Medicare Advantage
  
  
  
  
  
  
  
  
  
  
MPattachmentdataPub
  
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2952Abatacept(Orencia®)forInjectionforIntravenousUseMA08.028fPharmacy (08)MA08.028fMA08.028c8843da7-d3aa-47c9-92f6-605aa648b496Abatacept (Orencia®) for Injection for Intravenous UseAbatacept (Orencia®) for Injection for Intravenous Use
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2507AbortionMA11.010aSurgery (11)MA11.010aMA11.0105e7d70e9-cd59-4945-8fd8-e5552ecdbe7fAbortionAbortion
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3023AcupunctureMA12.004cMiscellaneous (12)MA12.004cMA12.0048d122c3d-9edc-4add-81d3-b1c65ff2de78AcupunctureAcupuncture
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2689AcuteCareFacilityInpatientTransfersMA12.003aMiscellaneous (12)MA12.003aMA12.003534525a5-76f0-4bce-9bd9-d6dcff647b59Acute Care Facility Inpatient TransfersAcute Care Facility Inpatient Transfers
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2306Ado-TrastuzumabEmtansine(Kadcyla®)MA08.066dPharmacy (08)MA08.066dMA08.06653c4e67b-3cda-4ec6-8248-67773a3ce433Ado-Trastuzumab Emtansine (Kadcyla®)Ado-Trastuzumab Emtansine (Kadcyla®)
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2922Agalsidasebeta(Fabrazyme®)MA08.033cPharmacy (08)MA08.033cMA08.033d301d0d4-2e30-4f68-8c1c-e50d33608a42Agalsidase beta (Fabrazyme®)Agalsidase beta (Fabrazyme®)
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2758AirAmbulanceServicesMA12.007aMiscellaneous (12)MA12.007aMA12.0078e39da98-8d07-4c8a-bef5-02fa5b6a5006Air Ambulance ServicesAir Ambulance Services
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2768Alemtuzumab(Lemtrada®)MA08.015dPharmacy (08)MA08.015dMA08.01590901d4f-1362-4821-9241-f9bed7689f50Alemtuzumab (Lemtrada®)Alemtuzumab (Lemtrada®)
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2592AllergyImmunotherapyMA07.055dMedicine (07)MA07.055dMA07.055719b74d6-420c-4235-bd9c-701076317da1Allergy ImmunotherapyAllergy Immunotherapy
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2305Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C,AralastNP,Glassia,Zemaira)MA08.050bPharmacy (08)MA08.050bMA08.0503f61cbc3-b488-474e-9b87-7af08a0d7a37Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C, Aralast NP, Glassia, Zemaira)Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C, Aralast NP, Glassia, Zemaira)
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3077AlwaysBundledProcedureCodesMA00.026lAdministrative (00)MA00.026lMA00.026f14f1dfa-d418-492e-88b6-478406f7886fAlways Bundled Procedure CodesAlways Bundled Procedure Codes
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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
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2944AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)MonitoringMA07.026gMedicine (07)MA07.026gMA07.026baec73a2-2762-4c88-9c8d-44887fc2c828Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
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3064Anifrolumab-fnia(Saphnelo™)MA08.140Pharmacy (08)MA08.140MA08.140e34ed3bf-7a34-459f-ba1a-fa8595df92eaAnifrolumab-fnia (Saphnelo™)Anifrolumab-fnia (Saphnelo™)
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2830Ankle-Foot/Knee-Ankle-FootOrthosesMA05.010gDME (05)MA05.010gMA05.0104381bbfc-9be4-4c1d-be48-104f3d74cddfAnkle-Foot/Knee-Ankle-Foot OrthosesAnkle-Foot/Knee-Ankle-Foot Orthoses
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2223AnorectalManometry,Electromyography(EMG)ofAnorectalorUrethralSphincters;BiofeedbackTrainingforPerinealMusclesandAnorectalorUrethralSphinctersMA07.018bMedicine (07)MA07.018bMA07.0189f02b1b1-b4ae-4fb9-ba57-7b2967d1d6c2Anorectal 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
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2179ApheresisTherapyMA06.001ePathology and Laboratory (06)MA06.001eMA06.001a8e854f7-94e7-4833-a02c-b7fb4214ff25Apheresis TherapyApheresis Therapy
