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3594Abatacept(Orencia®)forInjectionforIntravenousUse08.00.62mPharmacy (08)08.00.62m08.00.62834bcbbf-eb2a-49a9-a954-5a4398bc345cAbatacept (Orencia®) for Injection for Intravenous UseAbatacept (Orencia®) for Injection for Intravenous Use
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3677Acupuncture(AmeriHealth)12.00.01gMiscellaneous (12)12.00.01g12.00.0169738b74-5838-4194-b77b-19438159b0a8Acupuncture (AmeriHealth)Acupuncture (AmeriHealth)
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3303AcuteCareFacilityInpatientTransfers12.04.04aMiscellaneous (12)12.04.04a12.04.04baf2b880-5954-469c-adfe-fcce98d1ed7eAcute Care Facility Inpatient TransfersAcute Care Facility Inpatient Transfers
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3886Ado-TrastuzumabEmtansine(Kadcyla®)08.01.11gPharmacy (08)08.01.11g08.01.114c4e349b-96ae-4b67-8665-e39cf4b971d0Ado-Trastuzumab Emtansine (Kadcyla®)Ado-Trastuzumab Emtansine (Kadcyla®)
{"3887": {"Id":3887,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes and Narratives","MPPolicyAttachmentInternalSourceId":5900,"PolicyAttachmentPageName":"0b37c703-c120-4191-8b91-c926cacc5277"},}
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4174Agalsidasebeta(Fabrazyme®)08.00.69cPharmacy (08)08.00.69c08.00.696b63a7e1-4463-4e1e-b63d-9246fce9041aAgalsidase beta (Fabrazyme®)Agalsidase beta (Fabrazyme®)
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3383AirAmbulanceServices12.04.03cMiscellaneous (12)12.04.03c12.04.03c7c932d9-9c5e-4b7d-845e-a6b2b3a53835Air Ambulance ServicesAir Ambulance Services
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3393Alemtuzumab(Lemtrada®)08.01.22dPharmacy (08)08.01.22d08.01.228d15f836-a0d2-4303-acef-f981a139b95cAlemtuzumab (Lemtrada®)Alemtuzumab (Lemtrada®)
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4265Alglucosidasealfa(e.g.,Lumizyme®),Avalglucosidasealfa-ngpt(Nexviazyme®)08.00.72kPharmacy (08)08.00.72k08.00.72db78fe85-fc99-4a2e-abea-24e3940e2471Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® )Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® )
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3199AllergyImmunotherapy07.00.21jMedicine (07)07.00.21j07.00.215bebba01-0b42-45ed-ae07-f386ffcff954Allergy ImmunotherapyAllergy Immunotherapy
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4201AllogeneicProcessedThymusTissue-agdc(Rethymic®)08.01.88Pharmacy (08)08.01.8808.01.883a1f86ae-9d7b-4d18-a99c-b44ed0f6cd73Allogeneic Processed Thymus Tissue-agdc (Rethymic®)Allogeneic Processed Thymus Tissue-agdc (Rethymic®)
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4198AlloMap™MolecularExpressionTestingforHeartTransplantRejection(AmeriHealthAdministrators)06.02.29dPathology and Laboratory (06)06.02.29d06.02.29ee3acd73-2ead-4f72-a15c-bddfc95ed3c7AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)
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3837Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C®,AralastNP®,Glassia®,Zemaira®)08.00.91ePharmacy (08)08.00.91e08.00.91bb43de82-f71f-4625-aee6-50336e39320fAlpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)
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4207AlwaysBundledProcedureCodes00.01.52pAdministrative (00)00.01.52p00.01.521c16cded-b770-4aa4-b763-1204e1dc69d5Always Bundled Procedure CodesAlways Bundled Procedure Codes
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3042AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)Devices07.02.09gMedicine (07)07.02.09g07.02.09c233d9c4-b48b-4763-a10b-7f4a06ccaad8Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) DevicesAmbulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
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3965AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)Monitoring07.02.21hMedicine (07)07.02.21h07.02.21566dc299-1d7d-47a0-b25f-8aa0a7df906fAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
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4185AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagement01.00.12Anesthesia (01)01.00.1201.00.12980512de-305e-46eb-a71f-bd4469be1e29Anesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint ManagementAnesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management
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4168Anifrolumab-fnia(Saphnelo™)08.01.82bPharmacy (08)08.01.82b08.01.82a5a442c8-1c78-4320-8da4-c92a3ab15c17Anifrolumab-fnia (Saphnelo™)Anifrolumab-fnia (Saphnelo™)
ec509307-9989-4a80-b1f1-e5d5eae25831.aspx
  
