Policy Bulletins
The Policy Bulletins listed below represent our catalogue of medical and claim payment policies. If you are looking for a specific type of policy, choose a category from the menu on the right. You may also use the search function in the top menu to search for policies by word or phrase.
 
   


Policy #
Policy Bulletin Title

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00.01.14r
Reporting and Documentation Requirements for Anesthesia Services
00.01.14r
Attachment A (ASA Anesthesia Procedure Codes) to 00.01.14r Reporting and Documentation Requirements for Anesthesia Services
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00.01.18d
Reimbursement for Associated Services Performed in Conjunction with Dental Care
00.01.18d
Attachment A (Diagnosis Codes) to 00.01.18d Reimbursement for Associated Services Performed in Conjunction with Dental Care
00.01.19d
Facility Reporting of Observation Services
00.01.24h
Obsolete or Unreliable Diagnostic Tests and Medical Services
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00.01.25ax
PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
00.01.25ax
Attachment A1 (DME Network Rules and Limited Circumstances) to 00.01.25ax PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
00.01.25ax
Attachment A2 (DME Network Rules and Limited Circumstances cont'd.) to 00.01.25ax PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
00.01.25ax
Attachment A3 (DME Network Rules and Limited Circumstances) to 00.01.25ax PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
00.01.25ax
Attachment B1 (Laboratory Network Rules and Limited Circumstances) to 00.01.25ax PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
00.01.25ax
Attachment B2 (Laboratory Network Rules and Limited Circumstances cont'd.) to 00.01.25ax PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
00.01.25ax
Attachment B3 (Laboratory Network Rules and Limited Circumstances cont'd.) to 00.01.25ax PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
00.01.25ax
Attachment C1 (Radiology Network Rules and Limited Circumstances) to 00.01.25ax PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
00.01.25ax
Attachment C2 (Radiology Network Rules and Limited Circumstances cont'd.) to 00.01.25ax PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
00.01.25ax
Attachment D (Physical Medicine & Rehabilitation Network Rules and Limited Circumstances) to 00.01.25ax PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
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00.01.41b
STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point of Service (POS) Products
00.01.41b
Attachment A to 00.01.41b STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point of Service (POS) Products
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00.01.44h
Never Events and Preventable Adverse Events
00.01.44h
Attachment A (Appendix I Hospital Acquired Conditions (HACS) List ) to 00.01.44h Never Events and Preventable Adverse Events
00.01.44h
Attachment B (Pennsylvania House Bill No. 84 addressing Never Events and Preventable Adverse Events) to 00.01.44h Never Events and Preventable Adverse Events
00.01.44h
Attachment C ( New Jersey Act No. 2471 ) to 00.01.44h Never Events and Preventable Adverse Events
00.01.44h
Attachment D (Never Event or Preventable Adverse Event Reporting Form ) to 00.01.44h Never Events and Preventable Adverse Events
00.01.45
Intravenous (IV) Administration of Fluids as a Treatment of a Medical Condition or for the Preparation of Pharmaceuticals, Biologics, and other Substances
00.01.47c
Inpatient Hospital Readmission
00.01.48c
Marijuana for Medical Use
00.01.49c
Reporting Requirements for Drugs and Biologics
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00.01.52i
Always Bundled Procedure Codes
00.01.52i
Attachment A (CPT Codes and HCPCS Codes) to 00.01.52i Always Bundled Procedure Codes
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00.01.55o
New Jersey Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Radiology Network Rules and Limited Circumstances
00.01.55o
Attachment A1 (NJ HMO & HMO-POS RADIOLOGY NETWORK RULES) to 00.01.55o New Jersey Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Radiology Network Rules and Limited Circumstances
00.01.55o
Attachment A2 (NJ HMO & HMO-POS RADIOLOGY LIMITED CIRCUMSTANCES) to 00.01.55o New Jersey Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Radiology Network Rules and Limited Circumstances
00.01.56a
National Correct Coding Initiative (NCCI) Code Pair Edits
00.01.59f
Care Management and Care Planning Services
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00.01.60d
Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services
00.01.60d
Attachment A (Multiple Reduction Diagnostic Services) to 00.01.60d Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services
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00.01.61
Reimbursement for Components of Comprehensive Laboratory Panels
00.01.61
Attachment A (CPT Codes) to 00.01.61 Reimbursement for Components of Comprehensive Laboratory Panels
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00.01.66b
Musculoskeletal Services (AmeriHealth)
00.01.66b
Attachment A (Procedure Codes for Spinal Surgery) to 00.01.66b Musculoskeletal Services (AmeriHealth)
00.01.66b
Attachment B (Procedure Codes for Joint Surgery) to 00.01.66b Musculoskeletal Services (AmeriHealth)
00.01.66b
Attachment C (Procedures Codes for Interventional Pain Management) to 00.01.66b Musculoskeletal Services (AmeriHealth)
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00.01.68
Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services
00.01.68
Attachment A (Multiple Reduction Always Therapy Procedure Codes) to 00.01.68 Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services
00.01.69
Consultation Services
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00.03.02aa
Diagnostic Radiology Services Included in Capitation
00.03.02aa
Attachment A (Diagnostic Radiology Procedure Codes Included in Capitation for Pennsylvania (PA) Health Maintenance Organization (HMO) Members ) to 00.03.02aa Diagnostic Radiology Services Included in Capitation
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00.03.03h
Outpatient Short-Term Rehabilitation Services Included in Capitation
00.03.03h
Attachment A to 00.03.03h Outpatient Short-Term Rehabilitation Services Included in Capitation
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00.03.06f
Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
00.03.06f
Attachment A1 (HAND THERAPY SERVICES) to 00.03.06f Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
00.03.06f
Attachment A2 (HAND THERAPY SERVICES) to 00.03.06f Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
00.03.06f
Attachment B (LYMPHEDEMA THERAPY SERVICES) to 00.03.06f Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
00.03.06f
Attachment C (PELVIC FLOOR THERAPY SERVICES) to 00.03.06f Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
00.03.06f
Attachment D (VESTIBULAR REHABILIATION SERVICES) to 00.03.06f Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
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00.03.07y
Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
00.03.07y
Attachment A1 (CPT CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE) to 00.03.07y Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
00.03.07y
Attachment A2 (HCPCS CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE) to 00.03.07y Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
00.03.07y
Attachment B1 (SERVICES ELIGIBLE FOR REIMBURSEMENT WHEN PERFORMED IN THE SPECIALIST OFFICE (THIS INCLUDES THE CERTIFIED REGISTERED NURSE PRACTITIONER (CRNP) AND PHYSICIAN ASSISTANT (PA) PRACTICING WITHIN THE SCOPE OF THEIR SPECIALTY) ) to 00.03.07y Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
00.03.07y
Attachment B2 (SERVICES ELIGIBLE FOR REIMBURSEMENT IN THE OUTPATIENT HOSPITAL LABORATORY) to 00.03.07y Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
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00.03.09d
X-rays Associated with Fractures in the Office Setting
00.03.09d
Attachment A (Codes Eligible for Reimbursement by Hand Surgeons, Orthopedic Surgeons, or Sports Medicine Specialists) to 00.03.09d X-rays Associated with Fractures in the Office Setting
00.03.09d
Attachment B (Codes Eligible for Reimbursement by Podiatrists) to 00.03.09d X-rays Associated with Fractures in the Office Setting
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00.03.10e
Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
00.03.10e
Attachment A (High Risk Pregnancy) to 00.03.10e Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
00.03.10e
Attachment B (Rule out Ectopic Pregnancy) to 00.03.10e Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
00.03.10e
Attachment C (Rule out intrauterine pathology and Screening for Fetal abnormalities) to 00.03.10e Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
00.03.10e
Attachment D (First-trimester screening and Ovarian Dysfunction) to 00.03.10e Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
00.05.01f
Guidelines for Home Care Visits Following Inpatient Maternity Stay
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00.06.02ab
Preventive Care Services (AmeriHealth)
00.06.02ab
Attachment A (Adult Preventive Services) to 00.06.02ab Preventive Care Services (AmeriHealth)
00.06.02ab
Attachment B (Female Preventive Care Services) to 00.06.02ab Preventive Care Services (AmeriHealth)
00.06.02ab
Attachment C (Pediatric Preventive Care Services) to 00.06.02ab Preventive Care Services (AmeriHealth)
00.06.02ab
Attachment D (ADDITIONAL PREVENTIVE SERVICES FOR MEMBERS ENROLLED IN NJ PLANS) to 00.06.02ab Preventive Care Services (AmeriHealth)
00.09.01f
Direct Access to Obstetrics/Gynecology (OB/GYN) Services
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00.10.01ab
Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
00.10.01ab
Attachment A (Pennsylvania Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers ) to 00.10.01ab Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
00.10.01ab
Attachment B (New Jersey Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers) to 00.10.01ab Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
00.10.03j
Criteria for Reimbursement of Emergency Room Services
00.10.11l
Modifier 62: Two Surgeons
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00.10.15c
Cast and Splint Applications and Associated Supplies Provided in the Office Setting
00.10.15c
Attachment A to 00.10.15c Cast and Splint Applications and Associated Supplies Provided in the Office Setting
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00.10.17i
Modifier 66: Surgical Team
00.10.17i
Attachment A (Team Surgery Review Form) to 00.10.17i Modifier 66: Surgical Team
00.10.17i
Attachment B (Eligible Indicators 1 and 2 Procedure Codes) to 00.10.17i Modifier 66: Surgical Team
00.10.18k
Modifiers for Assistant-at-Surgery Services: 80, 81, 82, and AS
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00.10.36q
Radiologic Guidance of a Procedure
00.10.36q
Attachment A (Radiologic Guidance and Supervision and Interpretation Procedure Codes) to 00.10.36q Radiologic Guidance of a Procedure
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00.10.38a
Billing Requirements for Multiple Births for Professional Providers
00.10.38a
Attachment A (MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ROUTINE OBSTETRIC (GLOBALE MATERNITY/OBSTETRIC [OB]) CARE WAS PROVIDED) to 00.10.38a Billing Requirements for Multiple Births for Professional Providers
00.10.38a
Attachment B (MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ANETEPARTUM CARE IS NOT PROVIDED) to 00.10.38a Billing Requirements for Multiple Births for Professional Providers
00.10.38a
Attachment C (CODING SCENARIOS FOR REPORTING HIGH-ORDER MULTIPLE (TRIPLETS, QUADRUPLETS, ETC) BIRTHS WHEN ROUTINE OBSTETRIC (GLOBAL MATERNITY/OBSTETRIC [OB]) CARE WAS PROVIDED) to 00.10.38a Billing Requirements for Multiple Births for Professional Providers
00.10.38a
Attachment D (MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF HIGH-ORDER MULTIPLES WHEN ANTEPARTUM CARE IS NOT PROVIDED) to 00.10.38a Billing Requirements for Multiple Births for Professional Providers
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00.10.39l
Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
00.10.39l
Attachment A to 00.10.39l Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
00.10.40d
Incident To and Non-Incident To Services Performed by Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs)
01.00.09c
Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump
02.01.01d
Home Health Care Services
02.01.02c
Private Duty Nursing
02.02.01g
Hospice Care
03.00.02b
Modifier 76: Repeat Procedure or Service by Same Physician or Qualified Health Professional
03.00.05k
Modifier 50: Bilateral Procedure
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03.00.06r
Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
03.00.06r
Attachment A (E&M codes appended with modifier 25 should be reimbursed at 50% of the applicable fee schedule amount when submitted on the same date of service, by the same professional provider or other qualified health care provider, as a minor procedure.) to 03.00.06r Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
03.00.06r
Attachment B (Problem-focused E&M Codes appended with modifier 25 should be reimbursed at 50% of the applicable fee schedule amount when submitted on the same date of service by the same professional provider or other qualified health care provider, as a preventive E&M.) to 03.00.06r Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
03.00.08e
Modifiers XE, XS, XP, XU, and 59
03.00.11b
Modifier 77: Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional
03.00.12f
Modifier 78 Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following the Initial Procedure for a Related Procedure During the Postoperative Period
03.00.15o
Modifier 24: Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period
03.00.16o
Modifier 57 Decision for Surgery
03.00.20j
Modifiers 26 (Professional Component) and TC (Technical Component)
03.00.28m
Modifier 79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
03.00.31f
Modifiers for Split or Shared Surgical Services (Modifiers 54, 55, and 56)
03.00.32a
Modifier 52 Reduced Services
03.00.33a
Modifier 53 Discontinued Procedure
04.00.05d
Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth
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05.00.01l
Pneumatic Compression Therapy Devices
05.00.01l
Attachment A (ICD-10 Codes) to 05.00.01l Pneumatic Compression Therapy Devices
05.00.04e
Coverage of Medical Devices
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05.00.05l
Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
05.00.05l
Attachment A (ICD 10 Codes) to 05.00.05l Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
05.00.05l
Attachment B (HCPCS Codes) to 05.00.05l Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
05.00.08e
Continuous Passive Motion (CPM) Devices in the Home Setting
05.00.09h
Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System
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05.00.11i
Therapeutic Shoes and Orthopedic Shoes
05.00.11i
Attachment A (ICD-10 Coding) to 05.00.11i Therapeutic Shoes and Orthopedic Shoes
05.00.12g
Manual Wheelchairs
05.00.14j
High-Frequency Chest Wall Oscillation Devices
05.00.15q
Nebulizers and Inhalation Solutions
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05.00.21u
Durable Medical Equipment (DME) and Consumable Medical Supplies
05.00.21u
Attachment A1 (Equipment that Meets the Definition of Durable Medical Equipment (DME)) to 05.00.21u Durable Medical Equipment (DME) and Consumable Medical Supplies
05.00.21u
Attachment A2 (Equipment that Meets the Definition of Durable Medical Equipment (DME)) to 05.00.21u Durable Medical Equipment (DME) and Consumable Medical Supplies
05.00.21u
Attachment B (Items that Do Not Meet the Definition of Durable Medical Equipment (DME)) to 05.00.21u Durable Medical Equipment (DME) and Consumable Medical Supplies
Hide details for
05.00.24q
Short-term Interstitial Continuous Glucose Monitoring Systems (CGMSs)
05.00.24q
Attachment A (ICD-10 Diagnosis Codes for Short-term Interstitial Continuous Glucose Monitoring System) to 05.00.24q Short-term Interstitial Continuous Glucose Monitoring Systems (CGMSs)
05.00.25i
Cranial Remolding Orthoses (Helmets)
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05.00.26i
Home Prothrombin Time Monitoring
05.00.26i
Attachment A (ICD-10-CODING) to 05.00.26i Home Prothrombin Time Monitoring
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05.00.29k
Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
05.00.29k
Attachment A (ICD-10 Codes used to represent the Wearable Automatic External Defibrillator (AED):) to 05.00.29k Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
05.00.29k
