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bca631c6-b2da-4b20-81cc-fad9292a75b3.aspx
  
4824Abatacept(Orencia®)forInjectionforIntravenousUseMA08.028hPharmacy (08)MA08.028hMA08.028bca631c6-b2da-4b20-81cc-fad9292a75b3Abatacept (Orencia®) for Injection for Intravenous UseAbatacept (Orencia®) for Injection for Intravenous Use
{"4825": {"Id":4825,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":7707,"PolicyAttachmentPageName":"8b08bc2e-87fd-4af0-b591-a3d72651fa91"},}
253e7c6f-dfb2-4f79-b7e7-c62680bc12c3.aspx
  
4328AbortionMA11.010aSurgery (11)MA11.010aMA11.010253e7c6f-dfb2-4f79-b7e7-c62680bc12c3AbortionAbortion
fe2f068a-caa7-4337-940c-21fff6e5379a.aspx
  
4499AcupunctureMA12.004cMiscellaneous (12)MA12.004cMA12.004fe2f068a-caa7-4337-940c-21fff6e5379aAcupunctureAcupuncture
{"4500": {"Id":4500,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Acupuncture","MPPolicyAttachmentInternalSourceId":7394,"PolicyAttachmentPageName":"58c5c20d-3385-48f1-ae19-ca766547253b"},}
cd466655-0ef1-4249-9599-28e5a0e0a86e.aspx
  
4632AcuteCareFacilityInpatientTransfersMA12.003bMiscellaneous (12)MA12.003bMA12.003cd466655-0ef1-4249-9599-28e5a0e0a86eAcute Care Facility Inpatient TransfersAcute Care Facility Inpatient Transfers
62e04270-b09a-42de-9ba4-248feb04627e.aspx
  
4094Ado-TrastuzumabEmtansine(Kadcyla®)MA08.066fPharmacy (08)MA08.066fMA08.06662e04270-b09a-42de-9ba4-248feb04627eAdo-Trastuzumab Emtansine (Kadcyla®)Ado-Trastuzumab Emtansine (Kadcyla®)
{"4095": {"Id":4095,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":6793,"PolicyAttachmentPageName":"16b65577-4b46-4911-94f6-c3c03734729f"},}
899c9577-2cf3-4cf9-80dd-865bc7bd577d.aspx
  
4316Agalsidasebeta(Fabrazyme®)MA08.033cPharmacy (08)MA08.033cMA08.033899c9577-2cf3-4cf9-80dd-865bc7bd577dAgalsidase beta (Fabrazyme®)Agalsidase beta (Fabrazyme®)
21b96147-07c3-431a-b6e2-54dcc732d539.aspx
  
4546AirAmbulanceServicesMA12.007bMiscellaneous (12)MA12.007bMA12.00721b96147-07c3-431a-b6e2-54dcc732d539Air Ambulance ServicesAir Ambulance Services
8067664a-80c3-4d44-a11e-3ced21699339.aspx
  
4438Alemtuzumab(Lemtrada®)MA08.015dPharmacy (08)MA08.015dMA08.0158067664a-80c3-4d44-a11e-3ced21699339Alemtuzumab (Lemtrada®)Alemtuzumab (Lemtrada®)
1ae76050-dc9f-4acc-8570-eedd1dd4bb9b.aspx
  
4476Alglucosidasealfa(e.g.,Lumizyme®),Avalglucosidasealfa-ngpt(Nexviazyme®)MA08.036fPharmacy (08)MA08.036fMA08.0361ae76050-dc9f-4acc-8570-eedd1dd4bb9bAlglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® )Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® )
3e070cb9-2526-4b23-bf99-c8aba195b1b2.aspx
  
4854AllergyImmunotherapyMA07.055dMedicine (07)MA07.055dMA07.0553e070cb9-2526-4b23-bf99-c8aba195b1b2Allergy ImmunotherapyAllergy Immunotherapy
18476a80-146f-492a-bf5d-642fda50dc24.aspx
  