3456Ankle-Foot/Knee-Ankle-FootOrthoses05.00.39rDME (05)05.00.39r05.00.39ec509307-9989-4a80-b1f1-e5d5eae25831Ankle-Foot/Knee-Ankle-Foot OrthosesAnkle-Foot/Knee-Ankle-Foot Orthoses
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2807ApheresisTherapy06.03.04nPathology and Laboratory (06)06.03.04n06.03.04b395fd09-303a-4b18-a74c-04bb56dc9226Apheresis TherapyApheresis Therapy
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4254ApplicationandRemovalofTattoos11.08.05gSurgery (11)11.08.05g11.08.058fad7e68-1f61-4469-8a09-0333356fb918Application and Removal of TattoosApplication and Removal of Tattoos
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3520Aprepitant(Cinvanti™),FosaprepitantDimeglumine(Emend®),Granisetron(Sustol®),andRolapitant(Varubi®)08.01.41cPharmacy (08)08.01.41c08.01.4144db3f87-de94-4415-b8cf-8c8f3b56bd72Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
{"3521": {"Id":3521,"MPAttachmentLetter":"A","Title":"Risk of Emesis Without Prophylaxis: Intravenous and Oral Antineoplastic Agents","MPPolicyAttachmentInternalSourceId":5660,"PolicyAttachmentPageName":"41416d06-beb2-4742-9635-590fcea6183c"},}
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4005AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucoma11.05.16jSurgery (11)11.05.16j11.05.16cbae5cb1-bbc3-49be-a2a5-bdc81e91fd0cAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
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3758ArtificialIntervertebralCervicalDiscInsertion(AmerihealthAdministrators)11.14.19pSurgery (11)11.14.19p11.14.196ab357b1-349e-429e-bdfe-ec87420c4790Artificial Intervertebral Cervical Disc Insertion (Amerihealth Administrators)Artificial Intervertebral Cervical Disc Insertion (Amerihealth Administrators)
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3721ArtificialIntervertebralLumbarDiscInsertion11.15.31Surgery (11)11.15.3111.15.316e26e848-ee5d-4b42-8215-06fa20219584Artificial Intervertebral Lumbar Disc InsertionArtificial Intervertebral Lumbar Disc Insertion
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4020AsparaginaseErwiniaChrysanthemi(Erwinaze®),asparaginaseerwiniachrysanthemi(recombinant)-rywn(Rylaze™)08.01.35ePharmacy (08)08.01.35e08.01.357d35bbfc-2050-4e90-b6e3-dda8ec8beb57Asparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze™)Asparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze™)
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3978AssaysofGeneticExpressioninTumorTissueforBreastCancerPrognosis(AmeriHealthAdministrators)06.02.27mPathology and Laboratory (06)06.02.27m06.02.27cdfe1bab-26bc-4f44-a661-53aad9aaf13bAssays 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)
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3833AssistedReproductiveTechnologyforInfertilityandOocyteCryopreservation07.10.06iMedicine (07)07.10.06i07.10.0679b13a12-1743-4991-8438-7312e26bd409Assisted Reproductive Technology for Infertility and Oocyte CryopreservationAssisted Reproductive Technology for Infertility and Oocyte Cryopreservation
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4114Atezolizumab(Tecentriq®)08.01.69bPharmacy (08)08.01.69b08.01.6982b3e9e5-7ed1-47c0-813a-b54b0f5797a6Atezolizumab (Tecentriq®)Atezolizumab (Tecentriq®)
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3788AutologousChondrocyteImplantation(ACI)andOtherCell-basedTreatmentsofFocalArticularCartilageLesions(AmerihealthAdministrators)11.14.06jSurgery (11)11.14.06j11.14.06cf94fedd-11fa-4401-a582-f18f4627fdf8Autologous 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)
373f2389-2605-4718-bf5b-aeacb92edb77.aspx
  