Attachment B (ICD-10 codes used to represent the Nonwearable Automatic External Defibrillator (AED):) to 05.00.29k Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
05.00.30m
Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) Devices and Bi-Level Devices (AmeriHealth Adminstrators)
05.00.31e
Pulse Oximetry Devices in the Home Setting
05.00.32i
Speech and Non-Speech Generating Devices
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05.00.35f
Foot Orthotics and Other Podiatric Appliances
05.00.35f
Attachment A (ICD-10 Codes) to 05.00.35f Foot Orthotics and Other Podiatric Appliances
05.00.37f
Compression Garments
05.00.38j
Negative-Pressure Wound Therapy (NPWT) Systems
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05.00.39o
Ankle-Foot/Knee-Ankle-Foot Orthoses
05.00.39o
Attachment A (HCPCS Codes) to 05.00.39o Ankle-Foot/Knee-Ankle-Foot Orthoses
05.00.42g
Patient Lifts
05.00.43f
Seat Lift Mechanisms
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05.00.44k
Repair and Replacement of Durable Medical Equipment (DME)
05.00.44k
Attachment A (HCPCS Codes For Repair and Replacment DME) to 05.00.44k Repair and Replacement of Durable Medical Equipment (DME)
05.00.45k
Repair or Replacement of an External Prosthetic Device
05.00.47n
Knee Orthoses
05.00.48j
Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
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05.00.50k
Ostomy Supplies
05.00.50k
Attachment A (HCPCS Codes for Ostomy Supplies) to 05.00.50k Ostomy Supplies
05.00.54g
Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices
05.00.55i
Wheelchair Cushions and Seating
05.00.56i
Hospital Beds and Accessories
05.00.58l
Home Oxygen Therapy
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05.00.59j
Lower Limb Prostheses
05.00.59j
Attachment A (HCPCS Level II Code Number(s) and Narrative(s)) to 05.00.59j Lower Limb Prostheses
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05.00.60h
Pressure-Reducing Support Surfaces
05.00.60h
Attachment A (ICD-10 Codes) to 05.00.60h Pressure-Reducing Support Surfaces
05.00.61f
Cervical Traction Devices for In-home Use
05.00.62h
Injectable Dermal Fillers
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05.00.67p
Wheelchair Options and Accessories
05.00.67p
Attachment A (HCPCS Level II Codes For Wheelchair Options And Accessories) to 05.00.67p Wheelchair Options and Accessories
05.00.69b
Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD)
05.00.70b
Mechanical Stretching Devices for the Treatment of Joint Stiffness or Contractures
05.00.71c
Standing Frames
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05.00.72f
Upper Limb Prostheses
05.00.72f
Attachment A (HCPCS Codes) to 05.00.72f Upper Limb Prostheses
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05.00.73c
Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES)
05.00.73c
Attachment A (ICD 10 Codes) to 05.00.73c Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES)
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05.00.74d
Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies
05.00.74d
Attachment A (ICD 10 Codes) to 05.00.74d Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies
05.00.75
Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)
05.00.76c
Breast Pumps
05.00.77a
Subcutaneous Implantable Cardioverter Defibrillator (S-ICD) for Treating Life-threatening Ventricular Tachyarrhythmia
05.00.78
Transtympanic Micropressure Device as a Treatment of Meniere's Disease
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05.00.79b
Insulin Pumps and Long term Interstitial Continuous Glucose Monitoring Systems
05.00.79b
Attachment A (ICD-10 Diagnosis Codes for Insulin Pumps) to 05.00.79b Insulin Pumps and Long term Interstitial Continuous Glucose Monitoring Systems
05.00.79b
Attachment B (ICD-10 Diagnosis Codes for the CGM supplies used in conjunction with the threshold suspend (low glucose) device system ) to 05.00.79b Insulin Pumps and Long term Interstitial Continuous Glucose Monitoring Systems
05.00.80a
Cranial Electrotherapy Stimulation
06.02.01j
Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic Therapy
06.02.04d
Fetal Fibronectin Enzyme (fFN) Immunoassay
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06.02.06p
Genetic Testing for Inherited Breast Cancer 1 (BRCA1) and Breast Cancer 2 (BRCA2) Mutations (AmeriHealth Administrators)
06.02.06p
Attachment A (ICD-10 codes) to 06.02.06p Genetic Testing for Inherited Breast Cancer 1 (BRCA1) and Breast Cancer 2 (BRCA2) Mutations (AmeriHealth Administrators)
06.02.09g
Human Immunodeficiency Virus (HIV) Genotyping and Phenotyping (AmeriHealth Administrators)
06.02.10q
Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome) (AmeriHealth Administrators)
06.02.14i
In Vitro Chemosensitivity and Chemoresistance Assays
06.02.17h
Serodiagnosis of Inflammatory Bowel Disease (IBD) and the Prometheus® IBD sgi Diagnostic™ Test
06.02.18l
Pharmacogenetics and Metabolite Monitoring for Using Azathioprine (AZA)/6-Mercaptopurine (6-MP) Therapy (AmeriHealth Administrators)
06.02.24j
Preimplantation Genetic Testing (AmeriHealth Administrators)
06.02.26d
In Vitro Allergy Testing
06.02.27l
Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (AmeriHealth Administrators)
06.02.29d
AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)
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06.02.30e
Pharmacogenetic Testing to Determine Drug Sensitivity (AmeriHealth Administrators)
06.02.30e
Attachment A (Cytochrome p450 Genotyping for Assessment of Individuals Prior to Initiation of Clopidogrel Bisulfate (Plavix®)) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (AmeriHealth Administrators)
06.02.30e
Attachment B (Genetic Testing for Warfarin (Coumadin®) Dose) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (AmeriHealth Administrators)
06.02.30e
Attachment C (Genetic Testing for Helicobacter pylori treatment) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (AmeriHealth Administrators)
06.02.30e
Attachment D (Genetic Testing for Tamoxifen Treatment ) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (AmeriHealth Administrators)
06.02.30e
Attachment E (KRAS and BRAF Mutation Analysis in Metastatic Colorectal Cancer prior to use of cetuximab (Erbitux®) and pantiumumab (Vectibix®)) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (AmeriHealth Administrators)
06.02.30e
Attachment F (KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (AmeriHealth Administrators)
06.02.30e
Attachment G (KRAS mutation analylsis to predict treatment response to elotinib (Tarceva®) in non-small cell lung cancer (NSCLC)) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (AmeriHealth Administrators)
06.02.30e
Attachment H (Epidermal Growth Factor (EGFR) Mutation Analysis for individuals with non-small cell lung cancer) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (AmeriHealth Administrators)
06.02.30e
Attachment I (BRAF for melanoma) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (AmeriHealth Administrators)
06.02.30e
Attachment J (BCR-ABL Testing for Monitoring of Individuals with Chronic Myelogenous Leukemia or Acute Myelogenous Leukemia, who are Receiving Imatinib Mesylate (Gleevec®) Therapy) to 06.02.30e Pharmacogenetic Testing to Determine Drug Sensitivity (AmeriHealth Administrators)
06.02.31f
Genetic Testing for Congenital Long QT Syndrome (AmeriHealth Administrators)
06.02.32d
Multigene Expression Assays for Predicting Recurrence in Colon Cancer (AmeriHealth Administrators)
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06.02.35x
Genetic Testing (AmeriHealth Administrators)
06.02.35x
Attachment A (Services that are Considered Medically Necessary) to 06.02.35x Genetic Testing (AmeriHealth Administrators)
06.02.35x
Attachment B (Services that are Considered Medically Necessary with Criteria) to 06.02.35x Genetic Testing (AmeriHealth Administrators)
06.02.35x
Attachment C (Services that are Considered Experimental/Investigational ) to 06.02.35x Genetic Testing (AmeriHealth Administrators)
06.02.36c
Molecular Testing for the Management of Pancreatic Cysts or Barrett's Esophagus (AmeriHealth Administrators)
06.02.37a
Immune Cell Function Assay
06.02.38d
Nerve Fiber Density Testing
06.02.39d
Measurement of Serum Antibodies to and Measurement of Serum Levels of Biologics
06.02.43b
Proteomic (Protein)-Based Testing for the Evaluation of Ovarian (Adnexal) Masses Using OVA1® Test and Risk of Ovarian Malignancy Algorithm (ROMA™)
06.02.44m
Presumptive and Definitive Drug Testing in Substance Abuse and Pain Management Treatments
