|  | | 4316 | Abatacept(Orencia®)forInjectionforIntravenousUse08.00.62n | Pharmacy (08) | 08.00.62n | 08.00.62 | b59cae2d-57f8-4cdb-b9af-b182573fa7a3 | Abatacept (Orencia®) for Injection for Intravenous Use | Abatacept (Orencia®) for Injection for Intravenous Use | {"4317": {"Id":4317,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":6281,"PolicyAttachmentPageName":"23995e7c-07d0-4f56-b252-d44d8d3ae0c0"},} |
| | | 4562 | Acupuncture(AmeriHealth)12.00.01g | Miscellaneous (12) | 12.00.01g | 12.00.01 | db140092-e4a2-4209-b40c-6aa36c212743 | Acupuncture (AmeriHealth) | Acupuncture (AmeriHealth) | {"4563": {"Id":4563,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Acupuncture","MPPolicyAttachmentInternalSourceId":6539,"PolicyAttachmentPageName":"950b5367-3996-47a3-bfb5-883cefbfa427"},} |
| | | 4767 | AcuteCareFacilityInpatientTransfers12.04.04b | Miscellaneous (12) | 12.04.04b | 12.04.04 | e30315a0-0657-4f6d-888a-2fa4b0aa46fd | Acute Care Facility Inpatient Transfers | Acute Care Facility Inpatient Transfers | |
| | | 4949 | Ado-TrastuzumabEmtansine(Kadcyla®)08.01.11h | Pharmacy (08) | 08.01.11h | 08.01.11 | 38d8a45c-488c-48e3-988a-04ec71fc747f | Ado-Trastuzumab Emtansine (Kadcyla®) | Ado-Trastuzumab Emtansine (Kadcyla®) | {"4950": {"Id":4950,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes and Narratives","MPPolicyAttachmentInternalSourceId":6792,"PolicyAttachmentPageName":"22019f47-888f-4ab7-b554-9fe0c2c91809"},} |
| | | 4427 | Aducanumab(Aduhelm)forAlzheimerDisease08.01.93 | Pharmacy (08) | 08.01.93 | 08.01.93 | d9e41786-d397-4077-99ef-24e9b3106343 | Aducanumab (Aduhelm) for Alzheimer Disease | Aducanumab (Aduhelm) for Alzheimer Disease | |
| | | 4174 | Agalsidasebeta(Fabrazyme®)08.00.69c | Pharmacy (08) | 08.00.69c | 08.00.69 | 6b63a7e1-4463-4e1e-b63d-9246fce9041a | Agalsidase beta (Fabrazyme®) | Agalsidase beta (Fabrazyme®) | |
| | | 5043 | AirAmbulanceServices12.04.03c | Miscellaneous (12) | 12.04.03c | 12.04.03 | 14f5591d-8f79-4b62-a760-2e53f042f272 | Air Ambulance Services | Air Ambulance Services | |
| | | 4304 | Alemtuzumab(Lemtrada®)08.01.22d | Pharmacy (08) | 08.01.22d | 08.01.22 | 40672c4d-e4fc-4fb0-9cea-cfbd53b89f1c | Alemtuzumab (Lemtrada®) | Alemtuzumab (Lemtrada®) | |
| | | 4265 | Alglucosidasealfa(e.g.,Lumizyme®),Avalglucosidasealfa-ngpt(Nexviazyme®)08.00.72k | Pharmacy (08) | 08.00.72k | 08.00.72 | db78fe85-fc99-4a2e-abea-24e3940e2471 | Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® ) | Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® ) | |
| | | 4820 | AllergyImmunotherapy07.00.21j | Medicine (07) | 07.00.21j | 07.00.21 | a1de565a-4780-477e-8f16-1cbce906084c | Allergy Immunotherapy | Allergy Immunotherapy | |
| | | 4201 | AllogeneicProcessedThymusTissue-agdc(Rethymic®)08.01.88 | Pharmacy (08) | 08.01.88 | 08.01.88 | 3a1f86ae-9d7b-4d18-a99c-b44ed0f6cd73 | Allogeneic Processed Thymus Tissue-agdc (Rethymic®) | Allogeneic Processed Thymus Tissue-agdc (Rethymic®) | |
| | | 4490 | AlloMap™MolecularExpressionTestingforHeartTransplantRejection(AmeriHealthAdministrators)06.02.29d | Pathology and Laboratory (06) | 06.02.29d | 06.02.29 | ecd32c25-e4fc-44ae-b107-02cd1a65f035 | AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators) | AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators) | |
| | | 4305 | Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C®,AralastNP®,Glassia®,Zemaira®)08.00.91e | Pharmacy (08) | 08.00.91e | 08.00.91 | 610ebc32-c1f7-43c8-9899-232ac2a13716 | Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®) | Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®) | |
| | | 5049 | AlwaysBundledProcedureCodes00.01.52r | Administrative (00) | 00.01.52r | 00.01.52 | b4c1fd43-8110-4431-8ec1-5eb58bfa6786 | Always Bundled Procedure Codes | Always Bundled Procedure Codes | {"5050": {"Id":5050,"MPAttachmentLetter":"B","Title":"Procedures/Services Not Eligible for Separate Reimbursement","MPPolicyAttachmentInternalSourceId":7148,"PolicyAttachmentPageName":"16222f74-7a66-426c-bf28-9763c1e649a4"},"5051": {"Id":5051,"MPAttachmentLetter":"A","Title":"Always Bundled Procedures (Indicator B)","MPPolicyAttachmentInternalSourceId":7149,"PolicyAttachmentPageName":"80a66e18-60d9-41ab-ab4b-9c6c620224f4"},"5052": {"Id":5052,"MPAttachmentLetter":"C","Title":"Procedures/Services Not Eligible for Reimbursement","MPPolicyAttachmentInternalSourceId":7150,"PolicyAttachmentPageName":"6ce8129c-60f2-4a1e-8923-6e9e664192e0"},} |