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2098ApplicationandRemovalofTattoosMA11.072Surgery (11)MA11.072MA11.0723639d8b3-9067-4cd7-9c4c-e376655e9ed3Application and Removal of TattoosApplication and Removal of Tattoos
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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®)
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2737AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucomaMA11.105gSurgery (11)MA11.105gMA11.1058b4414c0-deff-4fd5-aa8d-95a96a99ae28Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
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3056ArtificialIntervertebralLumbarDiscInsertionMA11.114Surgery (11)MA11.114MA11.114db5c146e-b18a-4e6a-931c-33f744b37c96Artificial Intervertebral Lumbar Disc InsertionArtificial Intervertebral Lumbar Disc Insertion
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2939Asparaginaseerwiniachrysanthemi(Erwinaze®),asparaginaseerwiniachrysanthemi(recombinant)-rywn(Rylaze™)MA08.085dPharmacy (08)MA08.085dMA08.085f25c08ee-b4c2-4803-9a8f-5dbc0e28387dAsparaginase erwinia chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze™)Asparaginase erwinia chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze™)
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2915Atezolizumab(Tecentriq®)MA08.127aPharmacy (08)MA08.127aMA08.127422b90c4-651b-41fe-ae27-e266badd3037Atezolizumab (Tecentriq®)Atezolizumab (Tecentriq®)
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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)
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2747AutonomicNervousSystemTestingMA07.027dMedicine (07)MA07.027dMA07.02776255c86-29e4-4040-ae57-1aef3cc8055fAutonomic Nervous System TestingAutonomic Nervous System Testing
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1921Avelumab(Bavencio®)MA08.122Pharmacy (08)MA08.122MA08.122f91a2c3b-4f6b-4c15-b58c-6d05bcd97376Avelumab (Bavencio®)Avelumab (Bavencio®)
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2144BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitisMA11.100eSurgery (11)MA11.100eMA11.100da677fd2-4630-47ac-af75-7526e365af35Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic RhinosinusitisBalloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
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2613belantamabmafodotin-blmf(Blenrep)MA08.119bPharmacy (08)MA08.119bMA08.119190a4a96-ec61-4357-837d-aaec160f4469belantamab mafodotin-blmf (Blenrep) belantamab mafodotin-blmf (Blenrep)
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2494Belimumab(Benlysta®)forIntravenousUseMA08.057cPharmacy (08)MA08.057cMA08.0570406eaa8-0ae9-4fa6-8803-025b9cfefbf2Belimumab (Benlysta®) for Intravenous UseBelimumab (Benlysta®) for Intravenous Use
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2957Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUseMA08.072hPharmacy (08)MA08.072hMA08.072d029cba2-4866-4aca-9d8f-019729a92250Bevacizumab (Avastin®) and Related Biosimilars For Oncologic UseBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
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2343BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampusMA00.037jAdministrative (00)MA00.037jMA00.037c3346ad1-b72f-4800-9cb4-abec12bcb1ecBilling 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
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3055BiofeedbackTherapyMA07.010aMedicine (07)MA07.010aMA07.010828edbc7-c517-4223-89ea-9740a68d2964Biofeedback TherapyBiofeedback Therapy
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2745BioimpedancefortheDetectionofLymphedemaMA07.052Medicine (07)MA07.052MA07.052c1e6aafa-0100-443d-9127-3883ac43bb26Bioimpedance for the Detection of LymphedemaBioimpedance for the Detection of Lymphedema
81caf8fe-115d-4de8-b7d6-6eeeb38650ad.aspx
  