4383Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C,AralastNP,Glassia,Zemaira)MA08.050bPharmacy (08)MA08.050bMA08.05018476a80-146f-492a-bf5d-642fda50dc24Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C, Aralast NP, Glassia, Zemaira)Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C, Aralast NP, Glassia, Zemaira)
598bf394-a168-4b03-ad90-085a747f8e49.aspx
  
4935AlwaysBundledProcedureCodesMA00.026sAdministrative (00)MA00.026sMA00.026598bf394-a168-4b03-ad90-085a747f8e49Always Bundled Procedure CodesAlways Bundled Procedure Codes
{"4936": {"Id":4936,"MPAttachmentLetter":"B","Title":"Procedures/Services Not Eligible for Separate Reimbursement","MPPolicyAttachmentInternalSourceId":7720,"PolicyAttachmentPageName":"bac2de36-0c6c-4551-85b1-6210ba4d14d0"},"4937": {"Id":4937,"MPAttachmentLetter":"C","Title":"Procedures/Services Not Eligible for Reimbursement","MPPolicyAttachmentInternalSourceId":7721,"PolicyAttachmentPageName":"cb7f4e09-ad5e-44c2-b8ca-3f13800d8d3c"},"4938": {"Id":4938,"MPAttachmentLetter":"A","Title":"Always Bundled Procedures (MPFSD Indicator B)","MPPolicyAttachmentInternalSourceId":7722,"PolicyAttachmentPageName":"058b2b4f-523f-4d3c-bf10-98adeacc5f7e"},}
bd28f435-0025-4898-8c46-6a83f3ffa465.aspx
  
4635AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)DevicesMA07.005cMedicine (07)MA07.005cMA07.005bd28f435-0025-4898-8c46-6a83f3ffa465Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) DevicesAmbulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
fc4e64b5-4bca-4b25-bdb5-3a75437ca432.aspx
  
5015AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)MonitoringMA07.026nMedicine (07)MA07.026nMA07.026fc4e64b5-4bca-4b25-bdb5-3a75437ca432Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
23e3aa80-5874-405c-a103-7e45fece45bd.aspx
  
4756AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagementMA01.008bAnesthesia (01)MA01.008bMA01.00823e3aa80-5874-405c-a103-7e45fece45bdAnesthesia 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
{}
b4d3f597-41f0-492e-b517-a8331717cee3.aspx
  
4539Anifrolumab-fnia(Saphnelo®)MA08.140bPharmacy (08)MA08.140bMA08.140b4d3f597-41f0-492e-b517-a8331717cee3Anifrolumab-fnia (Saphnelo®)Anifrolumab-fnia (Saphnelo®)
acabd5b9-f1d1-4bdd-ae49-da518c2798e8.aspx
  
4312Ankle-Foot/Knee-Ankle-FootOrthosesMA05.010hDME (05)MA05.010hMA05.010acabd5b9-f1d1-4bdd-ae49-da518c2798e8Ankle-Foot/Knee-Ankle-Foot OrthosesAnkle-Foot/Knee-Ankle-Foot Orthoses
{"4313": {"Id":4313,"MPAttachmentLetter":"A","Title":"HCPCS CODES FOR ANKLE-FOOT/ KNEE-ANKLE FOOT ORTHOSIS","MPPolicyAttachmentInternalSourceId":7045,"PolicyAttachmentPageName":"9b6beacb-0a52-4a50-b171-447055ee9c4f"},}
de604fb8-ee97-41c4-b98a-5bb8b7fb8a4c.aspx
  
4398AnorectalManometry,Electromyography(EMG)ofAnorectalorUrethralSphincters;BiofeedbackTrainingforPerinealMusclesandAnorectalorUrethralSphinctersMA07.018cMedicine (07)MA07.018cMA07.018de604fb8-ee97-41c4-b98a-5bb8b7fb8a4cAnorectal 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
39dcf591-f9fc-44f7-bfc4-2d1736f2fd49.aspx
  