| | | 4873 | AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)Devices07.02.09h | Medicine (07) | 07.02.09h | 07.02.09 | 48fdbbc0-05ed-4ff5-a173-261459ff7c09 | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | |
| | | 4980 | AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)Monitoring07.02.21k | Medicine (07) | 07.02.21k | 07.02.21 | 8bd51df3-472e-4025-9b4e-12c5110a60fa | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | |
| | | 4628 | AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagement01.00.12a | Anesthesia (01) | 01.00.12a | 01.00.12 | 7d51a925-318f-4d8e-a628-d7270db80137 | Anesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management | Anesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management | {"4629": {"Id":4629,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":6737,"PolicyAttachmentPageName":"3ef139f6-f99f-4cb9-8967-2d2a09aa3032"},} |
| | | 4307 | Anifrolumab-fnia(Saphnelo™)08.01.82b | Pharmacy (08) | 08.01.82b | 08.01.82 | cce61d28-3be6-4b9a-ac5f-58bb099d245c | Anifrolumab-fnia (Saphnelo™) | Anifrolumab-fnia (Saphnelo™) | |
| | | 3456 | Ankle-Foot/Knee-Ankle-FootOrthoses05.00.39r | DME (05) | 05.00.39r | 05.00.39 | ec509307-9989-4a80-b1f1-e5d5eae25831 | Ankle-Foot/Knee-Ankle-Foot Orthoses | Ankle-Foot/Knee-Ankle-Foot Orthoses | {"3457": {"Id":3457,"MPAttachmentLetter":"A","Title":"HCPCS Codes","MPPolicyAttachmentInternalSourceId":5437,"PolicyAttachmentPageName":"5d32ce1c-b867-42d3-b5ce-2492f31a60d6"},} |
| | | 2807 | ApheresisTherapy06.03.04n | Pathology and Laboratory (06) | 06.03.04n | 06.03.04 | b395fd09-303a-4b18-a74c-04bb56dc9226 | Apheresis Therapy | Apheresis Therapy | |
| | | 4254 | ApplicationandRemovalofTattoos11.08.05g | Surgery (11) | 11.08.05g | 11.08.05 | 8fad7e68-1f61-4469-8a09-0333356fb918 | Application and Removal of Tattoos | Application and Removal of Tattoos | |
| | | 5039 | AppliedBehaviorAnalysis(ABA)fortheTreatmentofAutismSpectrumDisorders(ASD)14.00.03 | Behavioral Health (14) | 14.00.03 | 14.00.03 | 5ab4e14d-6b67-4846-85eb-07d9a15c7819 | Applied Behavior Analysis (ABA) for the Treatment of Autism Spectrum Disorders (ASD) | Applied Behavior Analysis (ABA) for the Treatment of Autism Spectrum Disorders (ASD) | |
| | | 4993 | Aprepitant(Cinvanti™),FosaprepitantDimeglumine(Emend®),Granisetron(Sustol®),andRolapitant(Varubi®)08.01.41e | Pharmacy (08) | 08.01.41e | 08.01.41 | b59e539f-57fe-4c9e-97c1-f32cbacecfd4 | Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®) | Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®) | {"4994": {"Id":4994,"MPAttachmentLetter":"A","Title":"Risk of Emesis Without Prophylaxis: Intravenous and Oral Antineoplastic Agents","MPPolicyAttachmentInternalSourceId":7122,"PolicyAttachmentPageName":"3ba22a0e-77fb-40a0-b6ac-db0a5f7a1f4d"},} |
| | | 4998 | AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucoma11.05.16l | Surgery (11) | 11.05.16l | 11.05.16 | b55c31d5-eb8d-4517-bf3c-eeeb6c9b79a1 | Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | {"4999": {"Id":4999,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":7061,"PolicyAttachmentPageName":"fdf22af8-1f6d-44a3-bf8f-874a014f596a"},} |
| | | 4438 | ArtificialIntervertebralCervicalDiscInsertion(AmerihealthAdministrators)11.14.19p | Surgery (11) | 11.14.19p | 11.14.19 | 9140ddf8-1261-4329-91de-d8a3307362e0 | Artificial Intervertebral Cervical Disc Insertion (Amerihealth Administrators) | Artificial Intervertebral Cervical Disc Insertion (Amerihealth Administrators) | |
| | | 4989 | ArtificialIntervertebralLumbarDiscInsertion11.15.31b | Surgery (11) | 11.15.31b | 11.15.31 | afb41ec7-458d-467b-b4e7-e59d90e2de3d | Artificial Intervertebral Lumbar Disc Insertion | Artificial Intervertebral Lumbar Disc Insertion | |
