Setting
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5274Dostarlimab-gxly(Jemperli)MA08.136ePharmacy (08)MA08.136eMA08.13633c3e42b-4fa6-444d-ad2f-399988971cc5Dostarlimab-gxly (Jemperli)Dostarlimab-gxly (Jemperli)
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4971Drug-ElutingBeadsandBlandEmbolizationfortheTreatmentofHepaticMalignanciesMA07.041bMedicine (07)MA07.041bMA07.04108ccc71e-d011-4b15-9c05-434fc1442308Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic MalignanciesDrug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
c0d73a89-ba2a-4b2a-b327-aabb59da2e21.aspx
  
5463DurableMedicalEquipment(DME)MA05.044qDME (05)MA05.044qMA05.044c0d73a89-ba2a-4b2a-b327-aabb59da2e21Durable Medical Equipment (DME)Durable Medical Equipment (DME)
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4015DurableMedicalEquipment(DME)NotSubjecttoaRentaltoPurchaseMaximumMA05.028eDME (05)MA05.028eMA05.0281b12ffb5-60aa-4123-895e-6165136f7204Durable 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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5476Durvalumab(Imfinzi®)andTremelimumab-actl(Imjudo®)MA08.123dPharmacy (08)MA08.123dMA08.123a126f66b-dd30-4867-acc9-15c98ae07397Durvalumab (Imfinzi®) and Tremelimumab-actl (Imjudo®)Durvalumab (Imfinzi®) and Tremelimumab-actl (Imjudo®)
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4321Eculizumab(Soliris®)andRelatedBiosimilars,Ravulizumab-cwvz(Ultomiris™)MA08.044hPharmacy (08)MA08.044hMA08.04475362d2f-b4f7-4f18-90c0-e39dc57aaea7Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™)Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™)
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5612Efbemalenograstimalfa-vuxw(Ryzneuta®),Eflapegrastim-xnst(Rolvedon™),Pegfilgrastim(Neulasta®)andRelatedBiosimilarsMA08.082mPharmacy (08)MA08.082mMA08.08201d3741f-3291-4f05-8f2b-4ccdd5acabe9Efbemalenograstim alfa-vuxw (Ryzneuta®), Eflapegrastim-xnst (Rolvedon™), Pegfilgrastim (Neulasta®) and Related BiosimilarsEfbemalenograstim alfa-vuxw (Ryzneuta®), Eflapegrastim-xnst (Rolvedon™), Pegfilgrastim (Neulasta®) and Related Biosimilars
{"5613": {"Id":5613,"MPAttachmentLetter":"A","Title":"EXAMPLES OF DISEASE SETTINGS AND CHEMOTHERAPY REGIMENS WITH A HIGH (>20%) OR INTERMEDIATE (10-20%) RISK FOR FEBRILE NEUTROPENIA","MPPolicyAttachmentInternalSourceId":8752,"PolicyAttachmentPageName":"0ce70873-f8f0-4798-a0a4-9a56f3d512b7"},}
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5119Efgartigimodalfa-fcab(Vyvgart)andefgartigimodalfaandhyaluronidase-qvfc(VyvgartHytrulo)MA08.142cPharmacy (08)MA08.142cMA08.14232a0494d-89f3-48ca-af9a-b4f7254ff682Efgartigimod alfa - fcab (Vyvgart) and efgartigimod alfa and hyaluronidase-qvfc (Vyvgart Hytrulo)Efgartigimod alfa - fcab (Vyvgart) and efgartigimod alfa and hyaluronidase-qvfc (Vyvgart Hytrulo)
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5212ElectricalStimulationandElectromagneticStimulationfortheTreatmentofWoundsMA07.013dMedicine (07)MA07.013dMA07.013c835851d-a3e1-4abb-b0c3-e8388227a0acElectrical Stimulation and Electromagnetic Stimulation for the Treatment of WoundsElectrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
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5441ElectroconvulsiveTherapy(ECT)MA14.001aBehavioral Health (14)MA14.001aMA14.001f40f516e-894f-483d-a388-c9945b9d765cElectroconvulsive Therapy (ECT)Electroconvulsive Therapy (ECT)
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5281Electromyography(EMG)Studies,NerveConductionStudies(NCS),andRelatedElectrodiagnosticStudiesMA07.050lMedicine (07)MA07.050lMA07.050b889c657-8395-46af-8695-3141f205f441Electromyography (EMG) Studies, Nerve Conduction Studies (NCS), and Related Electrodiagnostic StudiesElectromyography (EMG) Studies, Nerve Conduction Studies (NCS), and Related Electrodiagnostic Studies
{"5282": {"Id":5282,"MPAttachmentLetter":"A","Title":"Recommended Guidelines for Electrodiagnostic Studies","MPPolicyAttachmentInternalSourceId":8120,"PolicyAttachmentPageName":"8243caa3-3a10-4498-9a14-41bd643d3dcf"},"5283": {"Id":5283,"MPAttachmentLetter":"D","Title":"ICD-10 Codes - Needle Electromyography for Guidance in Conjunction with Chemodenervation","MPPolicyAttachmentInternalSourceId":8436,"PolicyAttachmentPageName":"6c0ca294-4763-4698-a329-9269f379ed37"},"5284": {"Id":5284,"MPAttachmentLetter":"B","Title":"ICD10 Codes - Needle Electromyography and Nerve Conduction Studies","MPPolicyAttachmentInternalSourceId":8441,"PolicyAttachmentPageName":"e629c002-f21a-43c1-9548-1266bedd6ae7"},"5285": {"Id":5285,"MPAttachmentLetter":"C","Title":"ICD10 Codes - Electromyography of Anal or Urethral Sphincter","MPPolicyAttachmentInternalSourceId":8498,"PolicyAttachmentPageName":"63f6c25c-ec70-48c8-9fb8-4db29d7935c1"},"5286": {"Id":5286,"MPAttachmentLetter":"E","Title":"ICD10 Codes - Neuromuscular Junction Testing","MPPolicyAttachmentInternalSourceId":8499,"PolicyAttachmentPageName":"60da5bb5-97f7-4db9-904b-97cc97f8cb91"},"5287": {"Id":5287,"MPAttachmentLetter":"F","Title":"ICD10 Codes - Somatosensory Evoked Potentials (SSEPs)","MPPolicyAttachmentInternalSourceId":8502,"PolicyAttachmentPageName":"a8a36009-8594-41dc-9748-dfa336881de7"},}
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