2417Blepharoplasty,RepairofBlepharoptosis,RepairofBrowPtosis,andCanthoplasty/CanthopexyMA11.047dSurgery (11)MA11.047dMA11.04781caf8fe-115d-4de8-b7d6-6eeeb38650adBlepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/CanthopexyBlepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
{"2418": {"Id":2418,"MPAttachmentLetter":"A","Title":"ICD-10 Coding","MPPolicyAttachmentInternalSourceId":5007,"PolicyAttachmentPageName":"a24bd6c5-96b9-49b3-ab0d-a36c41d645b1"},}
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2707Blinatumomab(Blincyto®)MA08.058dPharmacy (08)MA08.058dMA08.0582ee48daf-823a-407f-9a59-ee7b1644b7e5Blinatumomab (Blincyto®)Blinatumomab (Blincyto®)
a82f627b-608e-46e6-8a8d-739c2bcd90f4.aspx
  
2149Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAidsMA11.049cSurgery (11)MA11.049cMA11.049a82f627b-608e-46e6-8a8d-739c2bcd90f4Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing AidsBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
dd7b7c4d-7b78-402b-85dd-c547c40d1959.aspx
  
2584Bortezomib(BortezomibforInjection,Velcade®)MA08.037gPharmacy (08)MA08.037gMA08.037dd7b7c4d-7b78-402b-85dd-c547c40d1959Bortezomib (Bortezomib for Injection, Velcade®)Bortezomib (Bortezomib for Injection, Velcade®)
0593ec5d-f9c2-4ed5-bc83-5f36d09570ee.aspx
  
2610BotulinumToxinAgentsMA08.017fPharmacy (08)MA08.017fMA08.0170593ec5d-f9c2-4ed5-bc83-5f36d09570eeBotulinum Toxin AgentsBotulinum Toxin Agents
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2971BrentuximabVedotin(Adcetris®)MA08.068fPharmacy (08)MA08.068fMA08.068d1c31d6f-4862-453e-89af-54d64ce7abc9Brentuximab Vedotin (Adcetris®)Brentuximab Vedotin (Adcetris®)
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1363Bronchial ThermoplastySurgery (11)MA11.006bMA11.00685257D39006E7945852585A400669A60Bronchial ThermoplastyBronchial Thermoplasty
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2493Burosumab-twza(Crysvita®)MA08.099bPharmacy (08)MA08.099bMA08.0995d2c8f79-65d8-4f87-958e-20593b9da6d7Burosumab-twza (Crysvita®)Burosumab-twza (Crysvita®)
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2449Canakinumab(Ilaris®)MA08.101aPharmacy (08)MA08.101aMA08.101da9e0793-604f-4c92-8e6c-21d765aac574Canakinumab (Ilaris®)Canakinumab (Ilaris®)
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2474CanesandCrutchesMA05.052bDME (05)MA05.052bMA05.052e7b87e7b-d3ea-4868-9135-b40a85b09ac6Canes and CrutchesCanes and Crutches
4242db3b-8710-49e1-9411-5b4bea68d707.aspx
  
2750CapsuleEndoscopyMA07.022cMedicine (07)MA07.022cMA07.0224242db3b-8710-49e1-9411-5b4bea68d707Capsule 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
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dce37063-3216-4d24-942a-4765161f8650.aspx
  
2314CareManagementandCarePlanningServicesMA00.006hAdministrative (00)MA00.006hMA00.006dce37063-3216-4d24-942a-4765161f8650Care Management and Care Planning ServicesCare Management and Care Planning Services
e395dee3-755a-471c-b8f1-ddc066123e9e.aspx
  
2101Carfilzomib(Kyprolis™)MA08.062ePharmacy (08)MA08.062eMA08.062e395dee3-755a-471c-b8f1-ddc066123e9eCarfilzomib (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
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2664CataractSurgeryMA11.054cSurgery (11)MA11.054cMA11.0549600c19c-6fc5-4a4d-a3f0-28229f1d24acCataract SurgeryCataract Surgery
{"2665": {"Id":2665,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":5478,"PolicyAttachmentPageName":"ca21cbcc-7d65-4bd0-aa7a-b84bd6c67607"},}
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2934CatheterAblationofCardiacArrhythmiasMA11.060cSurgery (11)MA11.060cMA11.0609a441eb3-4002-4e25-897f-78426ac3d2c4Catheter Ablation of Cardiac ArrhythmiasCatheter Ablation of Cardiac Arrhythmias
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1880Cemiplimab-rwlc (LIBTAYO®)MA08.124MA08.12485257D39006E79458525857B007B8F60Cemiplimab-rwlc (LIBTAYO®)Cemiplimab-rwlc (LIBTAYO®)
819bf893-34cb-4721-bfb5-b8fbc37d603e.aspx
  
2629Cerliponasealfa(Brineura®)MA08.089cPharmacy (08)MA08.089cMA08.089819bf893-34cb-4721-bfb5-b8fbc37d603eCerliponase alfa (Brineura®)Cerliponase alfa (Brineura®)
d5768947-b18e-4bd3-a798-3b5a7af86d2c.aspx
  