| | | 4552 | AsparaginaseErwiniaChrysanthemi(Erwinaze®),asparaginaseerwiniachrysanthemi(recombinant)-rywn(Rylaze™)08.01.35f | Pharmacy (08) | 08.01.35f | 08.01.35 | 84cbb299-b398-41f9-8fca-e8636350d26e | Asparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze™) | Asparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze™) | |
| | | 4489 | AssaysofGeneticExpressioninTumorTissueforBreastCancerPrognosis(AmeriHealthAdministrators)06.02.27n | Pathology and Laboratory (06) | 06.02.27n | 06.02.27 | 409b7171-d1a6-4ae0-9438-21770a53e0fb | Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (AmeriHealth Administrators) | Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (AmeriHealth Administrators) | |
| | | 4861 | AssistedReproductiveTechnologyforInfertilityandOocyteCryopreservation07.10.06i | Medicine (07) | 07.10.06i | 07.10.06 | 1957f95b-a5e6-40c1-befd-604f31a47e21 | Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation | Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation | |
| | | 4114 | Atezolizumab(Tecentriq®)08.01.69b | Pharmacy (08) | 08.01.69b | 08.01.69 | 82b3e9e5-7ed1-47c0-813a-b54b0f5797a6 | Atezolizumab (Tecentriq®) | Atezolizumab (Tecentriq®) | {"4115": {"Id":4115,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":6121,"PolicyAttachmentPageName":"1cacd22d-4763-4dae-917c-500de8069d0c"},} |
| | | 4439 | AutologousChondrocyteImplantation(ACI)andOtherCell-basedTreatmentsofFocalArticularCartilageLesions(AmerihealthAdministrators)11.14.06j | Surgery (11) | 11.14.06j | 11.14.06 | cfa96a75-c968-44fb-9c95-1f89049557bc | Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions (Amerihealth Administrators) | Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions (Amerihealth Administrators) | |
| | | 4870 | AutomaticExternalCardioverterDefibrillators(WearableandNonwearable)05.00.29n | DME (05) | 05.00.29n | 05.00.29 | 3b574e00-b30e-4b42-87e3-f17689845506 | Automatic External Cardioverter Defibrillators (Wearable and Nonwearable) | Automatic External Cardioverter Defibrillators (Wearable and Nonwearable) | {"4871": {"Id":4871,"MPAttachmentLetter":"B","Title":"ICD-10 codes used to represent the Nonwearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":6577,"PolicyAttachmentPageName":"81b1b9fa-986a-4325-9c78-a3175d3f4dc5"},"4872": {"Id":4872,"MPAttachmentLetter":"A","Title":"ICD-10 Codes used to represent the Wearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":6578,"PolicyAttachmentPageName":"141a3a4c-2bc8-4fba-bc8d-d9a8b564a2ef"},} |
| | | 4638 | AutonomicNervousSystemTesting07.03.23f | Medicine (07) | 07.03.23f | 07.03.23 | 5280bd9c-a7a7-4c25-8f2c-ee1aa4539dd7 | Autonomic Nervous System Testing | Autonomic Nervous System Testing | |
| | | 4958 | Avelumab(Bavencio®)08.01.64b | Pharmacy (08) | 08.01.64b | 08.01.64 | f20a2a02-1ded-4005-9bf4-693e1c2fd092 | Avelumab (Bavencio®) | Avelumab (Bavencio®) | {"4959": {"Id":4959,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":7008,"PolicyAttachmentPageName":"f9d6f03c-2dca-4ee9-b5d8-afcceee6e029"},} |
| | | 4372 | BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitis11.16.06j | Surgery (11) | 11.16.06j | 11.16.06 | 926a095e-bacc-47d8-9382-4a5601a1aa8a | Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis | Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis | |
| | | 2824 | BariatricSurgery11.03.02t | Surgery (11) | 11.03.02t | 11.03.02 | deb6788b-9378-4634-bea1-f71971bb7026 | Bariatric Surgery | Bariatric Surgery | {"2825": {"Id":2825,"MPAttachmentLetter":"A","Title":"Body Mass Index (BMI) Charts","MPPolicyAttachmentInternalSourceId":4907,"PolicyAttachmentPageName":"1ae6209c-f0da-459c-adb3-cace9e40b535"},"2826": {"Id":2826,"MPAttachmentLetter":"B","Title":"Tanner Staging System Criteria for Adolescents","MPPolicyAttachmentInternalSourceId":4908,"PolicyAttachmentPageName":"3fc8cbfa-375e-4a3f-a769-c3bd36fe1065"},"2827": {"Id":2827,"MPAttachmentLetter":"C","Title":"ICD-10-CM codes","MPPolicyAttachmentInternalSourceId":4909,"PolicyAttachmentPageName":"778a747c-2dd7-41ec-a720-71eec3fa4351"},} |