4981ApheresisTherapyMA06.001ePathology and Laboratory (06)MA06.001eMA06.00139dcf591-f9fc-44f7-bfc4-2d1736f2fd49Apheresis TherapyApheresis Therapy
879ce4a4-c22d-428a-85bb-ad1c18403124.aspx
  
4262ApplicationandRemovalofTattoosMA11.072Surgery (11)MA11.072MA11.072879ce4a4-c22d-428a-85bb-ad1c18403124Application and Removal of TattoosApplication and Removal of Tattoos
ff104db5-0a07-4d08-9240-ca4aede56f1f.aspx
  
4132Aprepitant(Cinvanti™),FosaprepitantDimeglumine(Emend®),Granisetron(Sustol®),andRolapitant(Varubi®)MA08.091ePharmacy (08)MA08.091eMA08.091ff104db5-0a07-4d08-9240-ca4aede56f1fAprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
{"4133": {"Id":4133,"MPAttachmentLetter":"A","Title":"Risk of Emesis Without Prophylaxis: Intravenous and Oral Antineoplastic Agents","MPPolicyAttachmentInternalSourceId":7123,"PolicyAttachmentPageName":"558f07dc-00a1-44ad-bfa2-15f8d10d97c4"},}
df24c7d1-3b2b-41a3-ba0a-d25c9c5e7d70.aspx
  
4137AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucomaMA11.105jSurgery (11)MA11.105jMA11.105df24c7d1-3b2b-41a3-ba0a-d25c9c5e7d70Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
{"4138": {"Id":4138,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":7062,"PolicyAttachmentPageName":"bad39d3e-be8b-4144-b280-a37f967082f1"},}
9772efeb-a7bd-4217-ac52-ea05bc5a3d31.aspx
  
4884ArtificialIntervertebralLumbarDiscInsertionMA11.114bSurgery (11)MA11.114bMA11.1149772efeb-a7bd-4217-ac52-ea05bc5a3d31Artificial Intervertebral Lumbar Disc InsertionArtificial Intervertebral Lumbar Disc Insertion
7d0a7b7f-0ed5-4a94-ab38-982449843b7e.aspx
  
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®)
{"4273": {"Id":4273,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":7180,"PolicyAttachmentPageName":"9eff91d7-0b43-4fb4-9ac9-6c07148a0eff"},}
50cf8ab2-c1d7-4114-bf48-301031b97b42.aspx
  
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)
{"4760": {"Id":4760,"MPAttachmentLetter":"B","Title":"ICD-10 codes used to represent the Nonwearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":7704,"PolicyAttachmentPageName":"ae96ccb4-e007-4b22-a35a-db16d1e26d31"},"4761": {"Id":4761,"MPAttachmentLetter":"A","Title":"ICD-10 codes used to represent the Wearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":7705,"PolicyAttachmentPageName":"e746d254-5296-4104-8d51-c36caf53222f"},}
ff1221f9-30d9-4ac7-bbab-964e32913b1c.aspx
  
4469AutonomicNervousSystemTestingMA07.027fMedicine (07)MA07.027fMA07.027ff1221f9-30d9-4ac7-bbab-964e32913b1cAutonomic Nervous System TestingAutonomic Nervous System Testing
2940ef19-00de-46de-bbaa-aef9985a3ac2.aspx
  
4105Avelumab(Bavencio®)MA08.122bPharmacy (08)MA08.122bMA08.1222940ef19-00de-46de-bbaa-aef9985a3ac2Avelumab (Bavencio®)Avelumab (Bavencio®)
{"4106": {"Id":4106,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":7009,"PolicyAttachmentPageName":"15c6ab29-ebb0-4244-b462-2756d4f993b8"},}
6a0c5929-9fd0-40f2-8aee-a03e3c5d7160.aspx
  
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
bccd1651-281b-4398-bd5c-64d796fe33fb.aspx
  
4436Belimumab(Benlysta®)forIntravenousUseMA08.057dPharmacy (08)MA08.057dMA08.057bccd1651-281b-4398-bd5c-64d796fe33fbBelimumab (Benlysta®) for Intravenous UseBelimumab (Benlysta®) for Intravenous Use
46cea12e-7050-4ace-8a7f-113e18bd0426.aspx
  
