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3582Abatacept(Orencia®)forInjectionforIntravenousUseMA08.028gPharmacy (08)MA08.028gMA08.028b00ed136-3352-4223-b636-58021431bdedAbatacept (Orencia®) for Injection for Intravenous UseAbatacept (Orencia®) for Injection for Intravenous Use
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4016AbortionMA11.010aSurgery (11)MA11.010aMA11.0100fd171f7-f2b4-4b69-8563-7bdd2258b528AbortionAbortion
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3752AcupunctureMA12.004cMiscellaneous (12)MA12.004cMA12.004ba6bd7ca-d349-4200-b14d-b89ece686f02AcupunctureAcupuncture
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3936AcuteCareFacilityInpatientTransfersMA12.003bMiscellaneous (12)MA12.003bMA12.0032dd8737a-eb29-4514-acbd-7186ea78b680Acute Care Facility Inpatient TransfersAcute Care Facility Inpatient Transfers
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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"},}
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3434Agalsidasebeta(Fabrazyme®)MA08.033cPharmacy (08)MA08.033cMA08.03372b0047c-3b34-4685-ad68-a0a2b71933b1Agalsidase beta (Fabrazyme®)Agalsidase beta (Fabrazyme®)
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4020AirAmbulanceServicesMA12.007bMiscellaneous (12)MA12.007bMA12.007119bad1e-0fbf-441f-81d6-265b76cc87b6Air Ambulance ServicesAir Ambulance Services
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3568Alemtuzumab(Lemtrada®)MA08.015dPharmacy (08)MA08.015dMA08.0151f566b6c-8a94-4447-8e00-fe6c78c20462Alemtuzumab (Lemtrada®)Alemtuzumab (Lemtrada®)
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3525Alglucosidasealfa(e.g.,Lumizyme®),Avalglucosidasealfa-ngpt(Nexviazyme®)MA08.036fPharmacy (08)MA08.036fMA08.036e5598147-140e-442f-b181-fb610293bd70Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® )Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® )
2e1aa0fd-b9e3-4e44-b29c-e5b32a36e6de.aspx
  
4006AllergyImmunotherapyMA07.055dMedicine (07)MA07.055dMA07.0552e1aa0fd-b9e3-4e44-b29c-e5b32a36e6deAllergy ImmunotherapyAllergy Immunotherapy
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3569Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C,AralastNP,Glassia,Zemaira)MA08.050bPharmacy (08)MA08.050bMA08.0501200bd89-d573-4716-a175-5c772b242da4Alpha 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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4193AlwaysBundledProcedureCodesMA00.026oAdministrative (00)MA00.026oMA00.026aace969a-94c9-4637-9bf9-6ab17ccbcd0eAlways Bundled Procedure CodesAlways Bundled Procedure Codes
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3955AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)DevicesMA07.005cMedicine (07)MA07.005cMA07.005561210e3-3390-4956-b296-c2c2ef91b2f9Ambulatory 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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4121AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)MonitoringMA07.026kMedicine (07)MA07.026kMA07.02620d4debf-c979-474b-b325-3dcc70336021Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
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3813AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagementMA01.008aAnesthesia (01)MA01.008aMA01.0086a1b55c5-5993-4f32-a0ed-4fd61d9d86acAnesthesia 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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3571Anifrolumab-fnia(Saphnelo™)MA08.140bPharmacy (08)MA08.140bMA08.1402997254c-1be9-4fd5-9b6b-394b8f40bf96Anifrolumab-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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3503AnorectalManometry,Electromyography(EMG)ofAnorectalorUrethralSphincters;BiofeedbackTrainingforPerinealMusclesandAnorectalorUrethralSphinctersMA07.018bMedicine (07)MA07.018bMA07.0186784e81c-0d85-46ea-8570-0305b1408593Anorectal Manometry, Electromyography (EMG) of Anorectal or Urethral Sphincters; Biofeedback Training for Perineal Muscles and Anorectal or Urethral SphinctersAnorectal Manometry, Electromyography (EMG) of Anorectal or Urethral Sphincters; Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters
