Medicare Advantage
  
  
  
  
  
  
  
  
  
  
MPattachmentdataPub
  
85257D39006E7945852584EB005E7F40.aspx
  
1299Abatacept (Orencia®) for Injection for Intravenous UsePharmacy (08)MA08.028dMA08.02885257D39006E7945852584EB005E7F40Abatacept (Orencia®) for Injection for Intravenous UseAbatacept (Orencia®) for Injection for Intravenous Use
{"1823":{"Id":1823,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E7945852584EB005E7F48"},}
85257D39006E79458525854300496FA9.aspx
  
1649AbortionSurgery (11)MA11.010aMA11.01085257D39006E79458525854300496FA9AbortionAbortion
85257D39006E7945852585660066FB4B.aspx
  
1349AcupunctureMA12.004aMA12.00485257D39006E7945852585660066FB4BAcupunctureAcupuncture
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85257D39006E7945852585970047577D.aspx
  
1344Acute Care Facility Inpatient TransfersMA12.003aMA12.00385257D39006E7945852585970047577DAcute Care Facility Inpatient TransfersAcute Care Facility Inpatient Transfers
85257D39006E7945852583C4005C5F03.aspx
  
1430Ado-Trastuzumab Emtansine (Kadcyla®)Pharmacy (08)MA08.066cMA08.06685257D39006E7945852583C4005C5F03Ado-Trastuzumab Emtansine (Kadcyla®)Ado-Trastuzumab Emtansine (Kadcyla®)
{"1705":{"Id":1705,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E7945852583C4005C5F0E"},}
85257D39006E7945852585430046609C.aspx
  
1645Agalsidase beta (Fabrazyme®)Pharmacy (08)MA08.033bMA08.03385257D39006E7945852585430046609CAgalsidase beta (Fabrazyme®)Agalsidase beta (Fabrazyme®)
85257D39006E79458525859700487CB6.aspx
  
1345Air Ambulance ServicesMiscellaneous (12)MA12.007aMA12.00785257D39006E79458525859700487CB6Air Ambulance ServicesAir Ambulance Services
85257D39006E7945852584EB0059DBD8.aspx
  
1666Alemtuzumab (Lemtrada™)MA08.015dMA08.01585257D39006E7945852584EB0059DBD8Alemtuzumab (Lemtrada™)Alemtuzumab (Lemtrada™)
85257D39006E794585258543004566E0.aspx
  
1646Alglucosidase alfa (e.g., Lumizyme®)Pharmacy (08)MA08.036cMA08.03685257D39006E794585258543004566E0Alglucosidase alfa (e.g., Lumizyme®)Alglucosidase alfa (e.g., Lumizyme®)
85257D39006E7945852584E9007261D7.aspx
  
1587Allergy ImmunotherapyMedicine (07)MA07.055cMA07.05585257D39006E7945852584E9007261D7Allergy ImmunotherapyAllergy Immunotherapy
85257D39006E7945852585340058AB4F.aspx
  
1617AlloMap™ Molecular Expression Testing for Heart Transplant RejectionPathology and Laboratory (06)MA06.015cMA06.01585257D39006E7945852585340058AB4FAlloMap™ Molecular Expression Testing for Heart Transplant RejectionAlloMap™ Molecular Expression Testing for Heart Transplant Rejection
E5CF8D3FC1845D768525851F0066272E.aspx
  
1607Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)Pharmacy (08)MA08.050aMA08.050E5CF8D3FC1845D768525851F0066272EAlpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)
85257D39006E7945852584BE00618356.aspx
  
1559Always Bundled Procedure CodesAdministrative (00)MA00.026gMA00.02685257D39006E7945852584BE00618356Always Bundled Procedure CodesAlways Bundled Procedure Codes
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85257D39006E79458525852700659BB3.aspx
  
1641Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) DevicesMedicine (07)MA07.005cMA07.00585257D39006E79458525852700659BB3Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) DevicesAmbulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
85257D39006E79458525849B0072F230.aspx
  
1558Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringMA07.026eMA07.02685257D39006E79458525849B0072F230Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
85257D39006E79458525847900571033.aspx
  