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
{"4503": {"Id":4503,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":7281,"PolicyAttachmentPageName":"801fe1a9-7997-4d08-9710-3e524241440b"},"4504": {"Id":4504,"MPAttachmentLetter":"B","Title":"ICD 10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":7323,"PolicyAttachmentPageName":"ad90e584-84ce-4f28-8798-8e3380ae2f1f"},}
df2725e5-51fc-4d42-95c9-22377801776d.aspx
  
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"},}
186e43b9-48ee-4ef3-842d-adf5eef12376.aspx
  
4276BiofeedbackTherapyMA07.010aMedicine (07)MA07.010aMA07.010186e43b9-48ee-4ef3-842d-adf5eef12376Biofeedback TherapyBiofeedback Therapy
1511575d-8683-46df-9aae-8fd9d97cc10d.aspx
  
4719BioimpedancefortheDetectionofLymphedemaMA07.052Medicine (07)MA07.052MA07.0521511575d-8683-46df-9aae-8fd9d97cc10dBioimpedance for the Detection of LymphedemaBioimpedance for the Detection of Lymphedema
471e433d-f780-4d16-882b-1406395273b3.aspx
  
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
{"4005": {"Id":4005,"MPAttachmentLetter":"A","Title":"ICD-10 Coding","MPPolicyAttachmentInternalSourceId":6998,"PolicyAttachmentPageName":"dacc12f4-b2a3-4a21-9dd1-580964f7c079"},}
03966d42-a58c-417b-ad2a-bd444959368a.aspx
  
4269Blinatumomab(Blincyto®)MA08.058fPharmacy (08)MA08.058fMA08.05803966d42-a58c-417b-ad2a-bd444959368aBlinatumomab (Blincyto®)Blinatumomab (Blincyto®)
2dd2a688-6d08-4df7-896f-d7428b2ed564.aspx
  
4686Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAidsMA11.049eSurgery (11)MA11.049eMA11.0492dd2a688-6d08-4df7-896f-d7428b2ed564Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing AidsBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
914820d9-a5e5-4afc-8485-d9e01ce5b0ae.aspx
  
4815Bortezomib(BortezomibforInjection,Velcade®)MA08.037jPharmacy (08)MA08.037jMA08.037914820d9-a5e5-4afc-8485-d9e01ce5b0aeBortezomib (Bortezomib for Injection, Velcade®)Bortezomib (Bortezomib for Injection, Velcade®)
{"4816": {"Id":4816,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":7709,"PolicyAttachmentPageName":"581cd9b4-4ad8-4128-8862-a8c8377f3390"},}
e196fa27-34f5-4e62-98af-922a3647dd39.aspx
  
4820BotulinumToxinAgentsMA08.017jPharmacy (08)MA08.017jMA08.017e196fa27-34f5-4e62-98af-922a3647dd39Botulinum Toxin AgentsBotulinum Toxin Agents
{"4821": {"Id":4821,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":7745,"PolicyAttachmentPageName":"9bfeffe7-c2cd-4c5c-9ad0-564706dc4b78"},}
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"},}
a709d47e-0945-492c-b064-7ffe02701b0c.aspx
  
4633BronchialValvesMA11.020Surgery (11)MA11.020MA11.020a709d47e-0945-492c-b064-7ffe02701b0cBronchial ValvesBronchial Valves
139fe438-ff72-40f7-98d1-4bfe79daf96e.aspx
  
4477Burosumab-twza(Crysvita®)MA08.099bPharmacy (08)MA08.099bMA08.099139fe438-ff72-40f7-98d1-4bfe79daf96eBurosumab-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®)
b9a4e942-4f22-4e46-b71d-bb61455dd52a.aspx
  
4246CanesandCrutchesMA05.052bDME (05)MA05.052bMA05.052b9a4e942-4f22-4e46-b71d-bb61455dd52aCanes and CrutchesCanes and Crutches
f1b3ebed-0d89-4fc1-bfb7-384ea15ad86f.aspx
  