3543AutomaticExternalCardioverterDefibrillators(WearableandNonwearable)05.00.29lDME (05)05.00.29l05.00.29373f2389-2605-4718-bf5b-aeacb92edb77Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
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3989AutonomicNervousSystemTesting07.03.23eMedicine (07)07.03.23e07.03.23dfd20b04-691f-46d9-8071-5b7cb3453f08Autonomic Nervous System TestingAutonomic Nervous System Testing
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4013Avelumab(Bavencio®)08.01.64aPharmacy (08)08.01.64a08.01.64434a7d30-72aa-4ef4-ab31-7dfb73669346Avelumab (Bavencio®)Avelumab (Bavencio®)
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3839BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitis11.16.06jSurgery (11)11.16.06j11.16.065c324c9e-38cd-4d6f-bdc0-7c5ac6a15b2eBalloon Catheter Dilation of Sinus Ostia for Treatment of Chronic RhinosinusitisBalloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
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2824BariatricSurgery11.03.02tSurgery (11)11.03.02t11.03.02deb6788b-9378-4634-bea1-f71971bb7026Bariatric SurgeryBariatric 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"},}
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4276Belantamabmafodotin-blmf(Blenrep)08.01.70bPharmacy (08)08.01.70b08.01.70246806c0-46da-409c-b330-cdc5192c284aBelantamab mafodotin-blmf (Blenrep)Belantamab mafodotin-blmf (Blenrep)
1473376c-e0a2-4e8b-ab41-a63e294f68a6.aspx
  
4103Belimumab(Benlysta®)forIntravenousUse08.00.99dPharmacy (08)08.00.99d08.00.991473376c-e0a2-4e8b-ab41-a63e294f68a6Belimumab (Benlysta®) for Intravenous UseBelimumab (Benlysta®) for Intravenous Use
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4106Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUse08.00.66qPharmacy (08)08.00.66q08.00.665062db65-0522-438f-ace1-ea10b9a34423Bevacizumab (Avastin®) and Related Biosimilars For Oncologic UseBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
{"4107": {"Id":4107,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":6016,"PolicyAttachmentPageName":"b4293c8f-a019-4fc9-9567-c1419c7fc8c0"},}
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4031BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampus00.10.39oAdministrative (00)00.10.39o00.10.3993563ead-a585-4c93-a945-499bd6f8709fBilling for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility CampusBilling for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
{"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"},}
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3087BillingRequirementsforMultipleBirthsforProfessionalProviders00.10.38aAdministrative (00)00.10.38a00.10.38e862bc0b-0289-4661-bf0a-950e2efca6eeBilling Requirements for Multiple Births for Professional ProvidersBilling 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"},}
e2f75216-10d2-49bf-80f5-c9cd836a8ff0.aspx
  
3724BiofeedbackTherapy07.00.01jMedicine (07)07.00.01j07.00.01e2f75216-10d2-49bf-80f5-c9cd836a8ff0Biofeedback TherapyBiofeedback Therapy
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3362BioimpedencefortheDetectionofLymphedema07.06.03bMedicine (07)07.06.03b07.06.03cd8cf796-b592-420d-9cab-8d2f79ac5dd4Bioimpedence for the Detection of LymphedemaBioimpedence for the Detection of Lymphedema
ad5e9419-4c7a-4e80-a765-be53cf4cd729.aspx
  
3824Blepharoplasty,RepairofBlepharoptosis,RepairofBrowPtosis,andCanthoplasty/Canthopexy11.05.02jSurgery (11)11.05.02j11.05.02ad5e9419-4c7a-4e80-a765-be53cf4cd729Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/CanthopexyBlepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
{"3825": {"Id":3825,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5915,"PolicyAttachmentPageName":"b45f6745-e809-4139-af36-cf3eec5e9add"},}
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3329Blinatumomab(Blincyto®)08.01.21dPharmacy (08)08.01.21d08.01.216e7ed1b5-34ce-4ae4-b8dc-de98c39b1693Blinatumomab (Blincyto®)Blinatumomab (Blincyto®)
a04154ab-caaf-4033-ab58-95e6f7fcee3b.aspx
  
4041Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAids11.01.06fSurgery (11)11.01.06f11.01.06a04154ab-caaf-4033-ab58-95e6f7fcee3bBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing AidsBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
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3967BoneMineralDensity(BMD)Testing09.00.04lRadiology (09)09.00.04l09.00.041424659b-6e13-4b6d-9b0d-0c00f2437685Bone Mineral Density (BMD) TestingBone Mineral Density (BMD) Testing
1c1bf17a-c01a-4fdc-9e69-0c07a8e32ef7.aspx
  