1447Ankle-Foot/Knee-Ankle-Foot OrthosesDME (05)MA05.010dMA05.01085257D39006E79458525847900571033Ankle-Foot/Knee-Ankle-Foot OrthosesAnkle-Foot/Knee-Ankle-Foot Orthoses
{"1714":{"Id":1714,"MPAttachmentLetter":"A","Title":"HCPCS CODES FOR ANKLE-FOOT/ KNEE-ANKLE FOOT ORTHOSIS","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E79458525847900571039"},}
85257D39006E7945852584C8004B13BC.aspx
  
1548Anorectal Manometry, Electromyography (EMG) of Anorectal or Urethral Sphincters; Biofeedback Training for Perineal Muscles and Anorectal or Urethral SphinctersMedicine (07)MA07.018bMA07.01885257D39006E7945852584C8004B13BCAnorectal 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
85257D39006E7945852581E800533DBD.aspx
  
1376Apheresis TherapyPathology and Laboratory (06)MA06.001eMA06.00185257D39006E7945852581E800533DBDApheresis TherapyApheresis Therapy
85257D39006E794585258464005D9537.aspx
  
1461Application and Removal of TattoosSurgery (11)MA11.072MA11.07285257D39006E794585258464005D9537Application and Removal of TattoosApplication and Removal of Tattoos
85257D39006E79458525854200771F5A.aspx
  
1647Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)MA08.091cMA08.09185257D39006E79458525854200771F5AAprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
{"1800":{"Id":1800,"MPAttachmentLetter":"A","Title":"Risk of Emesis Without Prophylaxis: Intravenous and Oral Antineoplastic Agents","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E79458525854200771F88"},}
85257D39006E794585258397005A5730.aspx
  
1433Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaSurgery (11)MA11.105fMA11.10585257D39006E794585258397005A5730Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
{"1707":{"Id":1707,"MPAttachmentLetter":"A","Title":"No Title","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E794585258397005A5739"},}
85257D39006E7945852584CE0057BE40.aspx
  
1533Artificial Hearts and Ventricular Assist Devices (VADs)Surgery (11)MA11.011cMA11.01185257D39006E7945852584CE0057BE40Artificial Hearts and Ventricular Assist Devices (VADs)Artificial Hearts and Ventricular Assist Devices (VADs)
60E1FC5D8D97065A852585880062C00E.aspx
  
1311Artificial Intervertebral Disc InsertionSurgery (11)MA11.044gMA11.04460E1FC5D8D97065A852585880062C00EArtificial Intervertebral Disc InsertionArtificial Intervertebral Disc Insertion
85257D39006E79458525848D004D2F20.aspx
  
1519Asparaginase Erwinia Chrysanthemi (Erwinaze®)MA08.085bMA08.08585257D39006E79458525848D004D2F20Asparaginase Erwinia Chrysanthemi (Erwinaze®)Asparaginase Erwinia Chrysanthemi (Erwinaze®)
85257D39006E79458525849B0043944F.aspx
  
1316Autologous Chondrocyte Implantation (ACI)/Carticel® and Other Cell-based Treatments of Focal Articular Cartilage LesionsSurgery (11)MA11.082cMA11.08285257D39006E79458525849B0043944FAutologous Chondrocyte Implantation (ACI)/Carticel® and Other Cell-based Treatments of Focal Articular Cartilage LesionsAutologous Chondrocyte Implantation (ACI)/Carticel® and Other Cell-based Treatments of Focal Articular Cartilage Lesions
46045ED869F1832F852585AB0056C456.aspx
  
1879Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)DME (05)MA05.005dMA05.00546045ED869F1832F852585AB0056C456Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
{"1867": {"Id":1867,"MPAttachmentLetter":"A","Title":"ICD-10 codes used to represent the Wearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"5801A106F8EA95A1852585AB0056C464"},"1868": {"Id":1868,"MPAttachmentLetter":"B","Title":"ICD-10 codes used to represent the Nonwearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"BFE142D6DE3A8525852585AB0056C46C"},}
85257D39006E79458525853500666D0A.aspx
  