4492CapsuleEndoscopyMA07.022eMedicine (07)MA07.022eMA07.022f1b3ebed-0d89-4fc1-bfb7-384ea15ad86fCapsule EndoscopyCapsule Endoscopy
9c64a235-ae06-413c-acf3-bbc493c07fe5.aspx
  
5013CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)ProgramsMA10.002eRehabilitation Services (10)MA10.002eMA10.0029c64a235-ae06-413c-acf3-bbc493c07fe5Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) ProgramsCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
{"5014": {"Id":5014,"MPAttachmentLetter":"A","Title":"Medically Necessary ICD-10 Codes","MPPolicyAttachmentInternalSourceId":7616,"PolicyAttachmentPageName":"945cbd91-77ca-49dd-8b0d-7a3e2c8a5897"},}
e172f03c-54fe-4e01-8357-866843b8d2b5.aspx
  
4228CareManagementandCarePlanningServicesMA00.006mAdministrative (00)MA00.006mMA00.006e172f03c-54fe-4e01-8357-866843b8d2b5Care Management and Care Planning ServicesCare Management and Care Planning Services
cc00c34c-5b11-4450-9824-79ca51259fae.aspx
  
3969Carfilzomib(Kyprolis™)MA08.062gPharmacy (08)MA08.062gMA08.062cc00c34c-5b11-4450-9824-79ca51259faeCarfilzomib (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"},}
35d53c26-0c5b-4b14-b8b8-a5597e77fe0c.aspx
  
4010CataractSurgeryMA11.054dSurgery (11)MA11.054dMA11.05435d53c26-0c5b-4b14-b8b8-a5597e77fe0cCataract SurgeryCataract Surgery
{"4011": {"Id":4011,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":6669,"PolicyAttachmentPageName":"00eafbe0-27dc-4b22-bec7-d83dddcb66d7"},}
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®)
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4473Cerliponasealfa(Brineura®)MA08.089cPharmacy (08)MA08.089cMA08.089cbcee004-59ba-4f3d-ace3-5dd2bb9e1992Cerliponase alfa (Brineura®)Cerliponase alfa (Brineura®)
758792dc-b695-4e8f-8010-624a774b081b.aspx
  