4188Bortezomib(BortezomibforInjection,Velcade®)08.00.73nPharmacy (08)08.00.73n08.00.731c1bf17a-c01a-4fdc-9e69-0c07a8e32ef7Bortezomib (Bortezomib for Injection, Velcade®)Bortezomib (Bortezomib for Injection, Velcade®)
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4255BotulinumToxinAgents08.00.26yPharmacy (08)08.00.26y08.00.26c0537d15-4f42-47e4-9dbd-2d97caeb0ee7Botulinum Toxin AgentsBotulinum Toxin Agents
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3078BrachytherapyandAcceleratedWholeBreastIrradiationusingThree-DimensionalConformationRadiationTherapy09.00.10zRadiology (09)09.00.10z09.00.1058a9dc62-6d10-446e-83de-88737485a3d1Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation TherapyBrachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy
9be7e1b3-e90d-463a-8e7f-9b602aea3dad.aspx
  
3903BreastPumps05.00.76eDME (05)05.00.76e05.00.769be7e1b3-e90d-463a-8e7f-9b602aea3dadBreast PumpsBreast Pumps
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3602BrentuximabVedotin(Adcetris®)08.01.13fPharmacy (08)08.01.13f08.01.13b1114295-dcd2-4db2-9f0b-05fb8b724540Brentuximab Vedotin (Adcetris®)Brentuximab Vedotin (Adcetris®)
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4141BronchialValves11.16.09Surgery (11)11.16.0911.16.0952cbba4a-1c34-44f4-852c-2aa2af748210Bronchial ValvesBronchial Valves
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4264Burosumab-twza(Crysvita®)08.01.49bPharmacy (08)08.01.49b08.01.497af88e8b-93a3-4f90-8d3c-0784954a941bBurosumab-twza (Crysvita®)Burosumab-twza (Crysvita®)
84e6f9ee-5c3e-4179-9c84-40caa2a7e7d6.aspx
  
4128Canakinumab(Ilaris®)08.01.51aPharmacy (08)08.01.51a08.01.5184e6f9ee-5c3e-4179-9c84-40caa2a7e7d6Canakinumab (Ilaris®)Canakinumab (Ilaris®)
51849fc3-b6b2-4b18-9bb5-8d8b12e525c3.aspx
  
3727CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)Programs10.01.01nRehabilitation Services (10)10.01.01n10.01.0151849fc3-b6b2-4b18-9bb5-8d8b12e525c3Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) ProgramsCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
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4152CareManagementandCarePlanningServices00.01.59jAdministrative (00)00.01.59j00.01.59f2189574-3648-4c87-87b3-3cb4fd613f8aCare Management and Care Planning ServicesCare Management and Care Planning Services
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3885Carfilzomib(Kyprolis®)08.01.05hPharmacy (08)08.01.05h08.01.058000f759-7cf7-41f7-9f5c-9fec82cfe349Carfilzomib (Kyprolis®)Carfilzomib (Kyprolis®)
ead5d815-c736-402d-a236-12375fa27c39.aspx
  
2815CastandSplintApplicationsandAssociatedSupplies00.10.15dAdministrative (00)00.10.15d00.10.15ead5d815-c736-402d-a236-12375fa27c39Cast and Splint Applications and Associated SuppliesCast and Splint Applications and Associated Supplies
{"2816": {"Id":2816,"MPAttachmentLetter":"A","Title":"Procedure Codes Related to Cast and Splint Applications and Associated Supplies","MPPolicyAttachmentInternalSourceId":4979,"PolicyAttachmentPageName":"8e789d63-630d-4491-95de-91c11ca83242"},}
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3990CataractSurgery11.01.07fSurgery (11)11.01.07f11.01.070127f7e1-d5a9-4dff-a9de-d30cca593715Cataract SurgeryCataract Surgery
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3996CatheterAblationofCardiacArrhythmias11.02.06nSurgery (11)11.02.06n11.02.06c8fb9adf-c491-46e9-85b0-f15a282f509aCatheter Ablation of Cardiac ArrhythmiasCatheter Ablation of Cardiac Arrhythmias
5704d820-a99c-4ae5-beea-0a82cca6d121.aspx
  
