Medicare Advantage
Type
  
Name
  
ID
  
MPDispTitle
  
MPPolicyCategory
  
MPPolicyNumber
  
MPPolicyNumberwithoutversion
  
MPPolicyPageName
  
MPTitle
  
Title
  
MPattachmentdataPub
Checked Out To
  
e6ab9a34-6c77-4168-b73e-e42a6a23b38f.aspx
  
1956Abatacept(Orencia®)forInjectionforIntravenousUseMA08.028ePharmacy (08)MA08.028eMA08.028e6ab9a34-6c77-4168-b73e-e42a6a23b38fAbatacept (Orencia®) for Injection for Intravenous UseAbatacept (Orencia®) for Injection for Intravenous Use
{"1957": {"Id":1957,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":4836,"PolicyAttachmentPageName":"f8fe6bdc-30ad-47b8-a27f-01f1cdeffc2f"},}
85257D39006E79458525854300496FA9.aspx
  
1649AbortionSurgery (11)MA11.010aMA11.01085257D39006E79458525854300496FA9AbortionAbortion
85257D39006E7945852585660066FB4B.aspx
  
1349AcupunctureMA12.004aMA12.00485257D39006E7945852585660066FB4BAcupunctureAcupuncture
{"1855":{"Id":1855,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Acupuncture","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E794585258568005E04BD"},}
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™)
73b8df96-8340-4f08-9ca8-d6237c2ce288.aspx
  
2028AlwaysBundledProcedureCodesMA00.026hAdministrative (00)MA00.026hMA00.02673b8df96-8340-4f08-9ca8-d6237c2ce288Always Bundled Procedure CodesAlways Bundled Procedure Codes
{"2029": {"Id":2029,"MPAttachmentLetter":"A","Title":"CPT Codes and HCPCS Codes","MPPolicyAttachmentInternalSourceId":4952,"PolicyAttachmentPageName":"ba280893-e9df-483a-b31e-898a85466c02"},}
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
3639d8b3-9067-4cd7-9c4c-e376655e9ed3.aspx
  
2098ApplicationandRemovalofTattoosMA11.072Surgery (11)MA11.072MA11.0723639d8b3-9067-4cd7-9c4c-e376655e9ed3Application 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"},}
e5bdb582-1a6c-4cd1-935c-f5310b7873c8.aspx
  
2136AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucomaMA11.105gSurgery (11)MA11.105gMA11.105e5bdb582-1a6c-4cd1-935c-f5310b7873c8Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
{"2137": {"Id":2137,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":4937,"PolicyAttachmentPageName":"5182faf1-4a47-4c58-ae3f-33df15c64e88"},}
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®)
f4e0210e-b48a-4acf-bac3-8264b197062d.aspx
  
1935Atezolizumab(Tecentriq®)MA08.127Pharmacy (08)MA08.127MA08.127f4e0210e-b48a-4acf-bac3-8264b197062dAtezolizumab (Tecentriq®)Atezolizumab (Tecentriq®)
{"1936": {"Id":1936,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":4730,"PolicyAttachmentPageName":"f86f9b92-feec-4d82-bc81-7fc3f03eb9ef"},}
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"},}
da677fd2-4630-47ac-af75-7526e365af35.aspx
  
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
10b66a7d-b76d-41bd-bc2f-b56ba23f2503.aspx
  
2045belantamabmafodotin-blmf(Blenrep)MA08.119Pharmacy (08)MA08.119MA08.11910b66a7d-b76d-41bd-bc2f-b56ba23f2503belantamab mafodotin-blmf (Blenrep) belantamab mafodotin-blmf (Blenrep)
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
{"1805":{"Id":1805,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"8FBA5543688BDE9E852585690069FC9F"},}
35030340-9194-43f0-9088-206a9e2835b1.aspx
  
2053BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampusMA00.037iAdministrative (00)MA00.037iMA00.03735030340-9194-43f0-9088-206a9e2835b1Billing 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
{"2054": {"Id":2054,"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":4897,"PolicyAttachmentPageName":"56a556a7-1a60-4325-8342-9fc1cee6d2e4"},}
c8e9390f-47a4-4253-ac7c-d1678698c4fa.aspx
  
2107BiofeedbackTherapyMA07.010aMedicine (07)MA07.010aMA07.010c8e9390f-47a4-4253-ac7c-d1678698c4faBiofeedback 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®)
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
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
e395dee3-755a-471c-b8f1-ddc066123e9e.aspx
  
2101Carfilzomib(Kyprolis™)MA08.062ePharmacy (08)MA08.062eMA08.062e395dee3-755a-471c-b8f1-ddc066123e9eCarfilzomib (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"},}
3caf3ad6-1b9a-42aa-97ec-1a5e31058230.aspx
  
