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ec305867-b5e4-42d0-bd87-940bbeedb003.aspx
  
6709​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Low-LevelLaserTherapy07.00.14hMedicine (07)07.00.14h07.00.14ec305867-b5e4-42d0-bd87-940bbeedb003​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Low-Level Laser Therapy​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Low-Level Laser Therapy
408beb37-be23-40d5-9040-0c51e879186e.aspx
  
6750Abatacept(Orencia®)forInjectionforIntravenousUse08.00.62qPharmacy (08)08.00.62q08.00.62408beb37-be23-40d5-9040-0c51e879186eAbatacept (Orencia®) for Injection for Intravenous UseAbatacept (Orencia®) for Injection for Intravenous Use
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7c5ffd74-94d6-4cce-9934-cb60e7d6891b.aspx
  
7162Acupuncture12.00.01iMiscellaneous (12)12.00.01i12.00.017c5ffd74-94d6-4cce-9934-cb60e7d6891bAcupunctureAcupuncture
{"7163": {"Id":7163,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Acupuncture","MPPolicyAttachmentInternalSourceId":9335,"PolicyAttachmentPageName":"5ac146a2-128b-45fa-9c31-8d98dfbd7d48"},}
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6289AcuteCareFacilityInpatientTransfers12.04.04bMiscellaneous (12)12.04.04b12.04.04041a205f-0c15-47d8-b360-7e2ae95890a4Acute Care Facility Inpatient TransfersAcute Care Facility Inpatient Transfers
48b73346-595a-453a-a012-7e53761de789.aspx
  
6624ADAMTS13,recombinant-krhn(Adzynma)08.02.21Pharmacy (08)08.02.2108.02.2148b73346-595a-453a-a012-7e53761de789ADAMTS13, recombinant-krhn (Adzynma)ADAMTS13, recombinant-krhn (Adzynma)
6376f7cc-44ba-4f5a-8572-660cfea3b4bb.aspx
  
6203Ado-TrastuzumabEmtansine(Kadcyla®)08.01.11iPharmacy (08)08.01.11i08.01.116376f7cc-44ba-4f5a-8572-660cfea3b4bbAdo-Trastuzumab Emtansine (Kadcyla®)Ado-Trastuzumab Emtansine (Kadcyla®)
{"6204": {"Id":6204,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes and Narratives","MPPolicyAttachmentInternalSourceId":8429,"PolicyAttachmentPageName":"544c1cad-3eb3-435b-85f8-112bfaa35d21"},}
06566e59-609d-44b8-9945-f7df309a8893.aspx
  
6725Agalsidasebeta(Fabrazyme®)andpegunigalsidasealfa-iwxj(Elfabrio)08.00.69dPharmacy (08)08.00.69d08.00.6906566e59-609d-44b8-9945-f7df309a8893Agalsidase beta (Fabrazyme®) and pegunigalsidase alfa-iwxj (Elfabrio) Agalsidase beta (Fabrazyme®) and pegunigalsidase alfa-iwxj (Elfabrio)
0c439ba9-9ae5-469b-9a3d-6b3059dd86ad.aspx
  
6522AirAmbulanceServices12.04.03cMiscellaneous (12)12.04.03c12.04.030c439ba9-9ae5-469b-9a3d-6b3059dd86adAir Ambulance ServicesAir Ambulance Services
286fe526-ea7a-4849-be6c-90970e43a269.aspx
  
6313Alemtuzumab(Lemtrada®)08.01.22dPharmacy (08)08.01.22d08.01.22286fe526-ea7a-4849-be6c-90970e43a269Alemtuzumab (Lemtrada®)Alemtuzumab (Lemtrada®)
e5d1f91c-5781-472e-8a8f-aba999bdf8ee.aspx
  
6343Alglucosidasealfa(e.g.,Lumizyme®),Avalglucosidasealfa-ngpt(Nexviazyme®),Cipaglucosidasealfa-atga(Pombiliti™)08.00.72lPharmacy (08)08.00.72l08.00.72e5d1f91c-5781-472e-8a8f-aba999bdf8eeAlglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® ), Cipaglucosidase alfa-atga (Pombiliti™ )Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® ), Cipaglucosidase alfa-atga (Pombiliti™ )
e97c8f42-c197-410b-a30b-751901494dc7.aspx
  
6365AllergyImmunotherapy07.00.21jMedicine (07)07.00.21j07.00.21e97c8f42-c197-410b-a30b-751901494dc7Allergy ImmunotherapyAllergy Immunotherapy
7b6b45cc-a602-418b-80f7-d0d8796981ec.aspx
  