06.02.45
Vectra® DA Blood Test for Rheumatoid Arthritis
06.02.47d
Noninvasive Prenatal Screening for Fetal Aneuploidies Using Cell-Free Fetal DNA (AmeriHealth Administrators)
06.02.49b
VeriStrat® Testing for Targeted Therapy in Non-Small Cell Lung Cancer
06.02.50
GPS Cancer™ Testing by NantHealth
06.02.51c
Testing Serum Vitamin D Levels
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06.02.52p
eviCore Lab Management Program (AmeriHealth)
06.02.52p
Attachment A (Procedure Codes Requiring Precertification/Preapproval and Prepayment Review) to 06.02.52p eviCore Lab Management Program (AmeriHealth)
06.02.52p
Attachment B (Procedure Codes Requiring Prepayment Review) to 06.02.52p eviCore Lab Management Program (AmeriHealth)
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06.02.54
Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
06.02.54
Attachment A (MEDICALLY NECESSARY ICD 10 CODES FOR COBALAMIN (VITAMIN B12) AND/OR FOLIC ACID TESTING (CPT CODES 82607, 82608, 82746, AND 82747) ) to 06.02.54 Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
06.02.55
Therapeutic Drug Monitoring for Antidepressants, Antipsychotics, or Antiepileptics
06.02.56b
Noninvasive Techniques for the Evaluation and Monitoring of Individuals with Chronic Liver Disease
06.03.04n
Apheresis Therapy
07.00.01i
Biofeedback Therapy
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07.00.02i
Intravenous Chelation Therapy
07.00.02i
Attachment A (ICD-10 Codes) to 07.00.02i Intravenous Chelation Therapy
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07.00.03n
Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy
07.00.03n
Attachment A (Utilization Guidelines) to 07.00.03n Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy
07.00.05g
In Vivo Allergy Sensitivity Testing
07.00.09d
Topical Oxygenation
07.00.10i
Photodynamic Therapy (PDT) Using Porfimer Sodium (Photofrin®)
07.00.14g
Low-level Laser Therapy (LLLT)
07.00.15l
Reimbursement for the Administration of Immunizations
07.00.20f
Routine Costs Associated with Qualifying Clinical Trials
07.00.21i
Allergy Immunotherapy
07.02.05j
External Counterpulsation (ECP)
07.02.09g
Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
07.02.21e
Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
07.02.22a
Esophagogastroduodenoscopy (EGD) and Endoscopic Retrograde Cholangiopancreatography (ERCP)
07.03.03g
Medical Evaluation and Management for Attention-Deficit Hyperactivity Disorder (ADHD)
07.03.05w
Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies (AmeriHealth)
07.03.07t
Evaluation and Management of Autism Spectrum Disorder (ASD)
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07.03.08i
Neuropsychological Testing for Neurologically Based Conditions
07.03.08i
Attachment A (ICD-10 Codes) to 07.03.08i Neuropsychological Testing for Neurologically Based Conditions
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07.03.09p
Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment A (Recommended Guidelines for Electrodiagnostic Studies) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment B (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment C (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment D (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment E (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment F (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment G (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment H (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment I (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment J (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment K (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.10e
Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI)
07.03.14o
Intraoperative Neurophysiological Monitoring (INM)
07.03.15d
Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS)
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07.03.18o
Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment A (Recommended Guidelines for Electrodiagnostic Studies) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment B (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment C (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment D (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment E (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment F (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment G (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment H (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment I (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment J (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment K (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
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07.03.21k
Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
07.03.21k
Attachment A (ICD-10-CM codes) to 07.03.21k Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
07.03.22d
Transcranial Magnetic Stimulation (TMS)
07.03.23b
Autonomic Nervous System Testing
07.03.24a
Laboratory-Based Vestibular Function Testing
07.03.25a
Nonemergent Inpatient Video Electroencephalogram (EEG) Monitoring and Ambulatory EEG Monitoring in the Home
07.03.26a
Tumor Treating Fields
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07.05.02n
Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon
07.05.02n
Attachment A (ICD-10-CM Codes) to 07.05.02n Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon
07.05.06g
Transcatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies
07.05.07d
Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
07.05.08a
Fecal Microbiota Transplantation (FMT)
07.06.01b
Complete Decongestive Therapy (CDT)
07.06.03b
Bioimpedance for the Detection of Lymphedema
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07.07.01o
Routine Foot Care for Certain Medical Conditions
07.07.01o
Attachment A (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (A30.0 -E10.21)) to 07.07.01o Routine Foot Care for Certain Medical Conditions
07.07.01o
Attachment B (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (E10.22 - E13.3512), Continued) to 07.07.01o Routine Foot Care for Certain Medical Conditions
07.07.01o
Attachment C (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (E13.3513 - I87.093), Continued ) to 07.07.01o Routine Foot Care for Certain Medical Conditions
07.07.01o
Attachment D (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (I87.099 - S86.891S), Continued) to 07.07.01o Routine Foot Care for Certain Medical Conditions
07.07.01o
Attachment E (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (S86.892A - Z79.01), Continued) to 07.07.01o Routine Foot Care for Certain Medical Conditions
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07.07.02j
Ultraviolet Light Therapy for the Treatment of Dermatological Conditions
07.07.02j
Attachment A (ICD-10-CM codes ) to 07.07.02j Ultraviolet Light Therapy for the Treatment of Dermatological Conditions
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07.07.03m
Photodynamic Therapy (PDT) Using Levulan® Kerastick® or Ameluz® (Aminolevulinic Acid HCl [ALA])
07.07.03m
Attachment A (ICD-10 Diagnosis Code Number(s) and Narrative(s)) to 07.07.03m Photodynamic Therapy (PDT) Using Levulan® Kerastick® or Ameluz® (Aminolevulinic Acid HCl [ALA])
07.07.05b
Photography, Including Documentation and Record-Keeping Photography, Whole Body Integumentary Photography, Dermoscopy, and Dermatoscopy
07.07.09g
Stem-Cell Therapy for Orthopedic Applications and Autologous Platelet-Derived Growth Factors (PDGFs)/Platelet-Rich Plasmas (PRPs) for Acute or Chronic Wound Healing and Other Miscellaneous Conditions
07.08.01f
Non-Surgical Spinal Decompression Therapy
07.08.03e
Medical and Surgical Treatment of Temporomandibular Joint Disorder
07.10.04c
Parenterally Administered Terbutaline Sulfate for the Prevention or Treatment of Pre-Term Labor
07.10.05m
Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System
07.10.06h
Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation
07.11.01c
Smell and Taste Dysfunction Testing
07.11.02f
Measurement of Exhaled Nitric Oxide and Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders
07.12.01e
Pelvic Floor Stimulation as a Treatment of Incontinence
07.13.01h
Orthoptic/Pleoptic Training
07.13.05k
Photodynamic Therapy (PDT) Using Verteporfin (Visudyne®)
07.13.06k
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
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07.13.07j
