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6014​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Low-LevelLaserTherapy07.00.14hMedicine (07)07.00.14h07.00.1443121ad2-eedf-4ffe-b0c3-2ea66971af89​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Low-Level Laser Therapy​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Low-Level Laser Therapy
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5626Abatacept(Orencia®)forInjectionforIntravenousUse08.00.62pPharmacy (08)08.00.62p08.00.623f223e2e-8b21-479a-bb77-5c350f2780f1Abatacept (Orencia®) for Injection for Intravenous UseAbatacept (Orencia®) for Injection for Intravenous Use
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6157Acupuncture12.00.01hMiscellaneous (12)12.00.01h12.00.0151b33f90-efbb-44ea-81f0-df77ba8b4765AcupunctureAcupuncture
{"6158": {"Id":6158,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Acupuncture","MPPolicyAttachmentInternalSourceId":8417,"PolicyAttachmentPageName":"9152bc08-603b-4aac-896d-7e466c32a8dc"},}
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5536AcuteCareFacilityInpatientTransfers12.04.04bMiscellaneous (12)12.04.04b12.04.041cfcdcfa-8618-4278-b580-4cb85d35ce0cAcute Care Facility Inpatient TransfersAcute Care Facility Inpatient Transfers
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6203Ado-TrastuzumabEmtansine(Kadcyla®)08.01.11iPharmacy (08)08.01.11i08.01.116376f7cc-44ba-4f5a-8572-660cfea3b4bbAdo-Trastuzumab Emtansine (Kadcyla®)Ado-Trastuzumab Emtansine (Kadcyla®)
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5163Agalsidasebeta(Fabrazyme®)08.00.69cPharmacy (08)08.00.69c08.00.69b8b27d69-62ab-4921-9ae8-f074ee40c9dcAgalsidase beta (Fabrazyme®)Agalsidase beta (Fabrazyme®)
54421f21-0a89-4d2b-b568-b43c51393668.aspx
  
5440AirAmbulanceServices12.04.03cMiscellaneous (12)12.04.03c12.04.0354421f21-0a89-4d2b-b568-b43c51393668Air Ambulance ServicesAir Ambulance Services
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5305Alemtuzumab(Lemtrada®)08.01.22dPharmacy (08)08.01.22d08.01.22253c8671-81ff-425d-9d8e-309011c90aa0Alemtuzumab (Lemtrada®)Alemtuzumab (Lemtrada®)
8efb377e-0527-4def-a962-5f79e0b36912.aspx
  
5359Alglucosidasealfa(e.g.,Lumizyme®),Avalglucosidasealfa-ngpt(Nexviazyme®)08.00.72kPharmacy (08)08.00.72k08.00.728efb377e-0527-4def-a962-5f79e0b36912Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® )Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® )
8e17145c-3132-4375-af9c-eaea67ad6d35.aspx
  
5778AllergyImmunotherapy07.00.21iMedicine (07)07.00.21i07.00.218e17145c-3132-4375-af9c-eaea67ad6d35Allergy ImmunotherapyAllergy Immunotherapy
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6175AllogeneicProcessedThymusTissue-agdc(Rethymic®)08.01.88Pharmacy (08)08.01.8808.01.887b6b45cc-a602-418b-80f7-d0d8796981ecAllogeneic Processed Thymus Tissue-agdc (Rethymic®)Allogeneic Processed Thymus Tissue-agdc (Rethymic®)
8e33c660-965c-4bdc-a6fd-f2d0999aac45.aspx
  
6154AlloMap™MolecularExpressionTestingforHeartTransplantRejection(AmeriHealthAdministrators)06.02.29dPathology and Laboratory (06)06.02.29d06.02.298e33c660-965c-4bdc-a6fd-f2d0999aac45AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)
89deaeea-96aa-4381-9a71-4bc587fb08c9.aspx
  