2112CatheterAblationofCardiacArrhythmiasMA11.060cSurgery (11)MA11.060cMA11.0603caf3ad6-1b9a-42aa-97ec-1a5e31058230Catheter 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®)
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
85257D39006E79458525846C00639663.aspx
  
1507Cetuximab (Erbitux®)Pharmacy (08)MA08.031dMA08.03185257D39006E79458525846C00639663Cetuximab (Erbitux®)Cetuximab (Erbitux®)
{"1762":{"Id":1762,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E79458525846C0063966E"},"1763":{"Id":1763,"MPAttachmentLetter":"B","Title":"ICD-10 Codes for Cetuximab (Erbitux®)","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E79458525846C00639677"},}
f37d8c75-abe0-4d37-b0c0-c18d46ab4c17.aspx
  
2115ChemicalPeelsMA11.103aSurgery (11)MA11.103aMA11.103f37d8c75-abe0-4d37-b0c0-c18d46ab4c17Chemical PeelsChemical Peels
85257D39006E7945852584770059E7B0.aspx
  
1514Chimeric Antigen Receptor (CAR) TherapyMA08.093eMA08.09385257D39006E7945852584770059E7B0Chimeric Antigen Receptor (CAR) TherapyChimeric Antigen Receptor (CAR) Therapy
f82146f9-0cf1-4da3-9708-df006eda0513.aspx
  
2057ChiropracticServicesMA10.004gRehabilitation Services (10)MA10.004gMA10.004f82146f9-0cf1-4da3-9708-df006eda0513Chiropractic ServicesChiropractic Services
{"2058": {"Id":2058,"MPAttachmentLetter":"A","Title":"Medically neessary ICD-10 diagnosis codes","MPPolicyAttachmentInternalSourceId":4853,"PolicyAttachmentPageName":"2eefa6a2-e9e7-4b20-b95e-7913990c9dc0"},}
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
19b9a826-f613-4a37-9ef2-3b874f2f1b5a.aspx
  
2138Collagenaseclostridiumhistolyticum(Xiaflex®),collagenaseclostridiumhistolyticum-aaes(Qwo™)MA08.128Pharmacy (08)MA08.128MA08.12819b9a826-f613-4a37-9ef2-3b874f2f1b5aCollagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™)Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™)
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
1a75604c-5542-4601-b256-9e702f9428ba.aspx
  
2041ConsultationServicesMA00.049Administrative (00)MA00.049MA00.0491a75604c-5542-4601-b256-9e702f9428baConsultation ServicesConsultation Services
85257D39006E7945852585BB0065691E.aspx
  
1875Continuous Glucose Monitors and Artificial Pancreas Device Systems (APDS)Administrative (00)MA00.002gMA00.00285257D39006E7945852585BB0065691EContinuous Glucose Monitors and Artificial Pancreas Device Systems (APDS)Continuous Glucose Monitors and Artificial Pancreas Device Systems (APDS)
{"1877": {"Id":1877,"MPAttachmentLetter":"A","Title":"ICD-10: Short term CGM","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E7945852585BB00657567"},"1878": {"Id":1878,"MPAttachmentLetter":"B","Title":"THERAPEUTIC LONG-TERM INTERSTITIAL CGMS","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85257D39006E7945852585BB00657732"},}
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
e0f65852-e550-4adc-a4f3-d102b58690c0.aspx
  
2104CornealPachymetryUsingUltrasoundMA07.046fMedicine (07)MA07.046fMA07.046e0f65852-e550-4adc-a4f3-d102b58690c0Corneal Pachymetry Using UltrasoundCorneal Pachymetry Using Ultrasound
{"2105": {"Id":2105,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes Eligible to be Reported for Corneal Pachymetry Using Ultrasound","MPPolicyAttachmentInternalSourceId":4970,"PolicyAttachmentPageName":"1444f578-cd43-4d9b-8efc-e7fdbabdfb63"},}
ad0ebd72-6560-40a1-a162-47178bab8fd3.aspx
  
2119CosmeticProceduresMA12.009aMiscellaneous (12)MA12.009aMA12.009ad0ebd72-6560-40a1-a162-47178bab8fd3Cosmetic ProceduresCosmetic Procedures
85257D39006E7945852583F90064AAD0.aspx
  
1484Coverage of Medical DevicesDME (05)MA05.040bMA05.04085257D39006E7945852583F90064AAD0Coverage of Medical DevicesCoverage of Medical Devices
5d14dd79-3851-4eaf-bd7c-3896710bc679.aspx
  
2075CranialElectrotherapyStimulationMA05.066aDME (05)MA05.066aMA05.0665d14dd79-3851-4eaf-bd7c-3896710bc679Cranial 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
a32ec93e-b4fb-4b69-a647-5b3f7d48fdb4.aspx
  