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2179ApheresisTherapyMA06.001ePathology and Laboratory (06)MA06.001eMA06.001a8e854f7-94e7-4833-a02c-b7fb4214ff25Apheresis TherapyApheresis Therapy
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3515ApplicationandRemovalofTattoosMA11.072Surgery (11)MA11.072MA11.0725e7b3431-7254-494b-91b5-f3edb685eb24Application and Removal of TattoosApplication and Removal of Tattoos
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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"},}
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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"},}
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4129ArtificialIntervertebralLumbarDiscInsertionMA11.114bSurgery (11)MA11.114bMA11.1144d0593ea-c69f-4b0e-8370-ebed3c66e12fArtificial Intervertebral Lumbar Disc InsertionArtificial Intervertebral Lumbar Disc Insertion
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3742Asparaginaseerwiniachrysanthemi(Erwinaze®),asparaginaseerwiniachrysanthemi(recombinant)-rywn(Rylaze™)MA08.085fPharmacy (08)MA08.085fMA08.08553bac0ed-9c15-45d1-a6eb-df0442a11e2aAsparaginase erwinia chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze™)Asparaginase erwinia chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze™)
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3391Atezolizumab(Tecentriq®)MA08.127bPharmacy (08)MA08.127bMA08.127cde82c5a-0a80-4bfb-9c2f-a6bec18e4a07Atezolizumab (Tecentriq®)Atezolizumab (Tecentriq®)
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4023AutomaticExternalCardioverterDefibrillators(WearableandNonwearable)MA05.005fDME (05)MA05.005fMA05.00531ffd380-3f3a-469d-8a3d-744ef976f1edAutomatic External Cardioverter Defibrillators (Wearable and Nonwearable)Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
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3819AutonomicNervousSystemTestingMA07.027fMedicine (07)MA07.027fMA07.0273af75148-49ba-4d1c-ba97-554d5699a376Autonomic Nervous System TestingAutonomic Nervous System Testing
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4105Avelumab(Bavencio®)MA08.122bPharmacy (08)MA08.122bMA08.1222940ef19-00de-46de-bbaa-aef9985a3ac2Avelumab (Bavencio®)Avelumab (Bavencio®)
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3619BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitisMA11.100eSurgery (11)MA11.100eMA11.100cabedfbf-0373-4c4a-92e4-36c05c25ded0Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic RhinosinusitisBalloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
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3532belantamabmafodotin-blmf(Blenrep)MA08.119bPharmacy (08)MA08.119bMA08.119cf4b9338-44d8-4be3-b8af-86f6920be908belantamab mafodotin-blmf (Blenrep) belantamab mafodotin-blmf (Blenrep)
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3930Belimumab(Benlysta®)forIntravenousUseMA08.057dPharmacy (08)MA08.057dMA08.0579903914d-e3cf-4399-ae00-108494eae90cBelimumab (Benlysta®) for Intravenous UseBelimumab (Benlysta®) for Intravenous Use
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4141Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUseMA08.072kPharmacy (08)MA08.072kMA08.07219d36ffa-eed6-4945-a394-53539c3e6c01Bevacizumab (Avastin®) and Related Biosimilars For Oncologic UseBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