1325Autonomic Nervous System TestingMA07.027cMA07.02785257D39006E79458525853500666D0AAutonomic Nervous System TestingAutonomic Nervous System Testing
f91a2c3b-4f6b-4c15-b58c-6d05bcd97376.aspx
  
1921Avelumab(Bavencio®)MA08.122Pharmacy (08)MA08.122MA08.122f91a2c3b-4f6b-4c15-b58c-6d05bcd97376Avelumab (Bavencio®)Avelumab (Bavencio®)
{"1922": {"Id":1922,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":4675,"PolicyAttachmentPageName":"765f7154-9f56-4ca8-bd28-3b9c1d7df492"},}
85257D39006E7945852584C8004B1B01.aspx
  
1555Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic RhinosinusitisSurgery (11)MA11.100eMA11.10085257D39006E7945852584C8004B1B01Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic RhinosinusitisBalloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
85257D39006E7945852584EB005E6F24.aspx
  
1301Belimumab (Benlysta®) for Intravenous UsePharmacy (08)MA08.057bMA08.05785257D39006E7945852584EB005E6F24Belimumab (Benlysta®) for Intravenous UseBelimumab (Benlysta®) for Intravenous Use
4263464DFB2126FA852585690069FC94.aspx
  
1671Bevacizumab (Avastin®) and Related Biosimilars For Oncologic UsePharmacy (08)MA08.072fMA08.0724263464DFB2126FA852585690069FC94Bevacizumab (Avastin®) and Related Biosimilars For Oncologic UseBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
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85257D39006E7945852582BA004934E6.aspx
  
1577Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility CampusAdministrative (00)MA00.037hMA00.03785257D39006E7945852582BA004934E6Billing 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
{"1784":{"Id":1784,"MPAttachmentLetter":"A","Title":"CPT/HCPCS Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E7945852582BA004934EC"},}
85257D39006E79458525847900620FF7.aspx
  
1448Biofeedback TherapyMedicine (07)MA07.010aMA07.01085257D39006E79458525847900620FF7Biofeedback TherapyBiofeedback Therapy
85257D39006E7945852585350057717D.aspx
  
1625Bioimpedance for the Detection of LymphedemaMedicine (07)MA07.052MA07.05285257D39006E7945852585350057717DBioimpedance for the Detection of LymphedemaBioimpedance for the Detection of Lymphedema
85257D39006E794585258535004891F6.aspx
  
1623Biomarkers for OncologyPathology and Laboratory (06)MA06.022fMA06.02285257D39006E794585258535004891F6Biomarkers for OncologyBiomarkers for Oncology
85257D39006E7945852583360046324E.aspx
  
1389Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/CanthopexySurgery (11)MA11.047cMA11.04785257D39006E7945852583360046324EBlepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/CanthopexyBlepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
{"1691":{"Id":1691,"MPAttachmentLetter":"A","Title":"ICD-10 Coding","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E79458525833600463254"},}
85257D39006E794585258400006DCAC0.aspx
  
1411Blinatumomab (Blincyto®)MA08.058cMA08.05885257D39006E794585258400006DCAC0Blinatumomab (Blincyto®)Blinatumomab (Blincyto®)
85257D39006E7945852583F20049C506.aspx
  
1420Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing AidsSurgery (11)MA11.049cMA11.04985257D39006E7945852583F20049C506Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing AidsBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
85257D39006E79458525838400616E51.aspx
  
1405Bortezomib (Bortezomib for Injection, Velcade®)Pharmacy (08)MA08.037fMA08.03785257D39006E79458525838400616E51Bortezomib (Bortezomib for Injection, Velcade®)Bortezomib (Bortezomib for Injection, Velcade®)
85257D39006E79458525853E00503779.aspx
  
1298Botulinum Toxin AgentsPharmacy (08)MA08.017eMA08.01785257D39006E79458525853E00503779Botulinum Toxin AgentsBotulinum Toxin Agents
{"1822":{"Id":1822,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E79458525853E00503797"},}
85257D39006E79458525848D004D227B.aspx
  