4017Cemiplimab-rwlc(Libtayo®)08.01.66aPharmacy (08)08.01.66a08.01.665704d820-a99c-4ae5-beea-0a82cca6d121Cemiplimab-rwlc (Libtayo®)Cemiplimab-rwlc (Libtayo®)
e6a2d37b-275f-4667-80c4-f1aa67d76f95.aspx
  
4266Cerliponasealfa(Brineura®)08.01.39cPharmacy (08)08.01.39c08.01.39e6a2d37b-275f-4667-80c4-f1aa67d76f95Cerliponase alfa (Brineura®)Cerliponase alfa (Brineura®)
19abc466-a082-44c4-b559-60ac37f1d500.aspx
  
4180CervicalTractionDevicesforIn-homeUse05.00.61gDME (05)05.00.61g05.00.6119abc466-a082-44c4-b559-60ac37f1d500Cervical Traction Devices for In-home UseCervical Traction Devices for In-home Use
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3551Cetuximab(Erbitux®)08.00.67mPharmacy (08)08.00.67m08.00.6797676303-7d9b-4fac-b144-cbb4ef0f89d2Cetuximab (Erbitux®)Cetuximab (Erbitux®)
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3567ChemicalPeels11.08.08gSurgery (11)11.08.08g11.08.08a47d58ff-608b-44de-aa95-33eacd21c307Chemical PeelsChemical Peels
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3979ChimericAntigenReceptor(CAR)Therapy08.01.43jPharmacy (08)08.01.43j08.01.43f831705f-1372-45a4-a683-340250445ddbChimeric Antigen Receptor (CAR) TherapyChimeric Antigen Receptor (CAR) Therapy
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3311ChiropracticSpinalandExtraspinalManipulationTherapy10.02.02jRehabilitation Services (10)10.02.02j10.02.0279223218-5ff1-491f-aae1-eb232d8fa401Chiropractic Spinal and Extraspinal Manipulation TherapyChiropractic Spinal and Extraspinal Manipulation Therapy
1c1ff6fe-09b9-436b-bf31-352aed9cc2d9.aspx
  
3773CoagulationFactors08.00.92adPharmacy (08)08.00.92ad08.00.921c1ff6fe-09b9-436b-bf31-352aed9cc2d9Coagulation Factors Coagulation Factors
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3895Cobalamin(VitaminB12),FolicAcid,andHomocysteineTesting06.02.54bPathology and Laboratory (06)06.02.54b06.02.54b53dc01a-b63f-4cd6-95b7-a214349dff14Cobalamin (Vitamin B12), Folic Acid, and Homocysteine TestingCobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
{"3896": {"Id":3896,"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":6108,"PolicyAttachmentPageName":"ba460233-61a2-414c-90dd-c9876003b9d7"},}
e4d1c502-60ae-4c63-8021-a778a10a3c5d.aspx
  
3164CochlearImplant11.01.02pSurgery (11)11.01.02p11.01.02e4d1c502-60ae-4c63-8021-a778a10a3c5dCochlear ImplantCochlear Implant
71f01bda-41b7-46f8-b05c-e931c2151821.aspx
  
4178Collagenaseclostridiumhistolyticum(Xiaflex®),collagenaseclostridiumhistolyticum-aaes(Qwo™)08.01.71Pharmacy (08)08.01.7108.01.7171f01bda-41b7-46f8-b05c-e931c2151821Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™)Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™)
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3897ColorectalCancerScreening11.03.12tSurgery (11)11.03.12t11.03.1221915e7a-f45a-4006-aab9-6b31af07abe7Colorectal Cancer ScreeningColorectal Cancer Screening
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1917Complementary and Integrative Health ServicesMiscellaneous (12)12.00.03g12.00.03B55889244594F1F085258574005DA579Complementary and Integrative Health ServicesComplementary and Integrative Health Services
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3371CompleteDecongestiveTherapy(CDT)07.06.01bMedicine (07)07.06.01b07.06.01335f806f-5741-4098-9952-55b12dc1e476Complete Decongestive Therapy (CDT)Complete Decongestive Therapy (CDT)
c4cb29d5-a6d2-451f-9cb0-66bc9d495580.aspx
  