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)
a0803772-4e4f-4d53-950e-4ee17a5c49bb.aspx
  
6369Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C®,AralastNP®,Glassia®,Zemaira®)08.00.91ePharmacy (08)08.00.91e08.00.91a0803772-4e4f-4d53-950e-4ee17a5c49bbAlpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)
722c8be7-9c9d-4742-a2d1-70450bfd3f83.aspx
  
7166AlwaysBundledProcedureCodes00.01.52xAdministrative (00)00.01.52x00.01.52722c8be7-9c9d-4742-a2d1-70450bfd3f83Always Bundled Procedure CodesAlways Bundled Procedure Codes
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c9a66572-70dc-4147-a937-58a4516686ff.aspx
  
6769AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)Devices07.02.09jMedicine (07)07.02.09j07.02.09c9a66572-70dc-4147-a937-58a4516686ffAmbulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) DevicesAmbulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
b3854c91-41aa-4539-aca0-29585c2aafa0.aspx
  
7125AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)Monitoring07.02.21qMedicine (07)07.02.21q07.02.21b3854c91-41aa-4539-aca0-29585c2aafa0Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
d486df02-e380-4bbf-a9da-16d8462925fd.aspx
  
6427Amivantamab-vmjw(Rybrevant®)08.01.90aPharmacy (08)08.01.90a08.01.90d486df02-e380-4bbf-a9da-16d8462925fdAmivantamab-vmjw (Rybrevant®)Amivantamab-vmjw (Rybrevant®)
e9c9f22f-4996-4b56-864f-d7416e17906f.aspx
  
6784AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagement01.00.12cAnesthesia (01)01.00.12c01.00.12e9c9f22f-4996-4b56-864f-d7416e17906fAnesthesia 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
{"6785": {"Id":6785,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":9043,"PolicyAttachmentPageName":"247b6adb-e4db-410a-aed9-ad0f5527430c"},}
e33cb071-de8f-4aad-aa56-740c78fa063a.aspx
  
6492Anifrolumab-fnia(Saphnelo®)08.01.82cPharmacy (08)08.01.82c08.01.82e33cb071-de8f-4aad-aa56-740c78fa063aAnifrolumab-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
{"6261": {"Id":6261,"MPAttachmentLetter":"A","Title":"HCPCS Codes","MPPolicyAttachmentInternalSourceId":8450,"PolicyAttachmentPageName":"3f67a3e8-aa0d-4b25-b163-ae0dc66386bb"},}
0d151aaf-53f7-4fc0-a0dc-540b0ed277a6.aspx
  
5901ApheresisTherapy06.03.04nPathology and Laboratory (06)06.03.04n06.03.040d151aaf-53f7-4fc0-a0dc-540b0ed277a6Apheresis TherapyApheresis Therapy
dcae2951-b257-4a13-a658-e9c9c8eb2102.aspx
  
6970Apos®biomechanicalshoesystem05.00.84DME (05)05.00.8405.00.84dcae2951-b257-4a13-a658-e9c9c8eb2102Apos® biomechanical shoe systemApos® biomechanical shoe system
8c8a85cf-d21e-4de9-8dba-2b996e35dbe4.aspx
  
6145ApplicationandRemovalofTattoos11.08.05gSurgery (11)11.08.05g11.08.058c8a85cf-d21e-4de9-8dba-2b996e35dbe4Application and Removal of TattoosApplication and Removal of Tattoos
6ce912d3-f485-4ddf-bcef-902616736b67.aspx
  
6705AppliedBehaviorAnalysis(ABA)fortheTreatmentofAutismSpectrumDisorders(ASD)14.00.03aBehavioral Health (14)14.00.03a14.00.036ce912d3-f485-4ddf-bcef-902616736b67Applied Behavior Analysis (ABA) for the Treatment of Autism Spectrum Disorders (ASD)Applied Behavior Analysis (ABA) for the Treatment of Autism Spectrum Disorders (ASD)
3b29ff29-2825-4509-a933-5c95d4212c15.aspx
  
6434AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucoma11.05.16lSurgery (11)11.05.16l11.05.163b29ff29-2825-4509-a933-5c95d4212c15Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
{"6435": {"Id":6435,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":8590,"PolicyAttachmentPageName":"77818cea-df5d-429c-a35c-a6f408125fbc"},}
5359873f-16e6-4ca2-aa4e-a9a35db59f52.aspx
  