1541Brentuximab Vedotin (Adcetris®)Pharmacy (08)MA08.068dMA08.06885257D39006E79458525848D004D227BBrentuximab Vedotin (Adcetris®)Brentuximab Vedotin (Adcetris®)
{"1771":{"Id":1771,"MPAttachmentLetter":"A","Title":"ICD 10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E79458525848D004D2283"},}
85257D39006E7945852585A400669A60.aspx
  
1363Bronchial ThermoplastySurgery (11)MA11.006bMA11.00685257D39006E7945852585A400669A60Bronchial ThermoplastyBronchial Thermoplasty
85257D39006E79458525847E006E809D.aspx
  
1452Burosumab-twza (Crysvita®)MA08.099aMA08.09985257D39006E79458525847E006E809DBurosumab-twza (Crysvita®)Burosumab-twza (Crysvita®)
85257D39006E79458525853D005AB4DA.aspx
  
1353Cabazitaxel (Jevtana®)Pharmacy (08)MA08.054cMA08.05485257D39006E79458525853D005AB4DACabazitaxel (Jevtana®)Cabazitaxel (Jevtana®)
85257D39006E794585258566007371F0.aspx
  
1677Canakinumab (Ilaris®)MA08.101MA08.10185257D39006E794585258566007371F0Canakinumab (Ilaris®)Canakinumab (Ilaris®)
85257D39006E794585258507004C92F8.aspx
  
1594Canes and CrutchesDME (05)MA05.052bMA05.05285257D39006E794585258507004C92F8Canes and CrutchesCanes and Crutches
85257D39006E79458525847E006B52C0.aspx
  
1453Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) ProgramsRehabilitation Services (10)MA10.002bMA10.00285257D39006E79458525847E006B52C0Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) ProgramsCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
{"1715":{"Id":1715,"MPAttachmentLetter":"A","Title":"Medically Necessary ICD-10 Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E79458525847E006B52C5"},}
85257D39006E79458525847F0061B2D9.aspx
  
1566Care Management and Care Planning ServicesAdministrative (00)MA00.006fMA00.00685257D39006E79458525847F0061B2D9Care Management and Care Planning ServicesCare Management and Care Planning Services
85257D39006E7945852583E60044123C.aspx
  
1428Carfilzomib (Kyprolis™)Pharmacy (08)MA08.062dMA08.06285257D39006E7945852583E60044123CCarfilzomib (Kyprolis™)Carfilzomib (Kyprolis™)
B62FA99106A1AEC1852581E9006281CE.aspx
  
1374Cast and Splint Applications and Associated Supplies Provided in the Office SettingAdministrative (00)MA00.012bMA00.012B62FA99106A1AEC1852581E9006281CECast and Splint Applications and Associated Supplies Provided in the Office SettingCast and Splint Applications and Associated Supplies Provided in the Office Setting
{"1681":{"Id":1681,"MPAttachmentLetter":"A","Title":"No Title","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"A2DFF3878C4FCBD3852581E9006281DF"},}
85257D39006E79458525857500659EB8.aspx
  
1297Cataract SurgerySurgery (11)MA11.054cMA11.05485257D39006E79458525857500659EB8Cataract SurgeryCataract Surgery
{"1821":{"Id":1821,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E79458525857500659EED"},}
85257D39006E7945852584120067A712.aspx
  
1471Catheter Ablation of Cardiac ArrhythmiasSurgery (11)MA11.060cMA11.06085257D39006E7945852584120067A712Catheter Ablation of Cardiac ArrhythmiasCatheter Ablation of Cardiac Arrhythmias
85257D39006E79458525857B007B8F60.aspx
  
1880Cemiplimab-rwlc (LIBTAYO®)MA08.124MA08.12485257D39006E79458525857B007B8F60Cemiplimab-rwlc (LIBTAYO®)Cemiplimab-rwlc (LIBTAYO®)
85257D39006E7945852585340054CA80.aspx
  
1628Cerliponase alfa (Brineura®)MA08.089cMA08.08985257D39006E7945852585340054CA80Cerliponase alfa (Brineura®)Cerliponase alfa (Brineura®)
85257D39006E7945852583CC00559198.aspx
  