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3321BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampusMA00.037kAdministrative (00)MA00.037kMA00.037fa386a65-d740-4764-878d-b0c03ccee966Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility CampusBilling for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
{"3322": {"Id":3322,"MPAttachmentLetter":"A","Title":"Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus - CPT/HCPCS Codes","MPPolicyAttachmentInternalSourceId":6120,"PolicyAttachmentPageName":"59902f83-9042-435b-95fb-a2fc79a83db1"},}
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3644BiofeedbackTherapyMA07.010aMedicine (07)MA07.010aMA07.010cd3494a3-4f4f-4dc3-b0ae-c7e16e45d55fBiofeedback TherapyBiofeedback Therapy
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3618BioimpedancefortheDetectionofLymphedemaMA07.052Medicine (07)MA07.052MA07.052fc94fb44-a8a9-41f6-8fe6-687483a6ebc6Bioimpedance 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"},}
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3631Blinatumomab(Blincyto®)MA08.058ePharmacy (08)MA08.058eMA08.0589169d365-5d9b-44b4-a3f9-3fa88e9a4a1aBlinatumomab (Blincyto®)Blinatumomab (Blincyto®)
cc5a905b-ad8a-487c-a688-6d3af1a4311a.aspx
  
4164Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAidsMA11.049eSurgery (11)MA11.049eMA11.049cc5a905b-ad8a-487c-a688-6d3af1a4311aBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing AidsBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
ae53fe4a-bce1-43e4-8f29-b3bfd9e5b0f5.aspx
  
4160Bortezomib(BortezomibforInjection,Velcade®)MA08.037iPharmacy (08)MA08.037iMA08.037ae53fe4a-bce1-43e4-8f29-b3bfd9e5b0f5Bortezomib (Bortezomib for Injection, Velcade®)Bortezomib (Bortezomib for Injection, Velcade®)
{"4161": {"Id":4161,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":7119,"PolicyAttachmentPageName":"571ad3d2-dde6-4cfa-a4f7-d851871d9e28"},}
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3855BotulinumToxinAgentsMA08.017hPharmacy (08)MA08.017hMA08.01718450aea-5590-4c1c-93f7-b826767af30cBotulinum Toxin AgentsBotulinum Toxin Agents
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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"},}
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3417BronchialValvesMA11.020Surgery (11)MA11.020MA11.02069c14601-19f4-4a22-869a-ce88af536766Bronchial ValvesBronchial Valves
6fab4e9d-5e32-4f2d-a48f-3b3b7d31608f.aspx
  
3524Burosumab-twza(Crysvita®)MA08.099bPharmacy (08)MA08.099bMA08.0996fab4e9d-5e32-4f2d-a48f-3b3b7d31608fBurosumab-twza (Crysvita®)Burosumab-twza (Crysvita®)
a9edc4ba-8e39-4e75-93f1-eccdd1d9391e.aspx
  
3402Canakinumab(Ilaris®)MA08.101aPharmacy (08)MA08.101aMA08.101a9edc4ba-8e39-4e75-93f1-eccdd1d9391eCanakinumab (Ilaris®)Canakinumab (Ilaris®)
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3401CanesandCrutchesMA05.052bDME (05)MA05.052bMA05.0529ed71d16-85d6-476c-9ed2-2e1a6fb65333Canes and CrutchesCanes and Crutches
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4118CapsuleEndoscopyMA07.022eMedicine (07)MA07.022eMA07.022bde6f5bb-a063-46ae-872f-2574f19b4f0eCapsule EndoscopyCapsule Endoscopy
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3807CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)ProgramsMA10.002cRehabilitation Services (10)MA10.002cMA10.002de73d54c-e82e-406d-a1d8-c94d36bf4fc5Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) ProgramsCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
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3878CareManagementandCarePlanningServicesMA00.006lAdministrative (00)MA00.006lMA00.0062411d8e2-991c-4860-a612-ba7bb8056705Care 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"},}
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4010CataractSurgeryMA11.054dSurgery (11)MA11.054dMA11.05435d53c26-0c5b-4b14-b8b8-a5597e77fe0cCataract SurgeryCataract Surgery