6743ArtificialIntervertebralCervicalDiscInsertion(AmeriHealthAdministrators)11.14.19pSurgery (11)11.14.19p11.14.195359873f-16e6-4ca2-aa4e-a9a35db59f52Artificial Intervertebral Cervical Disc Insertion (AmeriHealth Administrators)Artificial Intervertebral Cervical Disc Insertion (AmeriHealth Administrators)
ae518819-f5a1-49dd-b91e-882d8c56cdc3.aspx
  
7130AsparaginaseErwiniaChrysanthemi(recombinant)-rywn(Rylaze®)08.01.35iPharmacy (08)08.01.35i08.01.35ae518819-f5a1-49dd-b91e-882d8c56cdc3Asparaginase Erwinia Chrysanthemi (recombinant)-rywn (Rylaze®)Asparaginase Erwinia Chrysanthemi (recombinant)-rywn (Rylaze®)
0ee299f5-0fc4-4a92-a6e0-e86b1ab355bc.aspx
  
6865AssaysofGeneticExpressioninTumorTissueforBreastCancerPrognosis(AmeriHealthAdministrators)06.02.27oPathology and Laboratory (06)06.02.27o06.02.270ee299f5-0fc4-4a92-a6e0-e86b1ab355bcAssays 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)
6f3e894a-05bc-4cd3-bdef-f6cbc845ef41.aspx
  
6631AssistedReproductiveTechnologyforInfertilityandOocyteCryopreservation07.10.06jMedicine (07)07.10.06j07.10.066f3e894a-05bc-4cd3-bdef-f6cbc845ef41Assisted Reproductive Technology for Infertility and Oocyte CryopreservationAssisted Reproductive Technology for Infertility and Oocyte Cryopreservation
ede9f60a-566e-4695-8025-c7a073f24581.aspx
  
7128Atezolizumab(Tecentriq®)andAtezolizumabwithHyaluronidase-tqjs(TecentriqHybrezaTM)08.01.69dPharmacy (08)08.01.69d08.01.69ede9f60a-566e-4695-8025-c7a073f24581Atezolizumab (Tecentriq®) and Atezolizumab with Hyaluronidase-tqjs (Tecentriq Hybreza TM)Atezolizumab (Tecentriq®) and Atezolizumab with Hyaluronidase-tqjs (Tecentriq Hybreza TM)
{"7129": {"Id":7129,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":9178,"PolicyAttachmentPageName":"2e687cb1-6440-4047-ae03-48650c0f2f36"},}
df93a237-63a0-4414-b64f-2edea97c47b4.aspx
  
7052Atidarsageneautotemcel(Lenmeldy)08.02.24Pharmacy (08)08.02.2408.02.24df93a237-63a0-4414-b64f-2edea97c47b4Atidarsagene autotemcel (Lenmeldy)Atidarsagene autotemcel (Lenmeldy)
48247e2c-24d2-47e5-abb3-f29984e2fd33.aspx
  
6424AuricularProstheses05.00.82DME (05)05.00.8205.00.8248247e2c-24d2-47e5-abb3-f29984e2fd33Auricular ProsthesesAuricular Prostheses
6b5bdbf5-f556-4583-aa70-78730a56890c.aspx
  
6707AutologousChondrocyteImplantation(ACI)andOtherCell-basedTreatmentsofFocalArticularCartilageLesions(AmerihealthAdministrators)11.14.06jSurgery (11)11.14.06j11.14.066b5bdbf5-f556-4583-aa70-78730a56890cAutologous 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)
af455150-076e-4582-a958-6e8ed1d82b0a.aspx
  
6967AutomaticExternalCardioverterDefibrillators(WearableandNonwearable)05.00.29oDME (05)05.00.29o05.00.29af455150-076e-4582-a958-6e8ed1d82b0aAutomatic External Cardioverter Defibrillators (Wearable and Nonwearable)Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
{"6968": {"Id":6968,"MPAttachmentLetter":"B","Title":"ICD-10 codes used to represent the Nonwearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":9235,"PolicyAttachmentPageName":"1246344e-e764-4d48-96ba-2a501ba1fc9e"},"6969": {"Id":6969,"MPAttachmentLetter":"A","Title":"ICD-10 Codes used to represent the Wearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":9236,"PolicyAttachmentPageName":"f3bbe917-b3b2-4115-8579-ffab50661ba0"},}
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6805AutonomicNervousSystemTesting07.03.23gMedicine (07)07.03.23g07.03.2326fa6b18-0041-4f7a-b58a-bc314042689aAutonomic Nervous System TestingAutonomic Nervous System Testing
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7067Avelumab(Bavencio®)08.01.64dPharmacy (08)08.01.64d08.01.64043b3455-85fd-4892-a807-142649f1fd12Avelumab (Bavencio®)Avelumab (Bavencio®)
{"7068": {"Id":7068,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":9267,"PolicyAttachmentPageName":"13f5a18a-794f-48bb-ac11-2f904b0b0041"},}
e0e031ad-825b-428f-a15a-087a9c6b0709.aspx
  