1414Cervical Traction Devices for In-home UseDME (05)MA05.009MA05.00985257D39006E7945852583CC00559198Cervical Traction Devices for In-home UseCervical Traction Devices for In-home Use
85257D39006E79458525846C00639663.aspx
  
1507Cetuximab (Erbitux®)Pharmacy (08)MA08.031dMA08.03185257D39006E79458525846C00639663Cetuximab (Erbitux®)Cetuximab (Erbitux®)
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85257D39006E794585258464005D9E28.aspx
  
1463Chemical PeelsSurgery (11)MA11.103aMA11.10385257D39006E794585258464005D9E28Chemical PeelsChemical Peels
85257D39006E7945852584770059E7B0.aspx
  
1514Chimeric Antigen Receptor (CAR) TherapyMA08.093eMA08.09385257D39006E7945852584770059E7B0Chimeric Antigen Receptor (CAR) TherapyChimeric Antigen Receptor (CAR) Therapy
66554A217BE65DE68525856C00754BD5.aspx
  
1672Chiropractic ServicesRehabilitation Services (10)MA10.004gMA10.00466554A217BE65DE68525856C00754BD5Chiropractic ServicesChiropractic Services
{"1806":{"Id":1806,"MPAttachmentLetter":"A","Title":"Medically neessary ICD-10 diagnosis codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"7F18E7EAF5BAB6D98525856C00754BE0"},}
F371FB2E48AFB33885257DBE00723399.aspx
  
1368Circulating Tumor Cell (CTC) AssayPathology and Laboratory (06)MA06.030MA06.030F371FB2E48AFB33885257DBE00723399Circulating Tumor Cell (CTC) AssayCirculating Tumor Cell (CTC) Assay
85257D39006E7945852585830069B42A.aspx
  
1331Coagulation FactorsPharmacy (08)MA08.004qMA08.00485257D39006E7945852585830069B42ACoagulation FactorsCoagulation Factors
85257D39006E7945852585A400689511.aspx
  
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"},}
85257D39006E7945852584C50059456D.aspx
  
1564Cochlear ImplantationSurgery (11)MA11.039dMA11.03985257D39006E7945852584C50059456DCochlear ImplantationCochlear Implantation
85257D39006E794585258507004C1178.aspx
  
1590Cold Therapy DevicesDME (05)MA05.035bMA05.03585257D39006E794585258507004C1178Cold Therapy DevicesCold Therapy Devices
85257D39006E794585258507004F8C3D.aspx
  
1591Commode ChairsDME (05)MA05.036bMA05.03685257D39006E794585258507004F8C3DCommode ChairsCommode Chairs
85257D39006E7945852585040068A7CD.aspx
  
1668Complementary and Integrative Health ServicesMiscellaneous (12)MA12.001dMA12.00185257D39006E7945852585040068A7CDComplementary and Integrative Health ServicesComplementary and Integrative Health Services
85257D39006E7945852584A1004F1618.aspx
  
1511Complete Decongestive Therapy (CDT)Medicine (07)MA07.042MA07.04285257D39006E7945852584A1004F1618Complete Decongestive Therapy (CDT)Complete Decongestive Therapy (CDT)
85257D39006E79458525853800640308.aspx
  
1293Composite Tissue Allotransplantation of the Hand(s) and FaceMA11.112MA11.11285257D39006E79458525853800640308Composite Tissue Allotransplantation of the Hand(s) and FaceComposite Tissue Allotransplantation of the Hand(s) and Face
85257D39006E7945852585510077B9C7.aspx
  
1355Compression GarmentsDME (05)MA05.045aMA05.04585257D39006E7945852585510077B9C7Compression GarmentsCompression Garments
85257D39006E7945852584F2004CAC60.aspx
  
1599Computer Aided Detection (CAD) System for Use with Chest RadiographsRadiology (09)MA09.014aMA09.01485257D39006E7945852584F2004CAC60Computer Aided Detection (CAD) System for Use with Chest RadiographsComputer Aided Detection (CAD) System for Use with Chest Radiographs
85257D39006E7945852584E90067CC1C.aspx
  