| | | 4276 | Belantamabmafodotin-blmf(Blenrep)08.01.70b | Pharmacy (08) | 08.01.70b | 08.01.70 | 246806c0-46da-409c-b330-cdc5192c284a | Belantamab mafodotin-blmf (Blenrep) | Belantamab mafodotin-blmf (Blenrep) | |
| | | 4753 | Belimumab(Benlysta®)forIntravenousUse08.00.99e | Pharmacy (08) | 08.00.99e | 08.00.99 | e6effbe3-24af-4dcf-9ad1-6faf964ca378 | Belimumab (Benlysta®) for Intravenous Use | Belimumab (Benlysta®) for Intravenous Use | |
| | | 4970 | BetibeglogeneAutotemcel[Beti-Cel(ZYNTEGLO®)]08.01.89 | Pharmacy (08) | 08.01.89 | 08.01.89 | f4038900-116f-45a9-a1d0-49644aa0544d | Betibeglogene Autotemcel [Beti-Cel (ZYNTEGLO®)] | Betibeglogene Autotemcel [Beti-Cel (ZYNTEGLO®)] | |
| | | 5003 | Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUse08.00.66s | Pharmacy (08) | 08.00.66s | 08.00.66 | ac115993-2c1c-48ea-8c33-e953d1e8129a | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | {"5004": {"Id":5004,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":7070,"PolicyAttachmentPageName":"cef71558-23da-47a0-ba8a-9dbcfb729e8b"},} |
| | | 4031 | BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampus00.10.39o | Administrative (00) | 00.10.39o | 00.10.39 | 93563ead-a585-4c93-a945-499bd6f8709f | Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus | Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus | {"4032": {"Id":4032,"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","MPPolicyAttachmentInternalSourceId":6119,"PolicyAttachmentPageName":"7663b74d-b1a0-45bb-9e6a-d8c158edf943"},} |
| | | 3087 | BillingRequirementsforMultipleBirthsforProfessionalProviders00.10.38a | Administrative (00) | 00.10.38a | 00.10.38 | e862bc0b-0289-4661-bf0a-950e2efca6ee | Billing Requirements for Multiple Births for Professional Providers | Billing Requirements for Multiple Births for Professional Providers | {"3088": {"Id":3088,"MPAttachmentLetter":"A","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ROUTINE OBSTETRIC (GLOBALE MATERNITY/OBSTETRIC [OB]) CARE WAS PROVIDED","MPPolicyAttachmentInternalSourceId":5340,"PolicyAttachmentPageName":"ba5b6730-4f52-4c93-97c1-4ca8f4766879"},"3089": {"Id":3089,"MPAttachmentLetter":"B","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ANETEPARTUM CARE IS NOT PROVIDED","MPPolicyAttachmentInternalSourceId":5341,"PolicyAttachmentPageName":"494d41d3-1fd0-4df8-b729-ad76b6fc2723"},"3090": {"Id":3090,"MPAttachmentLetter":"C","Title":"CODING SCENARIOS FOR REPORTING HIGH-ORDER MULTIPLE (TRIPLETS, QUADRUPLETS, ETC) BIRTHS WHEN ROUTINE OBSTETRIC (GLOBAL MATERNITY/OBSTETRIC [OB]) CARE WAS PROVIDED","MPPolicyAttachmentInternalSourceId":5342,"PolicyAttachmentPageName":"1232f148-ec02-4366-a47a-8917edfa3d73"},"3091": {"Id":3091,"MPAttachmentLetter":"D","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF HIGH-ORDER MULTIPLES WHEN ANTEPARTUM CARE IS NOT PROVIDED","MPPolicyAttachmentInternalSourceId":5343,"PolicyAttachmentPageName":"dee47969-1193-42f8-9cc1-4dabfcc50995"},} |
| | | 4394 | BiofeedbackTherapy07.00.01j | Medicine (07) | 07.00.01j | 07.00.01 | 704d8479-8073-4f31-8bc7-6b30ae0e1a63 | Biofeedback Therapy | Biofeedback Therapy | |
| | | 4368 | BioimpedencefortheDetectionofLymphedema07.06.03b | Medicine (07) | 07.06.03b | 07.06.03 | 4f6901b4-8f19-4b3f-97f5-802d005c75cf | Bioimpedence for the Detection of Lymphedema | Bioimpedence for the Detection of Lymphedema | |
| | | 4845 | Blepharoplasty,RepairofBlepharoptosis,RepairofBrowPtosis,andCanthoplasty/Canthopexy11.05.02j | Surgery (11) | 11.05.02j | 11.05.02 | b491f109-dc4e-41fb-906a-5eb04fe2602d | Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy | Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy | {"4846": {"Id":4846,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":6997,"PolicyAttachmentPageName":"665d1d9d-23ab-4d5d-9822-e83db0e70d80"},} |
| | | 4375 | Blinatumomab(Blincyto®)08.01.21e | Pharmacy (08) | 08.01.21e | 08.01.21 | 01f91949-1097-4a9e-9302-81f23de23bff | Blinatumomab (Blincyto®) | Blinatumomab (Blincyto®) | |