Corneal Pachymetry Using Ultrasound
07.13.07j
Attachment A (ICD-10-CM codes) to 07.13.07j Corneal Pachymetry Using Ultrasound
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07.13.08e
Partial Coherence Interferometry
07.13.08e
Attachment A (ICD-10 Codes) to 07.13.08e Partial Coherence Interferometry
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07.13.11i
Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
07.13.11i
Attachment A (ICD-10 Codes) to 07.13.11i Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
07.13.12d
Instrument-Based Vision Screening
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07.13.13c
Prescription Lenses and Visual Devices
07.13.13c
Attachment A (Contains the applicable codes for prescription lenses and visual devices for Commercial (non-Medicare Advantage) members) to 07.13.13c Prescription Lenses and Visual Devices
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08.00.08j
Radioimmunotherapy with Ibritumomab Tiuxetan (Zevalin®) (AmeriHealth Administrators)
08.00.08j
Attachment A (ICD-10 Codes) to 08.00.08j Radioimmunotherapy with Ibritumomab Tiuxetan (Zevalin®) (AmeriHealth Administrators)
08.00.10
Luspatercept–aamt (Reblozyl®)
08.00.12
Fam-trastuzumab deruxtecan-nxki (Enhertu®)
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08.00.13v
Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
08.00.13v
Attachment A (Dosing and Frequency Requirements) to 08.00.13v Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
08.00.13v
Attachment B (ICD-10 DIAGNOSIS CODES) to 08.00.13v Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
08.00.15f
Off-label Coverage for Prescription Drugs and/or Biologics
08.00.17h
Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Parenteral Nutrition (IPN)
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08.00.18m
Nutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk
08.00.18m
Attachment A (PA Mandates) to 08.00.18m Nutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk
08.00.18m
Attachment B (NJ Mandates) to 08.00.18m Nutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk
08.00.18m
Attachment C (Caloric Requirements) to 08.00.18m Nutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk
08.00.22m
Immune Prophylaxis for Respiratory Syncytial Virus (RSV)
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08.00.25l
Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents
08.00.25l
Attachment A (Dosing and Frequency Requirements) to 08.00.25l Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents
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08.00.26v
Botulinum Toxin Agents
08.00.26v
Attachment A (ICD-10 Diagnosis Codes) to 08.00.26v Botulinum Toxin Agents
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08.00.33o
Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
08.00.33o
Attachment A (Dosing & Frequency Requirements for Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and hyaluronidase-oysk (Herceptin Hylecta)) to 08.00.33o Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
08.00.33o
Attachment B (ICD-10 CM Codes and Narratives) to 08.00.33o Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
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08.00.34m
Infliximab and Related Biosimilars
08.00.34m
Attachment A (Dosing and Frequency Requirements for Infliximab and Related Biosimilars) to 08.00.34m Infliximab and Related Biosimilars
08.00.34m
Attachment B (ICD-10-CM Codes and Narratives) to 08.00.34m Infliximab and Related Biosimilars
08.00.43
Enfortumab vedotin-ejfv (Padcev™)
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08.00.45
Eptinezumab-jjmr (VYEPTI™)
08.00.45
Attachment A (ICD 10 Diagnosis list G43.001   Migraine without aura, not intractable, with status migrainosus G43.009   Migraine without aura, not intractable, without status migrainosus G43.011   Migraine without aura, intractable, with status migrainosus G43.019   Migraine without aura, intractable, without status migrainosus G43.101   Migraine with aura, not intractable, with status migrainosus G43.109   Migraine with aura, not intractable, without status migrainosus G43.111   Migraine with aura, intractable, with status migrainosus G43.119   Migraine with aura, intractable, without status migrainosus G43.401   Hemiplegic migraine, not intractable, with status migrainosus G43.409   Hemiplegic migraine, not intractable, without status migrainosus G43.411   Hemiplegic migraine, intractable, with status migrainosus G43.419   Hemiplegic migraine, intractable, without status migrainosus G43.501   Persistent migraine aura without cerebral infarction, not intractable, with status migrainosus G43.509   Persistent migraine aura without cerebral infarction, not intractable, without status migrainosus G43.511   Persistent migraine aura without cerebral infarction, intractable, with status migrainosus G43.519   Persistent migraine aura without cerebral infarction, intractable, without status migrainosus G43.601   Persistent migraine aura with cerebral infarction, not intractable, with status migrainosus G43.609   Persistent migraine aura with cerebral infarction, not intractable, without status migrainosus G43.611   Persistent migraine aura with cerebral infarction, intractable, with status migrainosus G43.619   Persistent migraine aura with cerebral infarction, intractable, without status migrainosus G43.701   Chronic migraine without aura, not intractable, with status migrainosus G43.709   Chronic migraine without aura, not intractable, without status migrainosus G43.711   Chronic migraine without aura, intractable, with status migrainosus G43.719   Chronic migraine without aura, intractable, without status migrainosus G43.801   Other migraine, not intractable, with status migrainosus G43.809   Other migraine, not intractable, without status migrainosus G43.811   Other migraine, intractable, with status migrainosus G43.819   Other migraine, intractable, without status migrainosus G43.821   Menstrual migraine, not intractable, with status migrainosus G43.829   Menstrual migraine, not intractable, without status migrainosus G43.831   Menstrual migraine, intractable, with status migrainosus G43.839   Menstrual migraine, intractable, without status migrainosus G43.901   Migraine, unspecified, not intractable, with status migrainosus G43.909   Migraine, unspecified, not intractable, without status migrainosus G43.911   Migraine, unspecified, intractable, with status migrainosus G43.919   Migraine, unspecified, intractable, without status migrainosus ) to 08.00.45 Eptinezumab-jjmr (VYEPTI™)
08.00.46
Isatuximab-irfc (Sarclisa®)
08.00.49e
Dofetilide (Tikosyn®) Use in the Inpatient Setting
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08.00.50u
Rituximab (Rituxan®) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela®)
08.00.50u
Attachment A (Dosing and Frequency Requirements For Rituximab (Rituxan®) infusion and related biosimilars, and rituximab/hyaluronidase human for subcutaneous injection (Rituxan Hycela®)) to 08.00.50u Rituximab (Rituxan®) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela®)
08.00.50u
Attachment B (ICD-10 CODES AND NARRATIVES) to 08.00.50u Rituximab (Rituxan®) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela®)
08.00.51j
Enzyme Replacement for the Treatment of Gaucher's Disease
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08.00.55h
Omalizumab (Xolair®)
08.00.55h
Attachment A (Dosing and Frequency Requirements for Omalizumab (Xolair®)) to 08.00.55h Omalizumab (Xolair®)
08.00.57n
Treatments for Complex Regional Pain Syndrome (CRPS)
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08.00.62i
Abatacept (Orencia®) for Injection for Intravenous Use
08.00.62i
Attachment A (ICD-10 CODES AND NARRATIVES) to 08.00.62i Abatacept (Orencia®) for Injection for Intravenous Use
08.00.64g
Natalizumab (Tysabri®)
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08.00.66n
Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
08.00.66n
Attachment A (Dosing and Frequency Requirements) to 08.00.66n Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
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08.00.67l
Cetuximab (Erbitux®)
08.00.67l
Attachment A (Dosing and Frequency Requirements) to 08.00.67l Cetuximab (Erbitux®)
08.00.67l
Attachment B (ICD-10 Codes for Cetuximab (Erbitux®)) to 08.00.67l Cetuximab (Erbitux®)
08.00.69b
Agalsidase beta (Fabrazyme®)
08.00.70e
Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, Elaprase®, Vimizim®, Naglazyme®, Mepsevii™, etc.)