6924BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitisorRecurrentAcuteRhinosinusitis11.16.06kSurgery (11)11.16.06k11.16.06e0e031ad-825b-428f-a15a-087a9c6b0709Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis or Recurrent Acute RhinosinusitisBalloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis or Recurrent Acute Rhinosinusitis
1097a649-40e6-45e6-8366-4ab8c078fdb8.aspx
  
7115BariatricSurgery11.03.02uSurgery (11)11.03.02u11.03.021097a649-40e6-45e6-8366-4ab8c078fdb8Bariatric SurgeryBariatric Surgery
{"7116": {"Id":7116,"MPAttachmentLetter":"B","Title":"Tanner Staging System Criteria for Adolescents","MPPolicyAttachmentInternalSourceId":9168,"PolicyAttachmentPageName":"51cef79b-3185-406c-8e56-89ff08f08aa6"},"7117": {"Id":7117,"MPAttachmentLetter":"A","Title":"Body Mass Index (BMI) Charts","MPPolicyAttachmentInternalSourceId":9169,"PolicyAttachmentPageName":"87b2a023-3caf-439f-add0-f261bd88d2f1"},"7118": {"Id":7118,"MPAttachmentLetter":"C","Title":"ICD-10-CM codes","MPPolicyAttachmentInternalSourceId":9170,"PolicyAttachmentPageName":"5bbd443d-736f-46d1-bb19-3bd8b6c6757a"},}
51a01731-c3c5-4aa9-95c8-83a2cf8e12d3.aspx
  
6415Belimumab(Benlysta®)forIntravenousUse08.00.99ePharmacy (08)08.00.99e08.00.9951a01731-c3c5-4aa9-95c8-83a2cf8e12d3Belimumab (Benlysta®) for Intravenous UseBelimumab (Benlysta®) for Intravenous Use
67bd6cc4-ddf0-488d-96d2-3475d10fba45.aspx
  
6625BeremageneGeperpavec(Vyjuvek™)08.02.10bPharmacy (08)08.02.10b08.02.1067bd6cc4-ddf0-488d-96d2-3475d10fba45Beremagene Geperpavec (Vyjuvek™)Beremagene Geperpavec (Vyjuvek™)
8cdc388e-ec5b-49de-a6f9-a2140f482cf9.aspx
  
6561BetibeglogeneAutotemcel[Beti-Cel(ZYNTEGLO®)]08.01.89aPharmacy (08)08.01.89a08.01.898cdc388e-ec5b-49de-a6f9-a2140f482cf9Betibeglogene Autotemcel [Beti-Cel (ZYNTEGLO®)]Betibeglogene Autotemcel [Beti-Cel (ZYNTEGLO®)]
7231530b-27b5-4e1e-b814-7210e19f1277.aspx
  
7069Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUse08.00.66wPharmacy (08)08.00.66w08.00.667231530b-27b5-4e1e-b814-7210e19f1277Bevacizumab (Avastin®) and Related Biosimilars For Oncologic UseBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
{"7070": {"Id":7070,"MPAttachmentLetter":"A","Title":"ICD 10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":9221,"PolicyAttachmentPageName":"b2e1de9a-e39f-4b5e-96f5-9ad6f07871b0"},}
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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"},}
9be43eff-6b64-4e0b-a426-ef73f2537ec3.aspx
  