| | | 5030 | Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAids11.01.06g | Surgery (11) | 11.01.06g | 11.01.06 | e1490bfd-d6ac-4b00-a8c1-314c46c78d8f | Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids | Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids | |
| | | 4981 | BoneMineralDensity(BMD)Testing09.00.04m | Radiology (09) | 09.00.04m | 09.00.04 | f7005cd1-2e6a-4135-bcfe-9b67820a0fab | Bone Mineral Density (BMD) Testing | Bone Mineral Density (BMD) Testing | |
| | | 5023 | Bortezomib(BortezomibforInjection,Velcade®)08.00.73o | Pharmacy (08) | 08.00.73o | 08.00.73 | ec8ad7b9-59e3-4bd1-b521-dc205fe47298 | Bortezomib (Bortezomib for Injection, Velcade®) | Bortezomib (Bortezomib for Injection, Velcade®) | {"5024": {"Id":5024,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":7118,"PolicyAttachmentPageName":"123cd11e-0384-4510-9e89-891f066beb77"},} |
| | | 4636 | BotulinumToxinAgents08.00.26z | Pharmacy (08) | 08.00.26z | 08.00.26 | 262b8af6-c42b-4bee-8d1d-5b377356ef16 | Botulinum Toxin Agents | Botulinum Toxin Agents | {"4637": {"Id":4637,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":6760,"PolicyAttachmentPageName":"313ddfb1-5ecb-4cbc-b75e-8f69a484a88d"},} |
| | | 4495 | BrachytherapyandAcceleratedWholeBreastIrradiationusingThree-DimensionalConformationRadiationTherapy09.00.10z | Radiology (09) | 09.00.10z | 09.00.10 | f581558f-daff-4a3d-8a3f-4a5256e1bf06 | Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy | Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy | |
| | | 5033 | BreastPumps05.00.76g | DME (05) | 05.00.76g | 05.00.76 | 7e4c86e0-e560-421c-8463-60b4239e18fa | Breast Pumps | Breast Pumps | |
| | | 4607 | BrentuximabVedotin(Adcetris®)08.01.13h | Pharmacy (08) | 08.01.13h | 08.01.13 | 2f4b8bc7-824b-4bd1-bffe-bc24075eb16a | Brentuximab Vedotin (Adcetris®) | Brentuximab Vedotin (Adcetris®) | {"4608": {"Id":4608,"MPAttachmentLetter":"A","Title":"ICD CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":6762,"PolicyAttachmentPageName":"4ef59e2f-b124-4e39-bc83-d921fc98d944"},} |
| | | 4141 | BronchialValves11.16.09 | Surgery (11) | 11.16.09 | 11.16.09 | 52cbba4a-1c34-44f4-852c-2aa2af748210 | Bronchial Valves | Bronchial Valves | |
| | | 4264 | Burosumab-twza(Crysvita®)08.01.49b | Pharmacy (08) | 08.01.49b | 08.01.49 | 7af88e8b-93a3-4f90-8d3c-0784954a941b | Burosumab-twza (Crysvita®) | Burosumab-twza (Crysvita®) | |
| | | 4128 | Canakinumab(Ilaris®)08.01.51a | Pharmacy (08) | 08.01.51a | 08.01.51 | 84e6f9ee-5c3e-4179-9c84-40caa2a7e7d6 | Canakinumab (Ilaris®) | Canakinumab (Ilaris®) | |
| | | 4619 | CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)Programs10.01.01o | Rehabilitation Services (10) | 10.01.01o | 10.01.01 | cabc1c75-7431-49cc-9530-91eb57207d0f | Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs | Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs | {"4620": {"Id":4620,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":6701,"PolicyAttachmentPageName":"494bab88-d0fd-4cf6-8e31-f39da209b9f6"},} |
| | | 4691 | CareManagementandCarePlanningServices00.01.59l | Administrative (00) | 00.01.59l | 00.01.59 | 4a13780b-3cf6-457e-9645-6bbee7fd3bc4 | Care Management and Care Planning Services | Care Management and Care Planning Services | |
| | | 4813 | Carfilzomib(Kyprolis®)08.01.05i | Pharmacy (08) | 08.01.05i | 08.01.05 | 154ae50d-be6c-4132-ac0e-cd0daae0016c | Carfilzomib (Kyprolis®) | Carfilzomib (Kyprolis®) | |
| | | 4360 | CastandSplintApplicationsandAssociatedSupplies00.10.15d | Administrative (00) | 00.10.15d | 00.10.15 | 3d5103bb-27d5-4963-bd34-f6ba67f1076b | Cast and Splint Applications and Associated Supplies | Cast and Splint Applications and Associated Supplies | {"4361": {"Id":4361,"MPAttachmentLetter":"A","Title":"Procedure Codes Related to Cast and Splint Applications and Associated Supplies","MPPolicyAttachmentInternalSourceId":6421,"PolicyAttachmentPageName":"4af8b16b-794b-4533-a048-5413712cbe65"},} |