08.00.72h
Alglucosidase alfa (e.g., Lumizyme®)
08.00.73l
Bortezomib (Bortezomib for Injection, Velcade®)
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08.00.74n
Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists and Related Biosimilars
08.00.74n
Attachment A (ICD-10 Codes and Narratives) to 08.00.74n Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists and Related Biosimilars
08.00.75n
Erythropoiesis-Stimulating Agents (ESAs)
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08.00.78ad
Self-Administered Drugs
08.00.78ad
Attachment A (Prescription drugs that are considered by the Company to be self-administered.) to 08.00.78ad Self-Administered Drugs
08.00.82k
Ustekinumab (Stelara®)
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08.00.83h
Pralatrexate (Folotyn®) for Injection
08.00.83h
Attachment A (ICD-10 Codes Eligible to be Reported for Pralatrexate (Folotyn®) for Injection) to 08.00.83h Pralatrexate (Folotyn®) for Injection
08.00.84g
Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris®)
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08.00.85h
Tocilizumab (Actemra®) for Intravenous Infusion
08.00.85h
Attachment A (ICD-10 CODES AND NARRATIVES) to 08.00.85h Tocilizumab (Actemra®) for Intravenous Infusion
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08.00.87f
Pemetrexed (Alimta®)
08.00.87f
Attachment A (ICD-10 CODES AND NARRATIVES) to 08.00.87f Pemetrexed (Alimta®)
08.00.88f
Ofatumumab (Arzerra®)
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08.00.90j
Paclitaxel Protein-bound Particles for Injectable Suspension (Albumin-bound)/(Abraxane® for Injectable Suspension)
08.00.90j
Attachment A (ICD-10 codes) to 08.00.90j Paclitaxel Protein-bound Particles for Injectable Suspension (Albumin-bound)/(Abraxane® for Injectable Suspension)
08.00.91d
Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)
08.00.92aa
Coagulation Factors
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08.00.94m
Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)
08.00.94m
Attachment A (ICD-10-CM Codes) to 08.00.94m Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)
08.00.95d
Personalized Vaccines (e.g. Provenge®)
08.00.96d
Cabazitaxel (Jevtana®)
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08.00.98e
Eribulin Mesylate (Halaven®)
08.00.98e
Attachment A (ICD-10 Codes and Narratives) to 08.00.98e Eribulin Mesylate (Halaven®)
08.00.99b
Belimumab (Benlysta®) for Intravenous Use
08.01.00g
Hydroxyprogesterone Caproate Injection as a Technique to Reduce the Risk of Preterm Birth in High-Risk Pregnancies
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08.01.01i
Ipilimumab (Yervoy®)
08.01.01i
Attachment A (Dosing and Frequency Requirements For Ipilimumab (Yervoy®)) to 08.01.01i Ipilimumab (Yervoy®)
08.01.01i
Attachment B (ICD-10 Diagnosis codes) to 08.01.01i Ipilimumab (Yervoy®)
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08.01.02e
Pegloticase (Krystexxa®)
08.01.02e
Attachment A (ICD-10 Codes and Narratives) to 08.01.02e Pegloticase (Krystexxa®)
08.01.04v
Immunizations
08.01.05f
Carfilzomib (Kyprolis™)
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08.01.07f
Pertuzumab (Perjeta®)
08.01.07f
Attachment A (ICD-10-CM Codes and Narratives) to 08.01.07f Pertuzumab (Perjeta®)
08.01.08d
Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical Benefit
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08.01.10e
Octreotide Acetate (Sandostatin® LAR Depot)
08.01.10e
Attachment A (ICD-10 CODES AND NARRATIVES) to 08.01.10e Octreotide acetate (Sandostatin® LAR Depot)
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08.01.11e
Ado-Trastuzumab Emtansine (Kadcyla®)
08.01.11e
Attachment A (ICD-10-CM Codes and Narratives) to 08.01.11e Ado-Trastuzumab Emtansine (Kadcyla®)
08.01.12b
Repository Corticotropin (H.P. Acthar® Gel Injection)
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08.01.13d
Brentuximab Vedotin (Adcetris®)
08.01.13d
Attachment A (ICD CODES AND NARRATIVES) to 08.01.13d Brentuximab Vedotin (Adcetris®)
08.01.14e
Radium Ra 223 dichloride (Xofigo®) Injection (AmeriHealth Administrators)
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08.01.15d
Golimumab (Simponi Aria®) Intravenous (IV) Injection
08.01.15d
Attachment A (Medically Necessary ICD-10 Codes) to 08.01.15d Golimumab (Simponi Aria®) Intravenous (IV) Injection
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08.01.18e
Vedolizumab (Entyvio®)
08.01.18e
Attachment A (ICD-10 CODES AND NARRATIVES) to 08.01.18e Vedolizumab (Entyvio®)
08.01.19f
Siltuximab (Sylvant®)
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08.01.20j
Programmed Death Receptor-1 (PD-1) Antagonists (e.g., Keytruda®, Opdivo®) and Programmed Death-Ligand 1 (PD-L1) Antagonists (e.g., Tecentriq®, Bavencio®, Imfinzi™)
08.01.20j
Attachment A (ICD-10 Codes and Narratives) to 08.01.20j Programmed Death Receptor-1 (PD-1) Antagonists (e.g., Keytruda®, Opdivo®) and Programmed Death-Ligand 1 (PD-L1) Antagonists (e.g., Tecentriq®, Bavencio®, Imfinzi™)
08.01.21c
Blinatumomab (Blincyto®)
08.01.22d
Alemtuzumab (Lemtrada®)
08.01.23f
Interleukin-5 (IL-5) Antagonist (e.g., Cinqair®, Nucala®) and IL-5 Receptor Antagonist (e.g., Fasenra®)
08.01.24
Deoxycholic Acid (Kybella™)
08.01.25d
Ramucirumab (Cyramza®)
08.01.26b
Enzyme Replacement Therapy for Adenosine Deaminase Severe Combined Immune Deficiency (e.g., pegademase bovine [Adagen®], elapegademase-lvlr [Revcovi™])
08.01.28c
Sebelipase alfa (Kanuma®)
08.01.29e
Daratumumab (Darzalex™)
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08.01.32b
Pegfilgrastim (Neulasta®) and Related Biosimilars
08.01.32b
Attachment A (EXAMPLES OF DISEASE SETTINGS AND CHEMOTHERAPY REGIMENS WITH A HIGH (>20%) OR INTERMEDIATE (10-20%) RISK FOR FEBRILE NEUTROPENIA) to 08.01.32b Pegfilgrastim (Neulasta®) and Related Biosimilars
08.01.33b
Gonadotropin-Releasing Hormone Agonist (Eligard®, Lupron Depot®)
08.01.35b
Asparaginase Erwinia Chrysanthemi (Erwinaze®)
08.01.36d
Nusinersen (Spinraza®)
08.01.37a
Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Naltrexone Implants, Probuphine Implant, Sublocade Injection, Vivitrol Injection)
08.01.38c
Ocrelizumab (Ocrevus®)
08.01.39c
Cerliponase alfa (Brineura®)
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08.01.40b
Lanreotide (Somatuline® Depot)
08.01.40b
Attachment A (ICD-10 CODES AND NARRATIVES) to 08.01.40b Lanreotide (Somatuline® Depot)
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08.01.41c
Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
08.01.41c
Attachment A (Risk of Emesis Without Prophylaxis: Intravenous and Oral Antineoplastic Agents) to 08.01.41c Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
08.01.42a
Edaravone (Radicava™)
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08.01.43e
Chimeric Antigen Receptor (CAR) Therapy
08.01.43e
Attachment A (ICD-10 CODES AND NARRATIVES) to 08.01.43e Chimeric Antigen Receptor (CAR) Therapy
08.01.44c
Voretigene Neparvovec-rzyl (Luxturna™)
08.01.46a
Ibalizumab-uiyk (Trogarzo™)
08.01.47a
Triamcinolone Acetonide Extended-Release Injectable (Zilretta™)
08.01.48b
Tildrakizumab-asmn (Ilumya™)
08.01.49a
Burosumab-twza (Crysvita®)
08.01.50b
Patisiran (Onpattro™)
08.01.51