2096CervicalTractionDevicesforIn-homeUseMA05.009aDME (05)MA05.009aMA05.009d5768947-b18e-4bd3-a798-3b5a7af86d2cCervical Traction Devices for In-home UseCervical Traction Devices for In-home Use
c72d3dca-9d0d-4a60-8b91-7b43d611e591.aspx
  
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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3041ChimericAntigenReceptor(CAR)TherapyMA08.093iPharmacy (08)MA08.093iMA08.0938ac43769-be08-4769-b778-37cf5ec1d768Chimeric Antigen Receptor (CAR) TherapyChimeric Antigen Receptor (CAR) Therapy
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2960ChiropracticServicesMA10.004hRehabilitation Services (10)MA10.004hMA10.00482fa8d76-e28e-4d03-8e55-485c58416c4eChiropractic ServicesChiropractic Services
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1368Circulating Tumor Cell (CTC) AssayPathology and Laboratory (06)MA06.030MA06.030F371FB2E48AFB33885257DBE00723399Circulating Tumor Cell (CTC) AssayCirculating Tumor Cell (CTC) Assay
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2176CoagulationFactorsMA08.004rPharmacy (08)MA08.004rMA08.004f8924323-e7d0-413d-a657-ace27100d002Coagulation Factors Coagulation Factors
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1361Cobalamin (Vitamin B12), Folic Acid, and Homocysteine TestingMA06.032MA06.03285257D39006E7945852585A400689511Cobalamin (Vitamin B12), Folic Acid, and Homocysteine TestingCobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
{"1859":{"Id":1859,"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":0,"PolicyAttachmentPageName":"85257D39006E7945852585A400689538"},}
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2505CochlearImplantationMA11.039dSurgery (11)MA11.039dMA11.0392ff992d2-ca4a-42b9-b321-e387ed4804fdCochlear ImplantationCochlear Implantation
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2869Collagenaseclostridiumhistolyticum(Xiaflex®),collagenaseclostridiumhistolyticum-aaes(Qwo™)MA08.128Pharmacy (08)MA08.128MA08.1288aae66fd-e7ca-4cf4-a2b1-44c684d12b29Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™)Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™)
e541d72d-63cc-41ee-8d00-eef69df90a9f.aspx
  
2476CommodeChairsMA05.036bDME (05)MA05.036bMA05.036e541d72d-63cc-41ee-8d00-eef69df90a9fCommode ChairsCommode Chairs
85257D39006E7945852585040068A7CD.aspx
  
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)
c751b663-969e-44e9-9ed3-333584162b51.aspx
  
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
ab1071fd-1c46-4266-a71c-6dd8cea5c750.aspx
  
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
7eccc322-fc2c-4c32-97f5-d2792e48497b.aspx
  
2640Computer-AssistedMusculoskeletalSurgicalNavigationalOrthopedicProcedureMA11.088cSurgery (11)MA11.088cMA11.0887eccc322-fc2c-4c32-97f5-d2792e48497bComputer-Assisted Musculoskeletal Surgical Navigational Orthopedic ProcedureComputer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
1a75604c-5542-4601-b256-9e702f9428ba.aspx
  
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)
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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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2104CornealPachymetryUsingUltrasoundMA07.046fMedicine (07)MA07.046fMA07.046e0f65852-e550-4adc-a4f3-d102b58690c0Corneal Pachymetry Using UltrasoundCorneal Pachymetry Using Ultrasound
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2751CosmeticProceduresMA12.009aMiscellaneous (12)MA12.009aMA12.0090853e101-4b8c-412e-a9e4-ebc95dc4ec4cCosmetic ProceduresCosmetic Procedures
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3048CoverageofMedicalDevicesMA05.040bDME (05)MA05.040bMA05.04069c3f8a1-1044-489c-869e-7e78dbb55b06Coverage of Medical DevicesCoverage of Medical Devices
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2075CranialElectrotherapyStimulationMA05.066aDME (05)MA05.066aMA05.0665d14dd79-3851-4eaf-bd7c-3896710bc679Cranial 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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2614crizanlizumab-tmca(Adakveo®)MA08.109aPharmacy (08)MA08.109aMA08.109aa45bf6d-52fb-45cd-9290-1f0466d9eb3dcrizanlizumab-tmca (Adakveo®)crizanlizumab-tmca (Adakveo®)
f949b8ee-ae93-49e4-af37-675e06be8bd2.aspx
  