| | | 4854 | CataractSurgery11.01.07f | Surgery (11) | 11.01.07f | 11.01.07 | 999dab46-d26f-4042-bdec-44679dace028 | Cataract Surgery | Cataract Surgery | {"4855": {"Id":4855,"MPAttachmentLetter":"A","Title":"ICD 10 codes for policy 11.01.07d, Cataract Surgery","MPPolicyAttachmentInternalSourceId":6668,"PolicyAttachmentPageName":"705428a5-5a31-40d0-a0d2-354e451b3896"},} |
| | | 4621 | CatheterAblationofCardiacArrhythmias11.02.06o | Surgery (11) | 11.02.06o | 11.02.06 | 8adec0f3-a1ab-492b-af21-07ab6d6aae6a | Catheter Ablation of Cardiac Arrhythmias | Catheter Ablation of Cardiac Arrhythmias | |
| | | 4956 | Cemiplimab-rwlc(Libtayo®)08.01.66b | Pharmacy (08) | 08.01.66b | 08.01.66 | 5376605a-e682-418c-82d3-0e7b9a0df081 | Cemiplimab-rwlc (Libtayo®) | Cemiplimab-rwlc (Libtayo®) | |
| | | 4266 | Cerliponasealfa(Brineura®)08.01.39c | Pharmacy (08) | 08.01.39c | 08.01.39 | e6a2d37b-275f-4667-80c4-f1aa67d76f95 | Cerliponase alfa (Brineura®) | Cerliponase alfa (Brineura®) | |
| | | 4180 | CervicalTractionDevicesforIn-homeUse05.00.61g | DME (05) | 05.00.61g | 05.00.61 | 19abc466-a082-44c4-b559-60ac37f1d500 | Cervical Traction Devices for In-home Use | Cervical Traction Devices for In-home Use | |
| | | 5019 | Cetuximab(Erbitux®)08.00.67n | Pharmacy (08) | 08.00.67n | 08.00.67 | 7a91e8d9-4bfe-4deb-978d-8f088449f615 | Cetuximab (Erbitux®) | Cetuximab (Erbitux®) | {"5020": {"Id":5020,"MPAttachmentLetter":"B","Title":"ICD-10 Codes for Cetuximab (Erbitux®)","MPPolicyAttachmentInternalSourceId":7025,"PolicyAttachmentPageName":"9d4dd3a8-871d-43d3-8ff6-7f310fde867d"},"5021": {"Id":5021,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":7026,"PolicyAttachmentPageName":"aaa3078f-4999-485c-8564-30acef316ee7"},} |
| | | 4602 | ChemicalPeels11.08.08h | Surgery (11) | 11.08.08h | 11.08.08 | db5a3ccb-3f8a-411e-b545-f3ba973de1c5 | Chemical Peels | Chemical Peels | |
| | | 4605 | ChimericAntigenReceptor(CAR)Therapy08.01.43k | Pharmacy (08) | 08.01.43k | 08.01.43 | 828baa5b-e049-4764-b88b-528d65afed34 | Chimeric Antigen Receptor (CAR) Therapy | Chimeric Antigen Receptor (CAR) Therapy | {"4606": {"Id":4606,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":6560,"PolicyAttachmentPageName":"c3da6cc6-10d3-42cd-afb6-fd746f9885a5"},} |
| | | 4819 | ChiropracticSpinalandExtraspinalManipulationTherapy10.02.02j | Rehabilitation Services (10) | 10.02.02j | 10.02.02 | 41b59432-3402-4af7-aced-f58e3d7ff391 | Chiropractic Spinal and Extraspinal Manipulation Therapy | Chiropractic Spinal and Extraspinal Manipulation Therapy | |
| | | 4803 | CoagulationFactors08.00.92ae | Pharmacy (08) | 08.00.92ae | 08.00.92 | 5f61fef5-37e8-456e-bf9c-5b59e89362c1 | Coagulation Factors | Coagulation Factors | |
| | | 5066 | Cobalamin(VitaminB12),FolicAcid,andHomocysteineTesting06.02.54c | Pathology and Laboratory (06) | 06.02.54c | 06.02.54 | 359a2377-9b04-4dee-a8be-027bdc97c9b8 | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | {"5067": {"Id":5067,"MPAttachmentLetter":"A","Title":"MEDICALLY NECESSARY ICD 10 CODES FOR COBALAMIN (VITAMIN B12) AND/OR FOLIC ACID TESTING (CPT CODES 82607, 82608, 82746, AND 82747)","MPPolicyAttachmentInternalSourceId":7156,"PolicyAttachmentPageName":"9555cfd8-5d27-439f-98b9-f8ac99996c49"},} |
| | | 3164 | CochlearImplant11.01.02p | Surgery (11) | 11.01.02p | 11.01.02 | e4d1c502-60ae-4c63-8021-a778a10a3c5d | Cochlear Implant | Cochlear Implant | |
| | | 4178 | Collagenaseclostridiumhistolyticum(Xiaflex®),collagenaseclostridiumhistolyticum-aaes(Qwo™)08.01.71 | Pharmacy (08) | 08.01.71 | 08.01.71 | 71f01bda-41b7-46f8-b05c-e931c2151821 | Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™) | Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™) | |
| | | 4879 | ColorectalCancerScreening11.03.12t | Surgery (11) | 11.03.12t | 11.03.12 | 0290a952-ce69-44dd-b858-8c2d138066db | Colorectal Cancer Screening | Colorectal Cancer Screening | |
| | | 4362 | ComplementaryandIntegrativeHealthServices12.00.03g | Miscellaneous (12) | 12.00.03g | 12.00.03 | 78256c85-c80a-49b2-a307-d5efd4b20b60 | Complementary and Integrative Health Services | Complementary and Integrative Health Services | |