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3809CatheterAblationofCardiacArrhythmiasMA11.060eSurgery (11)MA11.060eMA11.060d64fed48-4aef-4817-967f-2e50017c1cb0Catheter Ablation of Cardiac ArrhythmiasCatheter Ablation of Cardiac Arrhythmias
43307a95-4d17-43d5-ae1d-447dee061b11.aspx
  
4103Cemiplimab-rwlc(Libtayo®)MA08.124bPharmacy (08)MA08.124bMA08.12443307a95-4d17-43d5-ae1d-447dee061b11Cemiplimab-rwlc (Libtayo®)Cemiplimab-rwlc (Libtayo®)
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3526Cerliponasealfa(Brineura®)MA08.089cPharmacy (08)MA08.089cMA08.089af3e4f67-0660-4149-b715-205f07d43919Cerliponase alfa (Brineura®)Cerliponase alfa (Brineura®)
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3438CervicalTractionDevicesforIn-homeUseMA05.009aDME (05)MA05.009aMA05.009c98e6881-f694-4a4a-93e0-12285cfbf202Cervical Traction Devices for In-home UseCervical Traction Devices for In-home Use
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4156Cetuximab(Erbitux®)MA08.031fPharmacy (08)MA08.031fMA08.031da641a6d-6927-4908-a969-1856f88de703Cetuximab (Erbitux®)Cetuximab (Erbitux®)
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3787ChemicalPeelsMA11.103bSurgery (11)MA11.103bMA11.103b89e88bc-c37b-4819-a4ea-af219a5cf05dChemical PeelsChemical Peels
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3790ChimericAntigenReceptor(CAR)TherapyMA08.093kPharmacy (08)MA08.093kMA08.0932aa985e5-66d4-4c33-9b92-cffca516451eChimeric Antigen Receptor (CAR) TherapyChimeric Antigen Receptor (CAR) Therapy
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3978ChiropracticServicesMA10.004hRehabilitation Services (10)MA10.004hMA10.0047d3057f3-c09c-492e-8583-c5300b165742Chiropractic 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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3958CoagulationFactorsMA08.004tPharmacy (08)MA08.004tMA08.004560ab61f-50a9-4fb5-9b2f-45445ab7a909Coagulation 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
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2505CochlearImplantationMA11.039dSurgery (11)MA11.039dMA11.0392ff992d2-ca4a-42b9-b321-e387ed4804fdCochlear ImplantationCochlear Implantation
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3437Collagenaseclostridiumhistolyticum(Xiaflex®),collagenaseclostridiumhistolyticum-aaes(Qwo™)MA08.128Pharmacy (08)MA08.128MA08.128c4e07093-c912-4146-8bab-3e038ab4fbceCollagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™)Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™)
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3383CommodeChairsMA05.036bDME (05)MA05.036bMA05.036b54c4527-287c-44b4-ba99-2781f6ea0463Commode ChairsCommode Chairs
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3614ComplementaryandIntegrativeHealthServicesMA12.001dMiscellaneous (12)MA12.001dMA12.001a62fd0fa-8e7b-4ed1-bb67-fd235c1159f0Complementary and Integrative Health ServicesComplementary and Integrative Health Services
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3617CompleteDecongestiveTherapy(CDT)MA07.042Medicine (07)MA07.042MA07.04274c1970e-fa1e-40e5-91ce-bd5dd3e8a6f5Complete Decongestive Therapy (CDT)Complete Decongestive Therapy (CDT)
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3648CompositeTissueAllotransplantationoftheHand(s)andFaceMA11.112Surgery (11)MA11.112MA11.1121361257a-290f-4536-95f4-94e8c6ac325aComposite Tissue Allotransplantation of the Hand(s) and FaceComposite Tissue Allotransplantation of the Hand(s) and Face
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3640CompressionGarmentsMA05.045aDME (05)MA05.045aMA05.04555f0dbf5-ae18-4373-b456-a221e9d39c1cCompression GarmentsCompression Garments