3239CompositeTissueAllotransplantationoftheHand(s)andFace11.14.30Surgery (11)11.14.3011.14.30c4cb29d5-a6d2-451f-9cb0-66bc9d495580Composite Tissue Allotransplantation of the Hand(s) and FaceComposite Tissue Allotransplantation of the Hand(s) and Face
d7412bfb-d233-41cb-abab-b9e378c4702b.aspx
  
3237CompressionGarments05.00.37fDME (05)05.00.37f05.00.37d7412bfb-d233-41cb-abab-b9e378c4702bCompression GarmentsCompression Garments
742c5690-7789-4c49-a3c4-f7fd8d3f4b9b.aspx
  
3575Computer-AidedDetection(CAD)SystemforUsewithChestRadiographs09.00.42cRadiology (09)09.00.42c09.00.42742c5690-7789-4c49-a3c4-f7fd8d3f4b9bComputer-Aided Detection (CAD) System for Use with Chest RadiographsComputer-Aided Detection (CAD) System for Use with Chest Radiographs
cea741ca-e1f5-411d-8d34-6af7ac2699a5.aspx
  
3241Computer-assistedMusculoskeletalSurgicalNavigationalOrthopedicProcedure11.14.17eSurgery (11)11.14.17e11.14.17cea741ca-e1f5-411d-8d34-6af7ac2699a5Computer-assisted Musculoskeletal Surgical Navigational Orthopedic ProcedureComputer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
F3BA7DB0E980312B8525854B005EE64C.aspx
  
1986Consultation ServicesAdministrative (00)00.01.6900.01.69F3BA7DB0E980312B8525854B005EE64CConsultation ServicesConsultation Services
1c569fa6-371f-4b4b-9200-c3ab329590bd.aspx
  
4282ContactLensesfortheTreatmentofPersistent(Corneal)EpithelialDefects07.13.11kMedicine (07)07.13.11k07.13.111c569fa6-371f-4b4b-9200-c3ab329590bdContact Lenses for the Treatment of Persistent (Corneal) Epithelial DefectsContact 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"},}
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3132ContrastAgentsUsedinConjunctionwithEchocardiography09.00.11eRadiology (09)09.00.11e09.00.116559b183-cc4e-4272-9c94-1515a87d738aContrast Agents Used in Conjunction with EchocardiographyContrast Agents Used in Conjunction with Echocardiography
c662c386-f536-47e5-b61c-97ecd3c341c2.aspx
  
3827CornealPachymetryUsingUltrasound07.13.07kMedicine (07)07.13.07k07.13.07c662c386-f536-47e5-b61c-97ecd3c341c2Corneal Pachymetry Using UltrasoundCorneal Pachymetry Using Ultrasound
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3fbb0f4b-f2c3-4e5e-8f16-ed646b2faaaf.aspx
  
3370CosmeticProcedures12.01.03aMiscellaneous (12)12.01.03a12.01.033fbb0f4b-f2c3-4e5e-8f16-ed646b2faaafCosmetic ProceduresCosmetic Procedures
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4163CoverageofAnticancerPrescriptionOralandInjectableDrugsandBiologicsandSupportiveAgents08.01.08hPharmacy (08)08.01.08h08.01.08be1d6603-25f7-4fee-add7-123d29eea45aCoverage of Anticancer Prescription Oral and Injectable Drugs and Biologics and Supportive AgentsCoverage of Anticancer Prescription Oral and Injectable Drugs and Biologics and Supportive Agents
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3720CoverageofMedicalDevices05.00.04eDME (05)05.00.04e05.00.0414669bc5-097a-4a2c-bbf0-82a2e0da5a62Coverage of Medical DevicesCoverage of Medical Devices
b3fb682c-aef5-4ba3-b62c-b8bf75862601.aspx
  
3864CranialElectrotherapyStimulation05.00.80aDME (05)05.00.80a05.00.80b3fb682c-aef5-4ba3-b62c-b8bf75862601Cranial Electrotherapy StimulationCranial Electrotherapy Stimulation
50ef9336-43ce-4d9b-a4dc-3e43464b5847.aspx
  
4130CranialRemoldingOrthoses(Helmets)05.00.25iDME (05)05.00.25i05.00.2550ef9336-43ce-4d9b-a4dc-3e43464b5847Cranial Remolding Orthoses (Helmets)Cranial Remolding Orthoses (Helmets)
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1811Criteria for Reimbursement of Emergency Room ServicesAdministrative (00)00.10.03j00.10.0385256AA800623D7A852584710058EC0ECriteria for Reimbursement of Emergency Room ServicesCriteria for Reimbursement of Emergency Room Services
06c04256-2595-4568-b588-ffe96ce41f54.aspx
  