1662Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic ProcedureSurgery (11)MA11.088bMA11.08885257D39006E7945852584E90067CC1CComputer-Assisted Musculoskeletal Surgical Navigational Orthopedic ProcedureComputer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
8DFCA2ECFC6B5415852582DC00509E93.aspx
  
1383Consultation ServicesMA00.049MA00.0498DFCA2ECFC6B5415852582DC00509E93Consultation ServicesConsultation Services
85257D39006E794585258241006B8F07.aspx
  
1379Continuous Glucose Monitors and Artificial Pancreas Device Systems (APDS)Administrative (00)MA00.002fMA00.00285257D39006E794585258241006B8F07Continuous Glucose Monitors and Artificial Pancreas Device Systems (APDS)Continuous Glucose Monitors and Artificial Pancreas Device Systems (APDS)
{"1686":{"Id":1686,"MPAttachmentLetter":"A","Title":"ICD-10: Short term CGM","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E794585258241006B8F0C"},"1687":{"Id":1687,"MPAttachmentLetter":"B","Title":"THERAPEUTIC LONG-TERM INTERSTITIAL CGMS","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E794585258241006B8F11"},}
85257D39006E7945852584E9007261C1.aspx
  
1583Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion PumpAnesthesia (01)MA01.004aMA01.00485257D39006E7945852584E9007261C1Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion PumpContinuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump
85257D39006E79458525851B005C2382.aspx
  
1608Contrast Agents Used in Conjunction with EchocardiographyRadiology (09)MA09.004bMA09.00485257D39006E79458525851B005C2382Contrast Agents Used in Conjunction with EchocardiographyContrast Agents Used in Conjunction with Echocardiography
85257D39006E7945852584B70053D84B.aspx
  
1503Corneal Pachymetry Using UltrasoundMedicine (07)MA07.046eMA07.04685257D39006E7945852584B70053D84BCorneal Pachymetry Using UltrasoundCorneal Pachymetry Using Ultrasound
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85257D39006E7945852583CC00558475.aspx
  
1410Cosmetic ProceduresMA12.009MA12.00985257D39006E7945852583CC00558475Cosmetic ProceduresCosmetic Procedures
85257D39006E7945852583F90064AAD0.aspx
  
1484Coverage of Medical DevicesDME (05)MA05.040bMA05.04085257D39006E7945852583F90064AAD0Coverage of Medical DevicesCoverage of Medical Devices
85257D39006E7945852584C8004B297A.aspx
  
1545Cranial Electrotherapy StimulationMA05.066aMA05.06685257D39006E7945852584C8004B297ACranial Electrotherapy StimulationCranial Electrotherapy Stimulation
85257D39006E7945852584FD00658A7A.aspx
  
1616Criteria for Reimbursement of Emergency Room ServicesAdministrative (00)MA00.044bMA00.04485257D39006E7945852584FD00658A7ACriteria for Reimbursement of Emergency Room ServicesCriteria for Reimbursement of Emergency Room Services
5df6dd06-003e-4b4a-9610-98bd62b9e38c.aspx
  
1925crizanlizumab-tmca(Adakveo®)MA08.109Pharmacy (08)MA08.109MA08.1095df6dd06-003e-4b4a-9610-98bd62b9e38ccrizanlizumab-tmca (Adakveo®)crizanlizumab-tmca (Adakveo®)
85257D39006E794585258535004D7D39.aspx
  
1630Cryosurgical Ablation of the Prostate GlandSurgery (11)MA11.022aMA11.02285257D39006E794585258535004D7D39Cryosurgical Ablation of the Prostate GlandCryosurgical Ablation of the Prostate Gland
85257D39006E79458525856F0067C06A.aspx
  
1882Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro™)Pharmacy (08)MA08.079fMA08.07985257D39006E79458525856F0067C06ADaratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro™)Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro™)
85257D39006E794585258588004883FD.aspx
  
1322Day RehabilitationRehabilitation Services (10)MA10.005bMA10.00585257D39006E794585258588004883FDDay RehabilitationDay Rehabilitation
85257D39006E7945852585270065A85E.aspx
  