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3685Computer-AidedDetection(CAD)SystemforUsewithChestRadiographsMA09.014aRadiology (09)MA09.014aMA09.0140e3d12af-5a08-4b0c-8211-19ac349faf3bComputer-Aided Detection (CAD) System for Use with Chest RadiographsComputer-Aided Detection (CAD) System for Use with Chest Radiographs
6c50e1d0-0b77-45d9-abd2-9c2633dc200e.aspx
  
3605Computer-AssistedMusculoskeletalSurgicalNavigationalOrthopedicProcedureMA11.088cSurgery (11)MA11.088cMA11.0886c50e1d0-0b77-45d9-abd2-9c2633dc200eComputer-Assisted Musculoskeletal Surgical Navigational Orthopedic ProcedureComputer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
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3588ConsultationServicesMA00.049aAdministrative (00)MA00.049aMA00.04957649d5c-49aa-4216-9686-3c820b5d1237Consultation ServicesConsultation Services
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4122ContinuousGlucoseMonitorsandHomeBloodGlucoseMonitorsandSuppliesMA00.002jAdministrative (00)MA00.002jMA00.0029cc59b93-9d13-4ffd-960e-be24eec1994bContinuous Glucose Monitors and Home Blood Glucose Monitors and SuppliesContinuous Glucose Monitors and Home Blood Glucose Monitors and Supplies
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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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3636CornealPachymetryUsingUltrasoundMA07.046gMedicine (07)MA07.046gMA07.0460d262908-e6ab-4ad9-a017-96491fb35ed8Corneal Pachymetry Using UltrasoundCorneal Pachymetry Using Ultrasound
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4014CosmeticProceduresMA12.009aMiscellaneous (12)MA12.009aMA12.00913c34059-266d-452b-a086-b5e79450d900Cosmetic 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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3935CranialElectrotherapyStimulationMA05.066cDME (05)MA05.066cMA05.06614ef6470-44f4-4099-881a-21521d12fec8Cranial 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
5c85f061-d9b8-458b-977b-a6d0470b0e1f.aspx
  
3387crizanlizumab-tmca(Adakveo®)MA08.109aPharmacy (08)MA08.109aMA08.1095c85f061-d9b8-458b-977b-a6d0470b0e1fcrizanlizumab-tmca (Adakveo®)crizanlizumab-tmca (Adakveo®)
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3623CryosurgicalAblationoftheProstateGlandMA11.022aSurgery (11)MA11.022aMA11.0224262ba16-e187-42a1-a358-5309ce6b6ea5Cryosurgical Ablation of the Prostate GlandCryosurgical Ablation of the Prostate Gland
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3746Daratumumab(Darzalex®),Daratumumab,andHyaluronidase-fihj(DarzalexFaspro®)MA08.079jPharmacy (08)MA08.079jMA08.079fc8bc0fe-8bb5-4590-830c-71eb68cd8fceDaratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®)Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®)
c7e08d9f-c93b-4f1c-a093-ee818b303290.aspx
  
3767DayRehabilitationMA10.005bRehabilitation Services (10)MA10.005bMA10.005c7e08d9f-c93b-4f1c-a093-ee818b303290Day RehabilitationDay Rehabilitation
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3688DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNailsMA11.014gSurgery (11)MA11.014gMA11.0145b93c7e1-f677-4375-922a-ca9531f9db6eDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe NailsDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
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3941DeepBrainStimulation(DBS)MA11.005eSurgery (11)MA11.005eMA11.005fa45f706-4ac4-436e-9728-ae8a125450dfDeep Brain Stimulation (DBS)Deep Brain Stimulation (DBS)
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3522Denosumab(Prolia®,Xgeva®),Romosozumab-aqqg(Evenity®)MA08.052jPharmacy (08)MA08.052jMA08.052116bf5f6-59fe-4c5b-b271-9a90bf62beb6Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)
{"3523": {"Id":3523,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes","MPPolicyAttachmentInternalSourceId":6189,"PolicyAttachmentPageName":"dd04c740-d70b-48c8-b128-cde0f0c0b1f9"},}