| | | 4367 | CompleteDecongestiveTherapy(CDT)07.06.01b | Medicine (07) | 07.06.01b | 07.06.01 | 548dc3c9-5890-41ab-9876-91c5c8624a2a | Complete Decongestive Therapy (CDT) | Complete Decongestive Therapy (CDT) | |
| | | 4397 | CompositeTissueAllotransplantationoftheHand(s)andFace11.14.30 | Surgery (11) | 11.14.30 | 11.14.30 | a42ccacb-d5a0-4c70-a25e-f5bd64c12a9d | Composite Tissue Allotransplantation of the Hand(s) and Face | Composite Tissue Allotransplantation of the Hand(s) and Face | |
| | | 4391 | CompressionGarments05.00.37f | DME (05) | 05.00.37f | 05.00.37 | 5380975a-b823-4c68-a242-ddbeb70ce277 | Compression Garments | Compression Garments | |
| | | 4458 | Computer-AidedDetection(CAD)SystemforUsewithChestRadiographs09.00.42c | Radiology (09) | 09.00.42c | 09.00.42 | e456d809-ee47-437a-9b1d-5125ba6cc561 | Computer-Aided Detection (CAD) System for Use with Chest Radiographs | Computer-Aided Detection (CAD) System for Use with Chest Radiographs | |
| | | 4351 | Computer-assistedMusculoskeletalSurgicalNavigationalOrthopedicProcedure11.14.17e | Surgery (11) | 11.14.17e | 11.14.17 | 38daba5e-1856-49a3-aa83-ad18bb5ba2ce | Computer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure | Computer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure | |
| | | 4325 | ConsultationServices00.01.69a | Administrative (00) | 00.01.69a | 00.01.69 | 3186b005-9972-4b7a-9585-4e09e7c6e6dc | Consultation Services | Consultation Services | |
| | | 4282 | ContactLensesfortheTreatmentofPersistent(Corneal)EpithelialDefects07.13.11k | Medicine (07) | 07.13.11k | 07.13.11 | 1c569fa6-371f-4b4b-9200-c3ab329590bd | Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects | Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects | {"4283": {"Id":4283,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":6289,"PolicyAttachmentPageName":"9f12f63f-88f6-416e-8633-2dea34950404"},} |
| | | 3132 | ContrastAgentsUsedinConjunctionwithEchocardiography09.00.11e | Radiology (09) | 09.00.11e | 09.00.11 | 6559b183-cc4e-4272-9c94-1515a87d738a | Contrast Agents Used in Conjunction with Echocardiography | Contrast Agents Used in Conjunction with Echocardiography | |
| | | 4382 | CornealPachymetryUsingUltrasound07.13.07l | Medicine (07) | 07.13.07l | 07.13.07 | abc9baf4-9e1b-4c13-bb6f-f5f65d443558 | Corneal Pachymetry Using Ultrasound | Corneal Pachymetry Using Ultrasound | {"4383": {"Id":4383,"MPAttachmentLetter":"A","Title":"ICD-10-CM codes","MPPolicyAttachmentInternalSourceId":6351,"PolicyAttachmentPageName":"d6fb930e-4bdf-47c7-afb2-9a67e3a91d0b"},} |
| | | 4858 | CosmeticProcedures12.01.03a | Miscellaneous (12) | 12.01.03a | 12.01.03 | b9702be8-f4d4-41a6-bbe6-b60213ba8e7d | Cosmetic Procedures | Cosmetic Procedures | |
| | | 4968 | CoverageofAnticancerPrescriptionOralandInjectableDrugsandBiologicsandSupportiveAgents08.01.08k | Pharmacy (08) | 08.01.08k | 08.01.08 | 2b2115cd-247d-4564-9ceb-79dc1d741c9f | Coverage of Anticancer Prescription Oral and Injectable Drugs and Biologics and Supportive Agents | Coverage of Anticancer Prescription Oral and Injectable Drugs and Biologics and Supportive Agents | {} |
| | | 3720 | CoverageofMedicalDevices05.00.04e | DME (05) | 05.00.04e | 05.00.04 | 14669bc5-097a-4a2c-bbf0-82a2e0da5a62 | Coverage of Medical Devices | Coverage of Medical Devices | |
| | | 4764 | CranialElectrotherapyStimulation05.00.80c | DME (05) | 05.00.80c | 05.00.80 | 8a359129-cc17-465a-8d22-11ea6180520f | Cranial Electrotherapy Stimulation | Cranial Electrotherapy Stimulation | |
| | | 4130 | CranialRemoldingOrthoses(Helmets)05.00.25i | DME (05) | 05.00.25i | 05.00.25 | 50ef9336-43ce-4d9b-a4dc-3e43464b5847 | Cranial Remolding Orthoses (Helmets) | Cranial Remolding Orthoses (Helmets) | |
| | | 5034 | CriteriaforReimbursementofEmergencyRoomServices00.10.03k | Administrative (00) | 00.10.03k | 00.10.03 | cde76797-199e-4918-9e43-897124bfa2c4 | Criteria for Reimbursement of Emergency Room Services | Criteria for Reimbursement of Emergency Room Services | |
| | | 4112 | crizanlizumab-tmca(Adakveo®)08.00.04 | Pharmacy (08) | 08.00.04 | 08.00.04 | 06c04256-2595-4568-b588-ffe96ce41f54 | crizanlizumab-tmca (Adakveo®) | crizanlizumab-tmca (Adakveo®) | |