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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4156Cetuximab(Erbitux®)MA08.031fPharmacy (08)MA08.031fMA08.031da641a6d-6927-4908-a969-1856f88de703Cetuximab (Erbitux®)Cetuximab (Erbitux®)
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4980ChemicalPeelsMA11.103bSurgery (11)MA11.103bMA11.10368af371b-fdac-4133-a97a-bf73d8c4b158Chemical PeelsChemical Peels
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4939ChimericAntigenReceptor(CAR)TherapyMA08.093lPharmacy (08)MA08.093lMA08.093d8d1be84-2787-48b6-bb3e-5777c6a2c939Chimeric Antigen Receptor (CAR) TherapyChimeric Antigen Receptor (CAR) Therapy
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4934ChiropracticServicesMA10.004iRehabilitation Services (10)MA10.004iMA10.0041d244cbe-e372-44f9-ad14-62a9ee25d888Chiropractic 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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4596CoagulationFactorsMA08.004uPharmacy (08)MA08.004uMA08.00457e7932f-24b6-47ae-bc0a-a5829583bc6dCoagulation Factors Coagulation Factors
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4206Cobalamin(VitaminB12),FolicAcid,andHomocysteineTestingMA06.032aPathology and Laboratory (06)MA06.032aMA06.03208299b3d-e691-4b8a-b760-476b6013cdcfCobalamin (Vitamin B12), Folic Acid, and Homocysteine TestingCobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
{"4207": {"Id":4207,"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":7157,"PolicyAttachmentPageName":"6730a75f-3149-47c6-90ac-aee646ce81f2"},}
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4631CochlearImplantationMA11.039eSurgery (11)MA11.039eMA11.0394bfe53c3-a7a4-4796-9218-525f38f768eeCochlear ImplantationCochlear Implantation
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4297Collagenaseclostridiumhistolyticum(Xiaflex®),collagenaseclostridiumhistolyticum-aaes(Qwo™)MA08.128Pharmacy (08)MA08.128MA08.128eb7a5b5b-9d54-474b-9874-57a8dce573fcCollagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™)Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™)
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4244CommodeChairsMA05.036bDME (05)MA05.036bMA05.036e33148b1-aa3c-4791-a297-b5f05efc14bcCommode 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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4584CompleteDecongestiveTherapy(CDT)MA07.042Medicine (07)MA07.042MA07.042b4e4e763-9995-4651-935b-e382cd5fb5beComplete Decongestive Therapy (CDT)Complete Decongestive Therapy (CDT)
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4251CompositeTissueAllotransplantationoftheHand(s)andFaceMA11.112Surgery (11)MA11.112MA11.112df7d7068-6c32-45da-b37f-2e979978b0d5Composite Tissue Allotransplantation of the Hand(s) and FaceComposite Tissue Allotransplantation of the Hand(s) and Face
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4852CompressionGarmentsMA05.045bDME (05)MA05.045bMA05.04517984772-6b97-4a66-99cd-2f82db044567Compression 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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4215Computer-AssistedMusculoskeletalSurgicalNavigationalOrthopedicProcedureMA11.088cSurgery (11)MA11.088cMA11.088ceec4bd5-f2ac-4512-b0e7-b6b2f8aea4b6Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic ProcedureComputer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
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4229ConsultationServicesMA00.049bAdministrative (00)MA00.049bMA00.04950f137b2-f09b-4bba-bf10-c689ad659402Consultation ServicesConsultation Services
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4956ContinuousGlucoseMonitorsandHomeBloodGlucoseMonitorsandSuppliesMA00.002lAdministrative (00)MA00.002lMA00.00234d742c6-9798-42bd-bed5-528dc7973f94Continuous 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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4669CornealPachymetryUsingUltrasoundMA07.046gMedicine (07)MA07.046gMA07.0468a3160e2-2cd8-48bb-8348-56066ba7c299Corneal Pachymetry Using UltrasoundCorneal Pachymetry Using Ultrasound
{"4670": {"Id":4670,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes Eligible to be Reported for Corneal Pachymetry Using Ultrasound","MPPolicyAttachmentInternalSourceId":7543,"PolicyAttachmentPageName":"f61fb559-401f-4234-b72e-e10ed71b4232"},}
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4217CosmeticProceduresMA12.009aMiscellaneous (12)MA12.009aMA12.0096db2e8ed-e67a-4ecf-aebd-400834738d29Cosmetic 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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4687CranialElectrotherapyStimulationMA05.066cDME (05)MA05.066cMA05.066d77e05da-1aea-4a99-b0ff-a614064127daCranial Electrotherapy StimulationCranial Electrotherapy Stimulation
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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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4810crizanlizumab-tmca(Adakveo®)MA08.109bPharmacy (08)MA08.109bMA08.10915a1b743-0c2d-4f22-bb7d-c37c2d029e27crizanlizumab-tmca (Adakveo®)crizanlizumab-tmca (Adakveo®)
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4974CryosurgicalAblationoftheProstateGlandMA11.022aSurgery (11)MA11.022aMA11.022f26ae49b-8ec6-4683-aaf4-48a783faf22fCryosurgical 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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4278DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNailsMA11.014gSurgery (11)MA11.014gMA11.0148aa69314-d990-40ec-a294-8971cc5c5e5bDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe NailsDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
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4803DeepBrainStimulation(DBS)MA11.005gSurgery (11)MA11.005gMA11.0053c43b8c3-37e8-4dd2-a4f6-1f22ae586315Deep Brain Stimulation (DBS)Deep Brain Stimulation (DBS)
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4818Denosumab(Prolia®,Xgeva®),Romosozumab-aqqg(Evenity®)MA08.052kPharmacy (08)MA08.052kMA08.05251c6efc9-dab9-4bd5-a611-744c068be1b9Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)
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4751DermabrasionforRhinophyma,Septoplasty,Rhinoplasty,andSeptorhinoplastyMA11.099dSurgery (11)MA11.099dMA11.099af858c6b-1475-4646-9116-3543770cabccDermabrasion 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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4540Dofetilide(Tikosyn®)UseintheInpatientSettingMA08.021bPharmacy (08)MA08.021bMA08.021d54e6d11-da78-4d6c-9188-af477cad5034Dofetilide (Tikosyn®) Use in the Inpatient SettingDofetilide (Tikosyn®) Use in the Inpatient Setting
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4310Dostarlimab-gxly(Jemperli)MA08.136dPharmacy (08)MA08.136dMA08.13618ff969a-7c89-4261-acdf-6c16773efc05Dostarlimab-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
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4864DurableMedicalEquipment(DME)MA05.044oDME (05)MA05.044oMA05.044f34f82bd-b6a8-4a4a-b979-bcca7cb6f7eaDurable 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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4684Durvalumab(Imfinzi®)andtremelimumab-act(Imjudo®)MA08.123cPharmacy (08)MA08.123cMA08.1234b3152da-96b0-4cf1-8b23-032f3ac547dcDurvalumab (Imfinzi®) and tremelimumab-act (Imjudo®)Durvalumab (Imfinzi®) and tremelimumab-act (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™)
93ee35b6-d0d3-4c1a-b0e0-152e9dd153e8.aspx
  