5230Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C®,AralastNP®,Glassia®,Zemaira®)08.00.91ePharmacy (08)08.00.91e08.00.9189deaeea-96aa-4381-9a71-4bc587fb08c9Alpha 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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6105AlwaysBundledProcedureCodes00.01.52uAdministrative (00)00.01.52u00.01.520db41c4e-eb75-4250-bca0-e925f91a9956Always Bundled Procedure CodesAlways Bundled Procedure Codes
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6179AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)Devices07.02.09iMedicine (07)07.02.09i07.02.094242bfce-640e-453e-9bf6-966b0382a8afAmbulatory 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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6000AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)Monitoring07.02.21oMedicine (07)07.02.21o07.02.21d476ca8b-c599-404d-97d6-6e91b5059b82Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
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5982Amivantamab-vmjw(Rybrevant™)08.01.90Pharmacy (08)08.01.9008.01.9017eb3582-ca7f-491f-ad2b-ffe0a3981b06Amivantamab-vmjw (Rybrevant™)Amivantamab-vmjw (Rybrevant™)
2d5afb71-f0c1-41d0-9ac2-8547f69eeced.aspx
  
5678AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagement01.00.12bAnesthesia (01)01.00.12b01.00.122d5afb71-f0c1-41d0-9ac2-8547f69eecedAnesthesia 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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5431Anifrolumab-fnia(Saphnelo®)08.01.82bPharmacy (08)08.01.82b08.01.827f881bbb-9ecf-4690-b6b8-6f5cb234c8f7Anifrolumab-fnia (Saphnelo®)Anifrolumab-fnia (Saphnelo®)
f06f0d8e-9656-427c-a18a-4e290d8ca5f1.aspx
  
6260Ankle-Foot/Knee-Ankle-FootOrthoses05.00.39uDME (05)05.00.39u05.00.39f06f0d8e-9656-427c-a18a-4e290d8ca5f1Ankle-Foot/Knee-Ankle-Foot OrthosesAnkle-Foot/Knee-Ankle-Foot Orthoses
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5901ApheresisTherapy06.03.04nPathology and Laboratory (06)06.03.04n06.03.040d151aaf-53f7-4fc0-a0dc-540b0ed277a6Apheresis TherapyApheresis Therapy
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5963Apos®biomechanicalshoesystem05.00.84DME (05)05.00.8405.00.84ba410497-dc76-45a7-86d1-89fdcb6cc851Apos® biomechanical shoe systemApos® biomechanical shoe system
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6145ApplicationandRemovalofTattoos11.08.05gSurgery (11)11.08.05g11.08.058c8a85cf-d21e-4de9-8dba-2b996e35dbe4Application and Removal of TattoosApplication and Removal of Tattoos
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5993AppliedBehaviorAnalysis(ABA)fortheTreatmentofAutismSpectrumDisorders(ASD)14.00.03aBehavioral Health (14)14.00.03a14.00.03f324487e-15c6-4961-844b-a9a43eb19d0aApplied Behavior Analysis (ABA) for the Treatment of Autism Spectrum Disorders (ASD)Applied Behavior Analysis (ABA) for the Treatment of Autism Spectrum Disorders (ASD)
b55c31d5-eb8d-4517-bf3c-eeeb6c9b79a1.aspx
  
4998AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucoma11.05.16lSurgery (11)11.05.16l11.05.16b55c31d5-eb8d-4517-bf3c-eeeb6c9b79a1Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
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5311ArtificialIntervertebralCervicalDiscInsertion(AmerihealthAdministrators)11.14.19pSurgery (11)11.14.19p11.14.19bc52c9e0-2f80-4074-92f6-4627d2247b46Artificial Intervertebral Cervical Disc Insertion (Amerihealth Administrators)Artificial Intervertebral Cervical Disc Insertion (Amerihealth Administrators)
14c6546f-9145-49d6-a22b-44f85ab32431.aspx
  
5808ArtificialIntervertebralLumbarDiscInsertion11.15.31bSurgery (11)11.15.31b11.15.3114c6546f-9145-49d6-a22b-44f85ab32431Artificial Intervertebral Lumbar Disc InsertionArtificial Intervertebral Lumbar Disc Insertion
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5453AsparaginaseErwiniaChrysanthemi(Erwinaze®),asparaginaseerwiniachrysanthemi(recombinant)-rywn(Rylaze®)08.01.35gPharmacy (08)08.01.35g08.01.3545eea1e5-d113-4c3c-a874-49b1e3d094b0Asparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze®)Asparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze®)
9df36788-e9f1-4d47-a9c2-21f112f4b6b4.aspx
  