1640Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe NailsSurgery (11)MA11.014eMA11.01485257D39006E7945852585270065A85EDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe NailsDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
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85257D39006E7945852583900059832C.aspx
  
1438Deep Brain Stimulation (DBS)Surgery (11)MA11.005cMA11.00585257D39006E7945852583900059832CDeep Brain Stimulation (DBS)Deep Brain Stimulation (DBS)
67CCEAB40582EA77852585880062CC28.aspx
  
1313Denervation of the Spinal Nerves for Chronic PainSurgery (11)MA11.102hMA11.10267CCEAB40582EA77852585880062CC28Denervation of the Spinal Nerves for Chronic PainDenervation of the Spinal Nerves for Chronic Pain
85257D39006E79458525847A0047B689.aspx
  
1467Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)Pharmacy (08)MA08.052gMA08.05285257D39006E79458525847A0047B689Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)
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85257D39006E7945852585880063600E.aspx
  
1338Deoxycholic Acid (Kybella™)MA08.074aMA08.07485257D39006E7945852585880063600EDeoxycholic Acid (Kybella™)Deoxycholic Acid (Kybella™)
85257D39006E7945852582CD00534D1B.aspx
  
1472Direct Access to Obstetrics/Gynecology (OB/GYN) ServicesAdministrative (00)MA00.032bMA00.03285257D39006E7945852582CD00534D1BDirect Access to Obstetrics/Gynecology (OB/GYN) ServicesDirect Access to Obstetrics/Gynecology (OB/GYN) Services
85257D39006E7945852585A4006756E7.aspx
  
1362Dofetilide (Tikosyn®) Use in the Inpatient SettingPharmacy (08)MA08.021bMA08.02185257D39006E7945852585A4006756E7Dofetilide (Tikosyn®) Use in the Inpatient SettingDofetilide (Tikosyn®) Use in the Inpatient Setting
85257D39006E7945852584A300471E42.aspx
  
1516Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic MalignanciesMedicine (07)MA07.041bMA07.04185257D39006E7945852584A300471E42Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic MalignanciesDrug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
85257D39006E7945852584D6005452FB.aspx
  
1568Durable Medical Equipment (DME)DME (05)MA05.044gMA05.04485257D39006E7945852584D6005452FBDurable Medical Equipment (DME)Durable Medical Equipment (DME)
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85257D39006E794585258360004DFC78.aspx
  
1392Durable Medical Equipment (DME) Not Subject to a Rental to Purchase MaximumDME (05)MA05.028dMA05.02885257D39006E794585258360004DFC78Durable Medical Equipment (DME) Not Subject to a Rental to Purchase MaximumDurable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
2cc301d3-5baf-4ab6-a6a5-21ce1991f10d.aspx
  
1923Durvalumab(Imfinzi™)MA08.123Pharmacy (08)MA08.123MA08.1232cc301d3-5baf-4ab6-a6a5-21ce1991f10dDurvalumab (Imfinzi™)Durvalumab (Imfinzi™)
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85257D39006E7945852584C800670CC3.aspx
  
1657Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™)Pharmacy (08)MA08.044fMA08.04485257D39006E7945852584C800670CC3Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™)Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™)
43933fd6-a89a-46a8-89a2-430e9625b5f6.aspx
  
1908Edaravone(Radicava™)MA08.092aPharmacy (08)MA08.092aMA08.09243933fd6-a89a-46a8-89a2-430e9625b5f6Edaravone (Radicava™)Edaravone (Radicava™)
85257D39006E794585258507004E769F.aspx
  
1595Electrical Continence AidDME (05)MA05.059MA05.05985257D39006E794585258507004E769FElectrical Continence AidElectrical Continence Aid
85257D39006E7945852584770068838C.aspx
  
1465Electrical Stimulation and Electromagnetic Stimulation for the Treatment of WoundsMedicine (07)MA07.013dMA07.01385257D39006E7945852584770068838CElectrical Stimulation and Electromagnetic Stimulation for the Treatment of WoundsElectrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
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85257D39006E7945852584B8006F6EFE.aspx
  
1504Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)Medicine (07)MA07.050fMA07.05085257D39006E7945852584B8006F6EFEElectromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
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