6405BillingRequirementsforMultipleBirthsforProfessionalProviders00.10.38aAdministrative (00)00.10.38a00.10.389be43eff-6b64-4e0b-a426-ef73f2537ec3Billing Requirements for Multiple Births for Professional ProvidersBilling Requirements for Multiple Births for Professional Providers
{"6406": {"Id":6406,"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":8677,"PolicyAttachmentPageName":"8f6b9a74-008f-4e82-8be7-60a9d2b4131a"},"6407": {"Id":6407,"MPAttachmentLetter":"A","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ROUTINE OBSTETRIC (GLOBALE MATERNITY/OBSTETRIC [OB]) CARE WAS PROVIDED","MPPolicyAttachmentInternalSourceId":8678,"PolicyAttachmentPageName":"b5c1c52a-6755-40e1-89ab-106d03f7d9d6"},"6408": {"Id":6408,"MPAttachmentLetter":"D","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF HIGH-ORDER MULTIPLES WHEN ANTEPARTUM CARE IS NOT PROVIDED","MPPolicyAttachmentInternalSourceId":8679,"PolicyAttachmentPageName":"5ae8f316-7805-4e4c-ac92-1e147d896d76"},"6409": {"Id":6409,"MPAttachmentLetter":"B","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ANETEPARTUM CARE IS NOT PROVIDED","MPPolicyAttachmentInternalSourceId":8680,"PolicyAttachmentPageName":"1aace5b3-ccc4-4d23-9916-fd982ce3e6ab"},}
9bbfe306-c517-4311-9e0c-3992dede578b.aspx
  
6623BiofeedbackTherapy07.00.01nMedicine (07)07.00.01n07.00.019bbfe306-c517-4311-9e0c-3992dede578bBiofeedback TherapyBiofeedback Therapy
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6708BioimpedancefortheDetectionofLymphedema07.06.03bMedicine (07)07.06.03b07.06.0330a57ce7-8380-4072-8656-3a9103506911Bioimpedance for the Detection of LymphedemaBioimpedance for the Detection of Lymphedema
0640cf4b-eb1e-42ae-b6a8-4ef24369748a.aspx
  
6961Blinatumomab(Blincyto®)08.01.21gPharmacy (08)08.01.21g08.01.210640cf4b-eb1e-42ae-b6a8-4ef24369748aBlinatumomab (Blincyto®)Blinatumomab (Blincyto®)
3242af25-c531-415a-ae26-e24a7c42c39d.aspx
  
6338Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAids11.01.06iSurgery (11)11.01.06i11.01.063242af25-c531-415a-ae26-e24a7c42c39dBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing AidsBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
9ed7ef7a-4ae7-48d2-820b-208e2d183121.aspx
  
6372BoneMineralDensity(BMD)Testing09.00.04oRadiology (09)09.00.04o09.00.049ed7ef7a-4ae7-48d2-820b-208e2d183121Bone Mineral Density (BMD) TestingBone Mineral Density (BMD) Testing
ff919628-9d60-4949-a4b1-093a98efd8ff.aspx
  
6390BotulinumToxinAgents08.00.26acPharmacy (08)08.00.26ac08.00.26ff919628-9d60-4949-a4b1-093a98efd8ffBotulinum Toxin AgentsBotulinum Toxin Agents
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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
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6734BreastPumps05.00.76hDME (05)05.00.76h05.00.761b4fd207-103e-43bd-877b-b5b6e1b9ac26Breast PumpsBreast Pumps
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6984BrentuximabVedotin(Adcetris®)08.01.13kPharmacy (08)08.01.13k08.01.13f13b61bd-5d57-4443-907a-9a119560f26cBrentuximab Vedotin (Adcetris®)Brentuximab Vedotin (Adcetris®)
{"6985": {"Id":6985,"MPAttachmentLetter":"A","Title":"ICD CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":8995,"PolicyAttachmentPageName":"09923d4d-3e7e-4ff8-9b03-f2cf9738f0b1"},}
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6412BronchialValves11.16.09Surgery (11)11.16.0911.16.09ee437b97-bae6-428a-9307-6821eb6b1f46Bronchial ValvesBronchial Valves
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6366Burosumab-twza(Crysvita®)08.01.49bPharmacy (08)08.01.49b08.01.4926b0281d-ae9c-41dd-bd7b-ac0c4c9581baBurosumab-twza (Crysvita®)Burosumab-twza (Crysvita®)
7cf3300c-8d20-4eb5-b3b6-d9f1a5afbe1f.aspx
  
7062Canakinumab(Ilaris®)08.01.51cPharmacy (08)08.01.51c08.01.517cf3300c-8d20-4eb5-b3b6-d9f1a5afbe1fCanakinumab (Ilaris®)Canakinumab (Ilaris®)
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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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7165CareManagementandCarePlanningServices00.01.59oAdministrative (00)00.01.59o00.01.596242f17c-6a75-4b31-8484-d56cbcb54923Care Management and Care Planning ServicesCare Management and Care Planning Services
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6983Carfilzomib(Kyprolis®)08.01.05lPharmacy (08)08.01.05l08.01.05dd05173e-58df-4139-834a-a1e830d3b3e8Carfilzomib (Kyprolis®)Carfilzomib (Kyprolis®)
1bb6839b-1e1b-4642-bddf-6aa6ade77ae4.aspx
  