5557AssaysofGeneticExpressioninTumorTissueforBreastCancerPrognosis(AmeriHealthAdministrators)06.02.27nPathology and Laboratory (06)06.02.27n06.02.279df36788-e9f1-4d47-a9c2-21f112f4b6b4Assays 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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4861AssistedReproductiveTechnologyforInfertilityandOocyteCryopreservation07.10.06iMedicine (07)07.10.06i07.10.061957f95b-a5e6-40c1-befd-604f31a47e21Assisted Reproductive Technology for Infertility and Oocyte CryopreservationAssisted Reproductive Technology for Infertility and Oocyte Cryopreservation
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5120Atezolizumab(Tecentriq®)08.01.69cPharmacy (08)08.01.69c08.01.693692eb86-55ea-4cdd-a607-efd8374b8545Atezolizumab (Tecentriq®)Atezolizumab (Tecentriq®)
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5239AutologousChondrocyteImplantation(ACI)andOtherCell-basedTreatmentsofFocalArticularCartilageLesions(AmerihealthAdministrators)11.14.06jSurgery (11)11.14.06j11.14.062128d5d8-b7a4-4ff5-9a1a-9608698cc0ebAutologous 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)
a590a8dc-f63a-4148-bbaf-c1db550f4901.aspx
  
5683AutomaticExternalCardioverterDefibrillators(WearableandNonwearable)05.00.29oDME (05)05.00.29o05.00.29a590a8dc-f63a-4148-bbaf-c1db550f4901Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
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5340AutonomicNervousSystemTesting07.03.23fMedicine (07)07.03.23f07.03.23b393d397-a419-44af-9b52-d0c610c1ee8cAutonomic Nervous System TestingAutonomic Nervous System Testing
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6091Avelumab(Bavencio®)08.01.64cPharmacy (08)08.01.64c08.01.648634181f-e7ae-4971-83be-45e7b99e6c46Avelumab (Bavencio®)Avelumab (Bavencio®)
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5096BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitis11.16.06jSurgery (11)11.16.06j11.16.06e6e1f2fb-cb7d-4b62-b88c-93f6f4dbaaa6Balloon 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
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5303Belimumab(Benlysta®)forIntravenousUse08.00.99ePharmacy (08)08.00.99e08.00.9948faca03-d3ad-4abd-af51-f1fdd06652c8Belimumab (Benlysta®) for Intravenous UseBelimumab (Benlysta®) for Intravenous Use
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5611BeremageneGeperpavec(Vyjuvek™)08.02.10Pharmacy (08)08.02.1008.02.1087c3f070-2bb4-4558-8c27-bb164294d05aBeremagene Geperpavec (Vyjuvek™)Beremagene Geperpavec (Vyjuvek™)
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5912BetibeglogeneAutotemcel[Beti-Cel(ZYNTEGLO®)]08.01.89Pharmacy (08)08.01.8908.01.89ab836383-d054-418c-884e-92fbedfadbdeBetibeglogene Autotemcel [Beti-Cel (ZYNTEGLO®)]Betibeglogene Autotemcel [Beti-Cel (ZYNTEGLO®)]
5e39b1ae-f374-4b43-a5f0-9444ff939207.aspx
  
5394Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUse08.00.66uPharmacy (08)08.00.66u08.00.665e39b1ae-f374-4b43-a5f0-9444ff939207Bevacizumab (Avastin®) and Related Biosimilars For Oncologic UseBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
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5883BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampus00.10.39pAdministrative (00)00.10.39p00.10.3995f9b3c1-bad5-4370-9529-72d47935639aBilling 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
{"5884": {"Id":5884,"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":7908,"PolicyAttachmentPageName":"51655d25-e2d1-4a76-b79a-b81778bf424c"},}
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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"},}
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6243BiofeedbackTherapy07.00.01lMedicine (07)07.00.01l07.00.0172ea9640-60d0-4bf2-9fd2-388300929138Biofeedback TherapyBiofeedback Therapy
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5794BioimpedancefortheDetectionofLymphedema07.06.03bMedicine (07)07.06.03b07.06.03d2ce5acb-ad2e-4114-a9b1-c21854d419ddBioimpedance for the Detection of LymphedemaBioimpedance for the Detection of Lymphedema
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4845Blepharoplasty,RepairofBlepharoptosis,RepairofBrowPtosis,andCanthoplasty/Canthopexy11.05.02jSurgery (11)11.05.02j11.05.02b491f109-dc4e-41fb-906a-5eb04fe2602dBlepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/CanthopexyBlepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
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5114Blinatumomab(Blincyto®)08.01.21fPharmacy (08)08.01.21f08.01.21b306af6e-813e-493c-8a8b-b57d5995a5e4Blinatumomab (Blincyto®)Blinatumomab (Blincyto®)
71cab426-451b-4fe7-8145-e03d74789638.aspx
  