| | | 4370 | CryosurgicalAblationoftheProstateGland11.11.03d | Surgery (11) | 11.11.03d | 11.11.03 | f1cff10d-b7bc-40e7-b5db-a6fe5f3bf3f2 | Cryosurgical Ablation of the Prostate Gland | Cryosurgical Ablation of the Prostate Gland | |
| | | 4558 | Daratumumab(Darzalex®),Daratumumab,andHyaluronidase-fihj(DarzalexFaspro®)08.01.29j | Pharmacy (08) | 08.01.29j | 08.01.29 | bac83114-7a60-4245-84f3-bd19dc5948d3 | Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®) | Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®) | |
| | | 4579 | DayRehabilitation10.00.02c | Rehabilitation Services (10) | 10.00.02c | 10.00.02 | 4f48cc01-773e-4a32-8967-91fb9b6a67c8 | Day Rehabilitation | Day Rehabilitation | |
| | | 4461 | DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNails11.08.17k | Surgery (11) | 11.08.17k | 11.08.17 | bcecfc79-5868-4b61-a23c-84617b4e8ce0 | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | {"4462": {"Id":4462,"MPAttachmentLetter":"E","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (S86.892A - Z79.01), Continued","MPPolicyAttachmentInternalSourceId":6444,"PolicyAttachmentPageName":"631ca1da-1bab-4e79-b523-1f83d76a4b61"},"4463": {"Id":4463,"MPAttachmentLetter":"D","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (I87.099 - S86.891S), Continued","MPPolicyAttachmentInternalSourceId":6445,"PolicyAttachmentPageName":"b3dd08d0-e9bf-4a4b-9115-7e7650ecd00d"},"4464": {"Id":4464,"MPAttachmentLetter":"C","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E13.3513 - I87.093), Continued","MPPolicyAttachmentInternalSourceId":6446,"PolicyAttachmentPageName":"4941a0cb-9b2b-4bd0-ad5b-aab9f279c51a"},"4465": {"Id":4465,"MPAttachmentLetter":"B","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E10.22 - E13.3512), Continued","MPPolicyAttachmentInternalSourceId":6447,"PolicyAttachmentPageName":"05c6ef53-95e9-4a0e-a9d7-f0c48cb8bbff"},"4466": {"Id":4466,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (A30.0 -E10.21)","MPPolicyAttachmentInternalSourceId":6448,"PolicyAttachmentPageName":"cb12558c-d46d-4970-a93c-28a59a8eb702"},} |
| | | 4772 | DeepBrainStimulation(DBS)11.15.20q | Surgery (11) | 11.15.20q | 11.15.20 | 20127810-2b58-439b-9b5e-579d724dfb7e | Deep Brain Stimulation (DBS) | Deep Brain Stimulation (DBS) | |
| | | 4440 | DenervationoftheSpinalNervesforChronicPain(AmerihealthAdministrators)11.15.09p | Surgery (11) | 11.15.09p | 11.15.09 | c640021e-dceb-4c7f-8b99-bce3299e1a43 | Denervation of the Spinal Nerves for Chronic Pain (Amerihealth Administrators) | Denervation of the Spinal Nerves for Chronic Pain (Amerihealth Administrators) | |
| | | 4262 | Denosumab(Prolia®,Xgeva®),Romosozumab-aqqg(Evenity®)08.00.94p | Pharmacy (08) | 08.00.94p | 08.00.94 | a59431fc-4e4a-4555-bd20-86abeafad4c3 | Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®) | Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®) | {"4263": {"Id":4263,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes","MPPolicyAttachmentInternalSourceId":6188,"PolicyAttachmentPageName":"0aaab259-024d-41d0-8f45-e4c2db3936e2"},} |
| | | 5000 | DermabrasionforRhinophyma,Septoplasty,Rhinoplasty,andSeptorhinoplasty11.16.01j | Surgery (11) | 11.16.01j | 11.16.01 | 2952bd67-7274-4c9d-adf0-b1cfb5131637 | Dermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and Septorhinoplasty | Dermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and Septorhinoplasty | |
| | | 5005 | DiagnosticRadiologyServicesIncludedinCapitation00.03.02ad | Administrative (00) | 00.03.02ad | 00.03.02 | 34cffd2e-5f5c-447d-95c6-4f2546aea666 | Diagnostic Radiology Services Included in Capitation | Diagnostic Radiology Services Included in Capitation | {"5006": {"Id":5006,"MPAttachmentLetter":"A","Title":"Diagnostic Radiology Procedure Codes Included in Capitation for Pennsylvania (PA) Health Maintenance Organization (HMO) Members","MPPolicyAttachmentInternalSourceId":7126,"PolicyAttachmentPageName":"41cccf03-47bb-4b9f-85ec-a3da4e01e20e"},} |