Canakinumab (Ilaris®)
08.01.52b
Mogamulizumab-kpkc (Poteligeo®)
08.01.53b
Moxetumomab Pasudotox-tdfk (Lumoxiti™)
08.01.54b
Emapalumab-lzsg (Gamifant®)
08.01.55b
Tagraxofusp-erzs (Elzonris™)
08.01.57
Lutathera® (Lutetium Lu 177 Dotatate) (AmeriHealth Administrators)
08.01.59b
Polatuzumab Vedotin-Piiq (Polivy™)
09.00.02e
Electron Beam Computed Tomography (EBCT) for Screening Evaluations
09.00.04k
Bone Mineral Density (BMD) Testing
09.00.10z
Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (AmeriHealth Administrators)
09.00.11d
Contrast Agents Used in Conjunction with Echocardiography
09.00.13c
High Osmolar Contrast Agents
09.00.17o
Intensity-Modulated Radiation Therapy (IMRT) (AmeriHealth Administrators)
09.00.24c
Full-Body Computerized Tomography (CT) Scan Screening
09.00.31d
Low Osmolar Contrast Agents
09.00.32u
Reimbursement for Radiopharmaceutical Agents for Professional Providers
09.00.36l
First-Trimester Prenatal Screening for Fetal Aneuploidy Using Fetal Ultrasound Markers
09.00.40d
Screening for Vertebral Fracture with Dual-Energy X-ray Absorptiometry (DEXA/DXA)
09.00.42c
Computer-Aided Detection (CAD) System for Use with Chest Radiographs
09.00.45h
Magnetic Resonance Imaging (MRI) Contrast Agents
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09.00.46aa
High-Technology Radiology Services (AmeriHealth)
09.00.46aa
Attachment A (High-Technology Radiology Services Code List ) to 09.00.46aa High-Technology Radiology Services (AmeriHealth)
09.00.48g
Radioembolization for Primary and Metastatic Tumors of the Liver (AmeriHealth Administrators)
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09.00.49l
Proton Beam Radiation Therapy
09.00.49l
Attachment A (ICD-10 Diagnosis Codes) to 09.00.49l Proton Beam Radiation Therapy
09.00.51a
Positron Emission Mammography (PEM)
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09.00.56j
Radiation Therapy Services (AmeriHealth)
09.00.56j
Attachment A (CPT, HCPCS and Revenue codes) to 09.00.56j Radiation Therapy Services (AmeriHealth)
10.00.02c
Day Rehabilitation
10.00.03
Pediatric Intensive Day Feeding Program
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10.01.01n
Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
10.01.01n
Attachment A (ICD-10 Codes) to 10.01.01n Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
10.02.02j
Chiropractic Spinal and Extraspinal Manipulation Therapy
10.03.01l
Physical Medicine, Rehabilitation, and Habilitation Services
10.04.01l
Pulmonary Rehabilitation
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10.06.01l
Speech Therapy
10.06.01l
Attachment A (NJ mandate for biologically-based mental illness (BBMI) regulations in regard to outpatient speech therapy) to 10.06.01l Speech Therapy
11.00.02f
Treatment of Medical and Surgical Complications
11.00.03j
Fetal Surgery
11.00.06k
Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring
11.00.09f
Solid Organ Transplantation and Procurement Cost of Organs and Tissues
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11.00.10w
Multiple Surgery Payment Reduction
11.00.10w
Attachment A1 (Current Procedural Terminology (CPT) Codes To Which Multiple Surgery Payment Reduction Applies) to 11.00.10w Multiple Surgery Payment Reduction
11.00.10w
Attachment A2 (Current Procedural Terminology (CPT) Codes To Which Multiple Surgery Payment Reduction Applies) to 11.00.10w Multiple Surgery Payment Reduction
11.00.10w
Attachment B (Healthcare Common Procedure Coding System (HCPCS) Codes To Which Multiple Surgery Payment Reduction Applies) to 11.00.10w Multiple Surgery Payment Reduction
11.00.13g
Hyperthermic Intraperitoneal Chemotherapy for Select Intra-abdominal and Pelvic Malignancies
11.00.14f
Treatment of Twin-Twin Transfusion Syndrome (TTTS)
11.00.16g
Radiofrequency Ablation and Cryosurgical Ablation of Lung Tumors
11.00.18a
Use of a Robotic-Assisted Surgical System
11.01.01j
Otoplasty or Non-Surgical External Ear Molding
11.01.02o
Cochlear Implant
11.01.06e
Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
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11.01.07e
Cataract Surgery
11.01.07e
Attachment A (ICD 10 codes for policy 11.01.07d, Cataract Surgery) to 11.01.07e Cataract Surgery
11.02.01s
Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence
11.02.06m
Catheter Ablation of Cardiac Arrhythmias
11.02.10n
Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms
11.02.11g
Transcatheter Closure of Cardiac Septal Defects
11.02.12i
Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery
11.02.16r
Ventricular Assist Devices (VADs)
11.02.17f
Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions
11.02.19f
Total Artificial Hearts (TAHs)
11.02.25g
Transcatheter Cardiac Valve Procedures
11.02.26b
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
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11.02.27b
Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound (AmeriHealth)
11.02.27b
Attachment A (Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound Code List) to 11.02.27b Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound (AmeriHealth)
11.03.01e
Repair of Cleft Lip, Cleft Nose, and/or Cleft Palate
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11.03.02s
Bariatric Surgery
11.03.02s
Attachment A (Body Mass Index (BMI) Charts) to 11.03.02s Bariatric Surgery
11.03.02s
Attachment B (Tanner Staging System Criteria for Adolescents) to 11.03.02s Bariatric Surgery
11.03.02s
Attachment C (ICD-10-CM codes) to 11.03.02s Bariatric Surgery
11.03.05d
Frenectomy, Frenotomy, or Frenoplasty for Ankyloglossia (Tongue-Tie)
11.03.11n
Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD)
11.03.12s
Colorectal Cancer Screening
11.03.15h
Gastric Electrical Stimulation (Enterra™), Gastric Pacing
11.04.01d
Islet Cell Transplantation
11.05.01f
Refractive Keratoplasty
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11.05.02i
Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
11.05.02i
Attachment A (ICD-10 Codes) to 11.05.02i Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
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11.05.07d
Surgical Correction of Strabismus
11.05.07d
Attachment A (ICD-10 Diagnosis Code Numbers and Narratives) to 11.05.07d Surgical Correction of Strabismus
11.05.08d
Photocoagulation of Macular Drusen
11.05.10b
Reimbursement for a Presbyopia- or Astigmatism-Correcting Intraocular Lens
11.05.11c
Implantation of Intrastromal Corneal Ring Segments (ICRS)
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11.05.16h
Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
11.05.16h
Attachment A (ICD-10 codes ) to 11.05.16h Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
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11.06.02i
Elective Abortion
11.06.02i
Attachment A (Diagnosis codes ICD-10) to 11.06.02i Elective Abortion
11.06.04k
Uterine Artery Embolization
11.06.05f
Endometrial Ablation
11.06.06e
Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Ablation
11.06.07d
Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome
11.06.09d
Labiaplasty
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11.07.01t
Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant)
11.07.01t