6012Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAids11.01.06hSurgery (11)11.01.06h11.01.0671cab426-451b-4fe7-8145-e03d74789638Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing AidsBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
a13be624-6881-4482-aee8-9f3a94154def.aspx
  
6015BoneMineralDensity(BMD)Testing09.00.04oRadiology (09)09.00.04o09.00.04a13be624-6881-4482-aee8-9f3a94154defBone Mineral Density (BMD) TestingBone Mineral Density (BMD) Testing
d2645ebf-b782-4091-8c20-1c86b49c10ad.aspx
  
5748BotulinumToxinAgents08.00.26abPharmacy (08)08.00.26ab08.00.26d2645ebf-b782-4091-8c20-1c86b49c10adBotulinum Toxin AgentsBotulinum Toxin Agents
{"5749": {"Id":5749,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":7744,"PolicyAttachmentPageName":"17b60ed1-42bd-476f-95ea-84da05815fc1"},}
ac7dfdb5-e79a-42d5-b6c3-681e9dcda63c.aspx
  
6181BrachytherapyandAcceleratedWholeBreastIrradiationusingThree-DimensionalConformationRadiationTherapy09.00.10zRadiology (09)09.00.10z09.00.10ac7dfdb5-e79a-42d5-b6c3-681e9dcda63cBrachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation TherapyBrachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy
e718aa9b-d3fc-4639-a5db-9da0f889ca0d.aspx
  
5974BreastPumps05.00.76hDME (05)05.00.76h05.00.76e718aa9b-d3fc-4639-a5db-9da0f889ca0dBreast PumpsBreast Pumps
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6082BrentuximabVedotin(Adcetris®)08.01.13iPharmacy (08)08.01.13i08.01.138fb16725-fe22-41e8-a8fd-d52ed540ecf3Brentuximab Vedotin (Adcetris®)Brentuximab Vedotin (Adcetris®)
{"6083": {"Id":6083,"MPAttachmentLetter":"A","Title":"ICD CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":7784,"PolicyAttachmentPageName":"f2f311e1-b1da-4680-9a0c-3ceaba5fa574"},}
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5537BronchialValves11.16.09Surgery (11)11.16.0911.16.092bab9fa4-c748-4063-85c4-82ade8f0220aBronchial ValvesBronchial Valves
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5360Burosumab-twza(Crysvita®)08.01.49bPharmacy (08)08.01.49b08.01.497086f118-eb42-44a3-8a89-e86e5c88d9cdBurosumab-twza (Crysvita®)Burosumab-twza (Crysvita®)
38c73bef-e52a-4cb7-a01c-656e866406c9.aspx
  
5367Canakinumab(Ilaris®)08.01.51bPharmacy (08)08.01.51b08.01.5138c73bef-e52a-4cb7-a01c-656e866406c9Canakinumab (Ilaris®)Canakinumab (Ilaris®)
4f05be45-fe22-4985-826c-1a29eeda3bd8.aspx
  
6201CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)Programs10.01.01rRehabilitation Services (10)10.01.01r10.01.014f05be45-fe22-4985-826c-1a29eeda3bd8Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) ProgramsCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
{"6202": {"Id":6202,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":8328,"PolicyAttachmentPageName":"d886555d-fed0-496e-be26-b5a45e431370"},}
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6110CareManagementandCarePlanningServices00.01.59nAdministrative (00)00.01.59n00.01.59b07fe1e1-bece-4278-976c-ff96c6008f21Care Management and Care Planning ServicesCare Management and Care Planning Services
f6351ed6-683e-4623-83d6-5dee552f7b29.aspx
  