1997crizanlizumab-tmca(Adakveo®)MA08.109aPharmacy (08)MA08.109aMA08.109a32ec93e-b4fb-4b69-a647-5b3f7d48fdb4crizanlizumab-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™)
47c29ee2-6b89-4781-9b06-f57ef31f898d.aspx
  
1955Daratumumab(Darzalex®),Daratumumab,andHyaluronidase-fihj(DarzalexFaspro™)MA08.079gPharmacy (08)MA08.079gMA08.07947c29ee2-6b89-4781-9b06-f57ef31f898dDaratumumab (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
d1e494aa-49f6-4b68-946e-573a56d2f8b1.aspx
  
2004DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNailsMA11.014fSurgery (11)MA11.014fMA11.014d1e494aa-49f6-4b68-946e-573a56d2f8b1Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe NailsDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
{"2005": {"Id":2005,"MPAttachmentLetter":"B","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E10.22 - E13.3512), Continued","MPPolicyAttachmentInternalSourceId":4877,"PolicyAttachmentPageName":"9c741574-2d46-40d4-83db-7ab901e02739"},"2006": {"Id":2006,"MPAttachmentLetter":"E","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (S86.892A - Z79.01), Continued","MPPolicyAttachmentInternalSourceId":4878,"PolicyAttachmentPageName":"8894a13e-e602-45df-8db9-1944154b1f75"},"2007": {"Id":2007,"MPAttachmentLetter":"C","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E13.3513 - I87.093), Continued","MPPolicyAttachmentInternalSourceId":4879,"PolicyAttachmentPageName":"36282eee-3e0d-4bc3-ad97-d1fe6168a949"},"2008": {"Id":2008,"MPAttachmentLetter":"D","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (I87.099 - S86.891S), Continued","MPPolicyAttachmentInternalSourceId":4880,"PolicyAttachmentPageName":"325ec966-870f-44d9-a94b-2ae1bfd5a16a"},"2009": {"Id":2009,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (A30.0 -E10.21)","MPPolicyAttachmentInternalSourceId":4881,"PolicyAttachmentPageName":"da409332-2260-4450-bcd1-f2f0eff1c6c7"},}
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
fe8b47e9-2455-4cec-88f0-e85cff136c80.aspx
  
2055Denosumab(Prolia®,Xgeva®),Romosozumab-aqqg(Evenity™)MA08.052hPharmacy (08)MA08.052hMA08.052fe8b47e9-2455-4cec-88f0-e85cff136c80Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)
{"2056": {"Id":2056,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes","MPPolicyAttachmentInternalSourceId":4831,"PolicyAttachmentPageName":"bd7428f9-6a6a-4666-b4e1-a294a453c3bf"},}
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
d23692bf-87f2-46e4-9ee8-4c39765b6b8d.aspx
  
2093Drug-ElutingBeadsandBlandEmbolizationfortheTreatmentofHepaticMalignanciesMA07.041bMedicine (07)MA07.041bMA07.041d23692bf-87f2-46e4-9ee8-4c39765b6b8dDrug-Eluting Beads and Bland Embolization for the Treatment of Hepatic MalignanciesDrug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
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
4b813f56-24ac-4e45-b434-95227dc923f3.aspx
  
2013DurableMedicalEquipment(DME)MA05.044hDME (05)MA05.044hMA05.0444b813f56-24ac-4e45-b434-95227dc923f3Durable Medical Equipment (DME)Durable Medical Equipment (DME)
{"2014": {"Id":2014,"MPAttachmentLetter":"B","Title":"Items that Do Not Meet the Definition of Durable Medical Equipment (DME) or Excluded from Coverage by Medicare","MPPolicyAttachmentInternalSourceId":4898,"PolicyAttachmentPageName":"1a5ee62a-f092-4abc-9b9a-9cc1652d4962"},"2015": {"Id":2015,"MPAttachmentLetter":"A1","Title":"Equipment that Meets the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":4899,"PolicyAttachmentPageName":"4de274b3-66b1-4f79-9e11-e0d84a74b1cd"},"2016": {"Id":2016,"MPAttachmentLetter":"A2","Title":"Equipment that Meets the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":4900,"PolicyAttachmentPageName":"d0eaacaa-8d8f-4118-a0c9-e5df202e29db"},}
2cc301d3-5baf-4ab6-a6a5-21ce1991f10d.aspx
  
1923Durvalumab(Imfinzi™)MA08.123Pharmacy (08)MA08.123MA08.1232cc301d3-5baf-4ab6-a6a5-21ce1991f10dDurvalumab (Imfinzi™)Durvalumab (Imfinzi™)
{"1924": {"Id":1924,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":4686,"PolicyAttachmentPageName":"2c353d16-201e-4684-9657-003c3bef9330"},}
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™)
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