4112crizanlizumab-tmca(Adakveo®)08.00.04Pharmacy (08)08.00.0408.00.0406c04256-2595-4568-b588-ffe96ce41f54crizanlizumab-tmca (Adakveo®)crizanlizumab-tmca (Adakveo®)
f8864ad8-763e-4de5-b347-c1e53faf3f62.aspx
  
3245CryosurgicalAblationoftheProstateGland11.11.03dSurgery (11)11.11.03d11.11.03f8864ad8-763e-4de5-b347-c1e53faf3f62Cryosurgical Ablation of the Prostate GlandCryosurgical Ablation of the Prostate Gland
caddc052-448d-47ed-ab6a-9038bbc469d3.aspx
  
3331Daratumumab(Darzalex®),Daratumumab,andHyaluronidase-fihj(DarzalexFaspro®)08.01.29iPharmacy (08)08.01.29i08.01.29caddc052-448d-47ed-ab6a-9038bbc469d3Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®)Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®)
d93acb77-0d6c-4707-bd4a-443705511a77.aspx
  
3395DayRehabilitation10.00.02cRehabilitation Services (10)10.00.02c10.00.02d93acb77-0d6c-4707-bd4a-443705511a77Day RehabilitationDay Rehabilitation
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3661DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNails11.08.17kSurgery (11)11.08.17k11.08.1762e02374-fa4f-44d0-92b6-3997cb88b0f8Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe NailsDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
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3782DeepBrainStimulation(DBS)11.15.20pSurgery (11)11.15.20p11.15.20a0a1c930-20bc-4e8a-b8d7-f758d46ef324Deep Brain Stimulation (DBS)Deep Brain Stimulation (DBS)
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3826DenervationoftheSpinalNervesforChronicPain(AmerihealthAdministrators)11.15.09pSurgery (11)11.15.09p11.15.0915a55608-5674-4b6c-8aac-afbe4e94dc43Denervation of the Spinal Nerves for Chronic Pain (Amerihealth Administrators)Denervation of the Spinal Nerves for Chronic Pain (Amerihealth Administrators)
a59431fc-4e4a-4555-bd20-86abeafad4c3.aspx
  
4262Denosumab(Prolia®,Xgeva®),Romosozumab-aqqg(Evenity®)08.00.94pPharmacy (08)08.00.94p08.00.94a59431fc-4e4a-4555-bd20-86abeafad4c3Denosumab (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"},}
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3986DermabrasionforRhinophyma,Septoplasty,Rhinoplasty,andSeptorhinoplasty11.16.01iSurgery (11)11.16.01i11.16.0126f68069-1450-4dc9-9b2e-95793e7d448cDermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and SeptorhinoplastyDermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and Septorhinoplasty
1afb2669-3344-48df-9b54-8fa9095f0681.aspx
  
4054DiagnosticRadiologyServicesIncludedinCapitation00.03.02acAdministrative (00)00.03.02ac00.03.021afb2669-3344-48df-9b54-8fa9095f0681Diagnostic Radiology Services Included in CapitationDiagnostic Radiology Services Included in Capitation
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4052DirectAccesstoObstetrics/Gynecology(OB/GYN)Services00.09.01iAdministrative (00)00.09.01i00.09.01898829fe-3262-4d01-9c71-4f71ed3a563dDirect Access to Obstetrics/Gynecology (OB/GYN) ServicesDirect Access to Obstetrics/Gynecology (OB/GYN) Services
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3252Dofetilide(Tikosyn®)UseintheInpatientSetting08.00.49ePharmacy (08)08.00.49e08.00.4946492617-4cbd-442b-a4e2-b29e7eee784dDofetilide (Tikosyn®) Use in the Inpatient SettingDofetilide (Tikosyn®) Use in the Inpatient Setting
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4137Dostarlimab-gxly(Jemperli)08.01.79cPharmacy (08)08.01.79c08.01.7914bced08-e2b4-42b3-a1ee-4baa5f9c9cefDostarlimab-gxly (Jemperli)Dostarlimab-gxly (Jemperli)
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