5994Carfilzomib(Kyprolis®)08.01.05jPharmacy (08)08.01.05j08.01.05f6351ed6-683e-4623-83d6-5dee552f7b29Carfilzomib (Kyprolis®)Carfilzomib (Kyprolis®)
3d5103bb-27d5-4963-bd34-f6ba67f1076b.aspx
  
4360CastandSplintApplicationsandAssociatedSupplies00.10.15dAdministrative (00)00.10.15d00.10.153d5103bb-27d5-4963-bd34-f6ba67f1076bCast and Splint Applications and Associated SuppliesCast 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"},}
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4854CataractSurgery11.01.07fSurgery (11)11.01.07f11.01.07999dab46-d26f-4042-bdec-44679dace028Cataract SurgeryCataract Surgery
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5689CatheterAblationofCardiacArrhythmias11.02.06qSurgery (11)11.02.06q11.02.069eccdc4b-79a3-4f95-8e04-651c93549127Catheter Ablation of Cardiac ArrhythmiasCatheter Ablation of Cardiac Arrhythmias
b06a7d38-c9e9-4610-916b-190365fe9fd8.aspx
  
5565Cemiplimab-rwlc(Libtayo®)08.01.66cPharmacy (08)08.01.66c08.01.66b06a7d38-c9e9-4610-916b-190365fe9fd8Cemiplimab-rwlc (Libtayo®)Cemiplimab-rwlc (Libtayo®)
c81b22ec-3ec7-4a91-85c1-70af8b7cf771.aspx
  
5344Cerliponasealfa(Brineura®)08.01.39cPharmacy (08)08.01.39c08.01.39c81b22ec-3ec7-4a91-85c1-70af8b7cf771Cerliponase alfa (Brineura®)Cerliponase alfa (Brineura®)
aff2b094-ca8b-410b-96e4-4a9c0c4fecbb.aspx
  
5183CervicalTractionDevicesforIn-homeUse05.00.61gDME (05)05.00.61g05.00.61aff2b094-ca8b-410b-96e4-4a9c0c4fecbbCervical Traction Devices for In-home UseCervical Traction Devices for In-home Use
2ba8dd03-1332-463a-bd4a-f6ad3e32ef5f.aspx
  
6170Cetuximab(Erbitux®)08.00.67oPharmacy (08)08.00.67o08.00.672ba8dd03-1332-463a-bd4a-f6ad3e32ef5fCetuximab (Erbitux®)Cetuximab (Erbitux®)
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5902ChemicalPeels11.08.08hSurgery (11)11.08.08h11.08.088aaecd67-1a97-4dba-8260-5b9df700036eChemical PeelsChemical Peels
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5859ChimericAntigenReceptor(CAR)Therapy08.01.43lPharmacy (08)08.01.43l08.01.4319564f85-f451-4f6b-85b4-852c20226363Chimeric Antigen Receptor (CAR) TherapyChimeric Antigen Receptor (CAR) Therapy
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5777ChiropracticSpinalandExtraspinalManipulationTherapy10.02.02jRehabilitation Services (10)10.02.02j10.02.029101d108-b826-4b00-a2dc-318443788396Chiropractic Spinal and Extraspinal Manipulation TherapyChiropractic Spinal and Extraspinal Manipulation Therapy
c40f3d9d-b80c-4073-a7b3-75b07f1d2132.aspx
  
6081CoagulationFactors08.00.92agPharmacy (08)08.00.92ag08.00.92c40f3d9d-b80c-4073-a7b3-75b07f1d2132Coagulation FactorsCoagulation Factors
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5066Cobalamin(VitaminB12),FolicAcid,andHomocysteineTesting06.02.54cPathology and Laboratory (06)06.02.54c06.02.54359a2377-9b04-4dee-a8be-027bdc97c9b8Cobalamin (Vitamin B12), Folic Acid, and Homocysteine TestingCobalamin (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"},}
4ee164ea-941e-469a-b9c0-41335b1bb8bd.aspx
  
5535CochlearImplantation11.01.02qSurgery (11)11.01.02q11.01.024ee164ea-941e-469a-b9c0-41335b1bb8bdCochlear ImplantationCochlear Implantation
180e2231-db77-429e-a2a2-26e6b1665e64.aspx
  