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4139DermabrasionforRhinophyma,Septoplasty,Rhinoplasty,andSeptorhinoplastyMA11.099cSurgery (11)MA11.099cMA11.0990254b636-2a8f-4b02-a7ca-0ea8002e8852Dermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and SeptorhinoplastyDermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and Septorhinoplasty
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3346DirectAccesstoObstetrics/Gynecology(OB/GYN)ServicesMA00.032dAdministrative (00)MA00.032dMA00.0323cc570f5-3a08-4974-a65d-e95d42146963Direct Access to Obstetrics/Gynecology (OB/GYN) ServicesDirect Access to Obstetrics/Gynecology (OB/GYN) Services
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3575Dofetilide(Tikosyn®)UseintheInpatientSettingMA08.021bPharmacy (08)MA08.021bMA08.021062b48a0-26a9-4077-805d-713072908f88Dofetilide (Tikosyn®) Use in the Inpatient SettingDofetilide (Tikosyn®) Use in the Inpatient Setting
c37d9c69-6413-4a3b-872a-d26735e8bd34.aspx
  
3413Dostarlimab-gxly(Jemperli)MA08.136cPharmacy (08)MA08.136cMA08.136c37d9c69-6413-4a3b-872a-d26735e8bd34Dostarlimab-gxly (Jemperli)Dostarlimab-gxly (Jemperli)
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3916Drug-ElutingBeadsandBlandEmbolizationfortheTreatmentofHepaticMalignanciesMA07.041bMedicine (07)MA07.041bMA07.0419b4d3cea-ae30-4134-98bd-9481da9fc035Drug-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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3912DurableMedicalEquipment(DME)MA05.044mDME (05)MA05.044mMA05.0447b2483b4-e675-4145-81dd-85fc1297f34dDurable 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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4113Durvalumab(Imfinzi®)MA08.123bPharmacy (08)MA08.123bMA08.1232c99c5d8-b866-4945-9fed-9fbc3712a42cDurvalumab (Imfinzi®)Durvalumab (Imfinzi®)
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3780Eculizumab(Soliris®)andRelatedBiosimilars,Ravulizumab-cwvz(Ultomiris™)MA08.044hPharmacy (08)MA08.044hMA08.04464ae9bd8-5b3d-49cd-a026-e438e17df1f1Eculizumab (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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3675Efgartigimod-alfa(VyvgartTM)MA08.142aPharmacy (08)MA08.142aMA08.1428c9b2f4f-e061-48c5-8b0c-6da861903805Efgartigimod-alfa (VyvgartTM)Efgartigimod-alfa (VyvgartTM)
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4017Eflapegrastim-xnst(Rolvedon™),Pegfilgrastim(Neulasta®)andRelatedBiosimilarsMA08.082iPharmacy (08)MA08.082iMA08.082faaaec04-b9fb-4119-9362-7725b156db87Eflapegrastim-xnst (Rolvedon™), Pegfilgrastim (Neulasta®) and Related BiosimilarsEflapegrastim-xnst (Rolvedon™), Pegfilgrastim (Neulasta®) and Related Biosimilars
{"4018": {"Id":4018,"MPAttachmentLetter":"A","Title":"EXAMPLES OF DISEASE SETTINGS AND CHEMOTHERAPY REGIMENS WITH A HIGH (>20%) OR INTERMEDIATE (10-20%) RISK FOR FEBRILE NEUTROPENIA","MPPolicyAttachmentInternalSourceId":6593,"PolicyAttachmentPageName":"ef81d4cd-efe9-4e4a-bb12-b87cbd538c23"},}
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3511ElectricalStimulationandElectromagneticStimulationfortheTreatmentofWoundsMA07.013dMedicine (07)MA07.013dMA07.0139c10b787-7936-43dc-85af-d1b5f8b51d28Electrical Stimulation and Electromagnetic Stimulation for the Treatment of WoundsElectrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
{"3512": {"Id":3512,"MPAttachmentLetter":"A","Title":"ICD-10 Coding","MPPolicyAttachmentInternalSourceId":6285,"PolicyAttachmentPageName":"30a7a7ad-1cae-4a55-857c-5dcd42b5d7e4"},}
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3937ElectroconvulsiveTherapy(ECT)MA14.001Behavioral Health (14)MA14.001MA14.00178280621-f992-4f8a-9825-368ec185cde4Electroconvulsive Therapy (ECT)Electroconvulsive Therapy (ECT)
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