3578Edaravone(Radicava®)MA08.092aPharmacy (08)MA08.092aMA08.09293ee35b6-d0d3-4c1a-b0e0-152e9dd153e8Edaravone (Radicava®)Edaravone (Radicava®)
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4860Efgartigimodalfa-fcab(Vyvgart)andefgartigimodalfaandhyaluronidase-qvfc(VyvgartHytrulo)MA08.142bPharmacy (08)MA08.142bMA08.142887670f7-cfb9-4645-8e2c-47662a42bed9Efgartigimod 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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4365Eflapegrastim-xnst(Rolvedon™),Pegfilgrastim(Neulasta®)andRelatedBiosimilarsMA08.082jPharmacy (08)MA08.082jMA08.082b1ce6a6e-dd13-40a1-bfda-991f36ee8d46Eflapegrastim-xnst (Rolvedon™), Pegfilgrastim (Neulasta®) and Related BiosimilarsEflapegrastim-xnst (Rolvedon™), Pegfilgrastim (Neulasta®) and Related Biosimilars
{"4366": {"Id":4366,"MPAttachmentLetter":"A","Title":"EXAMPLES OF DISEASE SETTINGS AND CHEMOTHERAPY REGIMENS WITH A HIGH (>20%) OR INTERMEDIATE (10-20%) RISK FOR FEBRILE NEUTROPENIA","MPPolicyAttachmentInternalSourceId":7289,"PolicyAttachmentPageName":"073d1324-e0f7-4423-8859-0c20e57e2ae1"},}
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4287ElectricalStimulationandElectromagneticStimulationfortheTreatmentofWoundsMA07.013dMedicine (07)MA07.013dMA07.0134d2edd4d-cda6-4f0a-90ca-019dfd361a62Electrical Stimulation and Electromagnetic Stimulation for the Treatment of WoundsElectrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
{"4288": {"Id":4288,"MPAttachmentLetter":"A","Title":"ICD-10 Coding","MPPolicyAttachmentInternalSourceId":7197,"PolicyAttachmentPageName":"682701e8-a236-4e4c-b4cc-69923e3999b7"},}
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4898ElectroconvulsiveTherapy(ECT)MA14.001aBehavioral Health (14)MA14.001aMA14.001b3df3c46-8422-4101-a5a0-0346f4da00f0Electroconvulsive Therapy (ECT)Electroconvulsive Therapy (ECT)
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4886Electromyography(EMG)Studies:NeedleEMG,SurfaceEMG(SEMG)MA07.050kMedicine (07)MA07.050kMA07.050f7f69693-100a-49a3-8994-a5924c2ac9e6Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
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