6151Collagenaseclostridiumhistolyticum(Xiaflex®),collagenaseclostridiumhistolyticum-aaes(Qwo®)08.01.71Pharmacy (08)08.01.7108.01.71180e2231-db77-429e-a2a2-26e6b1665e64Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo®)Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo®)
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5450ColorectalCancerScreening11.03.12tSurgery (11)11.03.12t11.03.12544ced3a-6c13-4171-8a56-94bd7fdaaa81Colorectal Cancer ScreeningColorectal Cancer Screening
75f1fb64-b681-4f20-935f-65210993c6b1.aspx
  
6274ComplementaryandIntegrativeHealthServices12.00.03hMiscellaneous (12)12.00.03h12.00.0375f1fb64-b681-4f20-935f-65210993c6b1Complementary and Integrative Health ServicesComplementary and Integrative Health Services
cd8eb507-7b90-4fb0-9ad4-8a3d1338f17c.aspx
  
5484CompleteDecongestiveTherapy(CDT)07.06.01bMedicine (07)07.06.01b07.06.01cd8eb507-7b90-4fb0-9ad4-8a3d1338f17cComplete Decongestive Therapy (CDT)Complete Decongestive Therapy (CDT)
9af50738-b876-485d-a1aa-ce59f7bc63bc.aspx
  
6250CompositeTissueAllotransplantationoftheHand(s)andFace11.14.30Surgery (11)11.14.3011.14.309af50738-b876-485d-a1aa-ce59f7bc63bcComposite Tissue Allotransplantation of the Hand(s) and FaceComposite Tissue Allotransplantation of the Hand(s) and Face
d26e483d-d440-4d8e-86ac-4bfd25e128d1.aspx
  
6129CompressionGarments05.00.37iDME (05)05.00.37i05.00.37d26e483d-d440-4d8e-86ac-4bfd25e128d1Compression GarmentsCompression Garments
b9742429-a8a1-4644-8b1c-2d8a9c69cbbb.aspx
  
5106Computer-AidedDetection(CAD)SystemforUsewithChestRadiographs09.00.42cRadiology (09)09.00.42c09.00.42b9742429-a8a1-4644-8b1c-2d8a9c69cbbbComputer-Aided Detection (CAD) System for Use with Chest RadiographsComputer-Aided Detection (CAD) System for Use with Chest Radiographs
74e08be5-b94f-4be4-a25b-b91380825a8e.aspx
  
6178Computer-assistedMusculoskeletalSurgicalNavigationalOrthopedicProcedure11.14.17eSurgery (11)11.14.17e11.14.1774e08be5-b94f-4be4-a25b-b91380825a8eComputer-assisted Musculoskeletal Surgical Navigational Orthopedic ProcedureComputer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
fa3b31f7-c0c1-46d2-9619-2f49ae0825f7.aspx
  
5083ConsultationServices00.01.69bAdministrative (00)00.01.69b00.01.69fa3b31f7-c0c1-46d2-9619-2f49ae0825f7Consultation ServicesConsultation Services
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5140ContactLensesfortheTreatmentofPersistent(Corneal)EpithelialDefects07.13.11kMedicine (07)07.13.11k07.13.1159bf419b-18ab-4008-accf-9b541d9bdb26Contact Lenses for the Treatment of Persistent (Corneal) Epithelial DefectsContact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
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5138ContrastAgentsUsedinConjunctionwithEchocardiography09.00.11eRadiology (09)09.00.11e09.00.1112ca4dc2-6f5b-4375-a86a-975789fb3469Contrast Agents Used in Conjunction with EchocardiographyContrast Agents Used in Conjunction with Echocardiography
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5581CornealPachymetryUsingUltrasound07.13.07lMedicine (07)07.13.07l07.13.07b3f30839-15d7-4589-9655-435e53e6412cCorneal Pachymetry Using UltrasoundCorneal Pachymetry Using Ultrasound
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77482876-6f27-4ea1-b0ec-3cc52520d7b6.aspx
  
5538CoronaryArteryCalcium(CAC)TestingUsingComputedTomography(AmeriHealthAdministrators)09.00.58Radiology (09)09.00.5809.00.5877482876-6f27-4ea1-b0ec-3cc52520d7b6Coronary Artery Calcium (CAC) Testing Using Computed Tomography (AmeriHealth Administrators)Coronary Artery Calcium (CAC) Testing Using Computed Tomography (AmeriHealth Administrators)
a0296243-13b3-4c16-8081-8892cb295c25.aspx
  