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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2079DeepBrainStimulation(DBS)MA11.005dSurgery (11)MA11.005dMA11.00516ffa733-0972-4703-be0f-1baa1a71f1f5Deep Brain Stimulation (DBS)Deep Brain Stimulation (DBS)
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2627Denosumab(Prolia®,Xgeva®),Romosozumab-aqqg(Evenity®)MA08.052iPharmacy (08)MA08.052iMA08.05204571c73-0e06-47e3-9709-e9ecdfa492d1Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)
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2334DirectAccesstoObstetrics/Gynecology(OB/GYN)ServicesMA00.032cAdministrative (00)MA00.032cMA00.032855c3dd7-e21c-4c80-966f-b8c6a15a3472Direct Access to Obstetrics/Gynecology (OB/GYN) ServicesDirect Access to Obstetrics/Gynecology (OB/GYN) Services
{"2335": {"Id":2335,"MPAttachmentLetter":"A","Title":"Procedure Code for Direct Access OB/GYN for Family Planning","MPPolicyAttachmentInternalSourceId":5194,"PolicyAttachmentPageName":"5f3e1a47-9b97-475d-a095-45b97f6c7876"},}
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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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3031Dostarlimab-gxly(Jemperli)MA08.136aPharmacy (08)MA08.136aMA08.1369f382b47-47c6-4b65-bf89-ccfd3112baacDostarlimab-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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1923Durvalumab(Imfinzi™)MA08.123Pharmacy (08)MA08.123MA08.1232cc301d3-5baf-4ab6-a6a5-21ce1991f10dDurvalumab (Imfinzi™)Durvalumab (Imfinzi™)
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2656Eculizumab(Soliris®)andRelatedBiosimilars,Ravulizumab-cwvz(Ultomiris™)MA08.044fPharmacy (08)MA08.044fMA08.0448f91f1e4-e60a-4d6e-917b-a08d665c22bdEculizumab (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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2454ElectricalContinenceAidMA05.059DME (05)MA05.059MA05.059d0ed73a0-1d77-4f22-9d58-a33008362521Electrical Continence AidElectrical Continence Aid
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2734ElectricalStimulationandElectromagneticStimulationfortheTreatmentofWoundsMA07.013dMedicine (07)MA07.013dMA07.01315c67d90-5ff8-4e28-badd-8cf8cfdd168aElectrical Stimulation and Electromagnetic Stimulation for the Treatment of WoundsElectrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
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2983Electromyography(EMG)Studies:NeedleEMG,SurfaceEMG(SEMG)MA07.050hMedicine (07)MA07.050hMA07.050ba9aa6d8-32cc-4359-8320-e65cf59d0b75Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
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2878ElectronBeamComputedTomography(EBCT)forScreeningEvaluationsMA09.011bRadiology (09)MA09.011bMA09.011bf92d1b4-0663-40e9-9c5b-229f94ff8e5dElectron Beam Computed Tomography (EBCT) for Screening EvaluationsElectron Beam Computed Tomography (EBCT) for Screening Evaluations
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2630Emapalumab-lzsg(Gamifant®)MA08.104bPharmacy (08)MA08.104bMA08.10459432da8-ece6-47a2-b673-19a3b614d8f0Emapalumab-lzsg (Gamifant®)Emapalumab-lzsg (Gamifant®)
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2666EndometrialAblationMA11.065dSurgery (11)MA11.065dMA11.0656ad99673-c741-41dc-b143-c1bd5cb7b82fEndometrial AblationEndometrial Ablation
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2492EndovascularGraftsforAbdominalAorticAneurysms,Aortic-IliacAneurysms,andInfrarenalAorticAneurysmsMA11.012eSurgery (11)MA11.012eMA11.012029ba1fb-6a2a-4996-8ac8-96de24387ca8Endovascular Grafts for Abdominal Aortic Aneurysms, Aortic-Iliac Aneurysms, and Infrarenal Aortic AneurysmsEndovascular Grafts for Abdominal Aortic Aneurysms, Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms
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