Attachment A (References for the hematopoietic stem cell transplantation policy.) to 11.07.01t Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant)
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11.07.02j
Sentinel Lymph Node Biopsy and Mapping
11.07.02j
Attachment A (ICD-10 Codes) to 11.07.02j Sentinel Lymph Node Biopsy and Mapping
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11.08.01g
Hair Transplants and Cranial Prostheses (Wigs)
11.08.01g
Attachment A (ICD-10-CM codes) to 11.08.01g Hair Transplants and Cranial Prostheses (Wigs)
11.08.02h
Reduction Mammoplasty
11.08.03j
Lipectomy and Liposuction
11.08.04h
Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)
11.08.05g
Application and Removal of Tattoos
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11.08.06j
Panniculectomy, Abdominoplasty, and Other Excisions of Redundant Skin
11.08.06j
Attachment A (ICD-10 codes) to 11.08.06j Panniculectomy, Abdominoplasty, and Other Excisions of Redundant Skin
11.08.08g
Chemical Peels
11.08.12h
Surgery for Gynecomastia
11.08.13g
Rhytidectomy and/or Cervicoplasty With or Without Liposuction and/or Platysmaplasty
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11.08.14j
Removal of Breast Implants
11.08.14j
Attachment A (ICD-10-CM codes) to 11.08.14j Removal of Breast Implants
11.08.15x
Reconstructive Breast Surgery
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11.08.17i
Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.08.17i
Attachment A (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (A30.0 -E10.21)) to 11.08.17i Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.08.17i
Attachment B (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E10.22 - E13.3512), Continued) to 11.08.17i Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.08.17i
Attachment C (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E13.3513 - I87.093), Continued) to 11.08.17i Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.08.17i
Attachment D (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (I87.099 - S86.891S), Continued) to 11.08.17i Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.08.17i
Attachment E (ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (S86.892A - Z79.01), Continued) to 11.08.17i Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.08.19o
Prophylactic Mastectomy, Oophorectomy/Salpingo-Oophorectomy, and Hysterectomy
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11.08.20u
Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds
11.08.20u
Attachment A (Skin substitutes and their approved indications.) to 11.08.20u Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds
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11.08.23j
Mohs' Micrographic Surgery
11.08.23j
Attachment A (ICD 10 Codes) to 11.08.23j Mohs' Micrographic Surgery
11.08.25m
Scar Revision
11.08.29e
Procedures for the Treatment of Acne
11.09.02h
Treatment of Gender Dysphoria
11.11.01i
Evaluation and Treatment of Erectile Dysfunction (ED)
11.11.03d
Cryosurgical Ablation of the Prostate Gland
11.11.06h
Saturation Needle Biopsy of the Prostate
11.14.01g
Mentoplasty or Genioplasty
11.14.02o
Trigger Point Injections
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11.14.03f
Meniscal Allograft Transplantation
11.14.03f
Attachment A (ICD-10-CM codes) to 11.14.03f Meniscal Allograft Transplantation
11.14.06i
Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions
11.14.07u
Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis
11.14.08d
Orthognathic Surgery
11.14.09g
Osteochondral Autograft Transplantation (OAT) Procedure
11.14.10q
Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
11.14.12e
Osteochondral Allograft Transplantation
11.14.13g
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions
11.14.14e
Percutaneous Intradiscal Annuloplasty (IDET/PIRFT)
11.14.17d
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures
11.14.19n
Artificial Intervertebral Disc Insertion
11.14.21h
Microprocessor-Controlled Prostheses for Lower-Extremity Amputees
11.14.22d
Spinal Decompression with Interspinous and Interlaminar Devices
11.14.23c
Surgical Treatment of Femoroacetabular Impingement
11.14.24b
Manipulation Under Anesthesia
11.14.26a
Surgical Treatments of Athletic Pubalgia
11.14.27c
Spinal Fusion
11.14.28b
Spinal Laminectomy
11.14.29e
Spinal Discectomy
11.14.30
Composite Tissue Allotransplantation of the Hand(s) and Face
11.15.01v
Spinal Cord and Dorsal Root Ganglion Stimulation
11.15.03k
Implantable Infusion Pumps
11.15.09m
Denervation of the Spinal Nerves for Chronic Pain
11.15.13d
Lysis of Epidural Adhesions
11.15.15g
Percutaneous Discectomy
11.15.16n
Vagus Nerve Stimulation (VNS)
11.15.19e
Nucleoplasty
11.15.20o
Deep Brain Stimulation (DBS)
11.15.22d
Percutaneous Image-Guided Lumbar Decompression (PILD) for Spinal Stenosis
11.15.23h
Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
11.15.24a
Migraine Deactivation Surgery
11.16.01h
Septoplasty, Rhinoplasty, and Septorhinoplasty
11.16.06j
Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
11.16.07b
Bronchial Thermoplasty
11.16.08c
Implantable Steroid-Eluting Sinus Stents
11.17.04s
Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence
11.17.06n
Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
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12.00.01f
Acupuncture (AmeriHealth)
12.00.01f
Attachment A (ICD-10 CM Codes Eligible to be Reported for Acupuncture) to 12.00.01f Acupuncture (AmeriHealth)
12.00.03g
Complementary and Integrative Health Services
Hide details for
12.01.01av
Experimental/Investigational Services
12.01.01av
Attachment A (Experimental/Investigational Services Represented by a Specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code.) to 12.01.01av Experimental/Investigational Services
12.01.01av
Attachment B (Experimental/Investigational Services without a Specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code.) to 12.01.01av Experimental/Investigational Services
12.01.01av
Attachment C (Experimental/Investigational services with a specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code, that are reported for other services.) to 12.01.01av Experimental/Investigational Services
12.01.02
Medical Necessity
12.01.03
Cosmetic Procedures
12.04.02i
Ground Ambulance Services (Emergency and Nonemergency) (AmeriHealth)
12.04.03c
Air Ambulance Services
12.04.04a
Acute Care Facility Inpatient Transfers
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12.05.01i
Outpatient Diabetes Education and Self-Management Training
12.05.01i
Attachment A (ICD-10 CM Codes Eligible to be Reported for Outpatient Diabetes Education and Self-Management Training (E08.00- E10.3491)) to 12.05.01i Outpatient Diabetes Education and Self-Management Training
12.05.01i
Attachment B (ICD-10 CM Codes Eligible to be Reported for Outpatient Diabetes Education and Self-Management Training (E10.3492- E13.37X2), Continued) to 12.05.01i Outpatient Diabetes Education and Self-Management Training
12.05.01i
Attachment C (ICD-10 CM Codes Eligible to be Reported for Outpatient Diabetes Education and Self-Management Training (E13.37X3- P70.2), Continued) to 12.05.01i Outpatient Diabetes Education and Self-Management Training