6160CosmeticProcedures12.01.03bMiscellaneous (12)12.01.03b12.01.03a0296243-13b3-4c16-8081-8892cb295c25Cosmetic ProceduresCosmetic Procedures
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6219CoverageofAnticancerPrescriptionOralandInjectableDrugsandBiologicsandSupportiveAgents08.01.08pPharmacy (08)08.01.08p08.01.08b41ad05d-cdaf-4b81-a83d-608a752d72bcCoverage 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
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6013CranialElectrotherapyStimulation05.00.80dDME (05)05.00.80d05.00.80db9f309a-ebf1-4ad3-8eaf-110049e9645aCranial Electrotherapy StimulationCranial Electrotherapy Stimulation
234626c7-025c-4f8c-bbe6-a1851c93420c.aspx
  
6122CranialRemoldingOrthoses(Helmets)05.00.25jDME (05)05.00.25j05.00.25234626c7-025c-4f8c-bbe6-a1851c93420cCranial Remolding Orthoses (Helmets)Cranial Remolding Orthoses (Helmets)
cde76797-199e-4918-9e43-897124bfa2c4.aspx
  
5034CriteriaforReimbursementofEmergencyRoomServices00.10.03kAdministrative (00)00.10.03k00.10.03cde76797-199e-4918-9e43-897124bfa2c4Criteria for Reimbursement of Emergency Room ServicesCriteria for Reimbursement of Emergency Room Services
177478c4-a9ce-4845-b972-98a5a3cf3df6.aspx
  
5727crizanlizumab-tmca(Adakveo®)08.00.04aPharmacy (08)08.00.04a08.00.04177478c4-a9ce-4845-b972-98a5a3cf3df6crizanlizumab-tmca (Adakveo®)crizanlizumab-tmca (Adakveo®)
68125ac1-2efe-4d92-961a-2859913ae981.aspx
  
5895CryosurgicalAblationoftheProstateGland11.11.03dSurgery (11)11.11.03d11.11.0368125ac1-2efe-4d92-961a-2859913ae981Cryosurgical Ablation of the Prostate GlandCryosurgical Ablation of the Prostate Gland
d350f089-498b-4395-a644-4f81c5503a93.aspx
  
5597Daratumumab(Darzalex®),DaratumumabandHyaluronidase-fihj(DarzalexFaspro®)08.01.29kPharmacy (08)08.01.29k08.01.29d350f089-498b-4395-a644-4f81c5503a93Daratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®)Daratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®)
803d7702-4e64-481a-a856-89a699b735d9.aspx
  
5378DayRehabilitation10.00.02cRehabilitation Services (10)10.00.02c10.00.02803d7702-4e64-481a-a856-89a699b735d9Day RehabilitationDay Rehabilitation
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5125DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNails11.08.17kSurgery (11)11.08.17k11.08.17d42f70a6-a972-422f-9fc4-142aa04bdff1Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe NailsDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
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6053DeepBrainStimulation(DBS)11.15.20tSurgery (11)11.15.20t11.15.20794efd54-5108-453a-99b1-67dde41a8a59Deep Brain Stimulation (DBS)Deep Brain Stimulation (DBS)
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6098Delandistrogenemoxeparvovec(delandistrogenemoxeparvovec-rokl;Elevidys®)08.02.13Pharmacy (08)08.02.1308.02.1347fff4e1-193c-4a2a-b781-a10c70f77a73Delandistrogene moxeparvovec (delandistrogene moxeparvovec-rokl; Elevidys®) Delandistrogene moxeparvovec (delandistrogene moxeparvovec-rokl; Elevidys®)
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5240DenervationoftheSpinalNervesforChronicPain(AmerihealthAdministrators)11.15.09pSurgery (11)11.15.09p11.15.097ad193a1-4356-4c00-8be7-6d555ca8dceeDenervation of the Spinal Nerves for Chronic Pain (Amerihealth Administrators)Denervation of the Spinal Nerves for Chronic Pain (Amerihealth Administrators)
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6089Denosumab(Prolia®,Xgeva®),Romosozumab-aqqg(Evenity®)08.00.94rPharmacy (08)08.00.94r08.00.945ffe687d-82f3-43a5-a88f-32aaabd1c021Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)
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