7021Casgevy™(exagamglogeneautotemcel)08.02.14Pharmacy (08)08.02.1408.02.141bb6839b-1e1b-4642-bddf-6aa6ade77ae4Casgevy™ (exagamglogene autotemcel)Casgevy™ (exagamglogene autotemcel)
ff41fdec-319e-4608-be2d-eee15f3bec86.aspx
  
6738CastandSplintApplicationsandAssociatedSupplies00.10.15dAdministrative (00)00.10.15d00.10.15ff41fdec-319e-4608-be2d-eee15f3bec86Cast and Splint Applications and Associated SuppliesCast and Splint Applications and Associated Supplies
{"6739": {"Id":6739,"MPAttachmentLetter":"A","Title":"Procedure Codes Related to Cast and Splint Applications and Associated Supplies","MPPolicyAttachmentInternalSourceId":8996,"PolicyAttachmentPageName":"e57f2559-9175-4c80-b8ea-259381682441"},}
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6493CataractSurgery11.01.07gSurgery (11)11.01.07g11.01.07fec31763-44fc-4101-8f21-6605830732d7Cataract SurgeryCataract Surgery
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7096CatheterAblationofCardiacArrhythmias11.02.06rSurgery (11)11.02.06r11.02.069df2f9df-0706-42e3-a35e-1d9bd498052cCatheter Ablation of Cardiac ArrhythmiasCatheter Ablation of Cardiac Arrhythmias
a78797d7-fe01-4323-b932-9f3f27ddc346.aspx
  
6988Cemiplimab-rwlc(Libtayo®)08.01.66dPharmacy (08)08.01.66d08.01.66a78797d7-fe01-4323-b932-9f3f27ddc346Cemiplimab-rwlc (Libtayo®)Cemiplimab-rwlc (Libtayo®)
5c89e0d7-8b1b-48bf-848d-445f4c9ddec5.aspx
  
7007Cerliponasealfa(Brineura®)08.01.39dPharmacy (08)08.01.39d08.01.395c89e0d7-8b1b-48bf-848d-445f4c9ddec5Cerliponase alfa (Brineura®)Cerliponase alfa (Brineura®)
{"7008": {"Id":7008,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements for Cerliponase alfa (Brineura®)","MPPolicyAttachmentInternalSourceId":9269,"PolicyAttachmentPageName":"5c4b9376-fdc2-4510-8dd6-440ed91b080e"},}
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7153CervicalTractionDevicesforIn-homeUse05.00.61hDME (05)05.00.61h05.00.61caf1a6dd-71ab-4537-a5f3-4aadda6bcb45Cervical 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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6853ChemicalPeels11.08.08hSurgery (11)11.08.08h11.08.0821a99081-eb8e-4ea4-93f5-62db83cc6161Chemical PeelsChemical Peels
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7109ChimericAntigenReceptor(CAR)Therapy08.01.43oPharmacy (08)08.01.43o08.01.4331128ea3-5cb2-4310-86b1-191a6caddf2dChimeric Antigen Receptor (CAR) TherapyChimeric Antigen Receptor (CAR) Therapy
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6544ChiropracticSpinalandExtraspinalManipulationTherapy10.02.02kRehabilitation Services (10)10.02.02k10.02.0203a1b92b-198a-466f-bdfb-61c4b8506e4dChiropractic Spinal and Extraspinal Manipulation TherapyChiropractic Spinal and Extraspinal Manipulation Therapy
98fcfd9e-fcb1-4332-ae80-c3c82d200989.aspx
  
7066CoagulationFactors08.00.92ahPharmacy (08)08.00.92ah08.00.9298fcfd9e-fcb1-4332-ae80-c3c82d200989Coagulation FactorsCoagulation Factors
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6603Cobalamin(VitaminB12),FolicAcid,andHomocysteineTesting06.02.54cPathology and Laboratory (06)06.02.54c06.02.546b7ebced-bcd0-4114-8045-d3344f571457Cobalamin (Vitamin B12), Folic Acid, and Homocysteine TestingCobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
{"6604": {"Id":6604,"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":8879,"PolicyAttachmentPageName":"8dfa2395-5829-45da-8e2b-8f9ba6540478"},}
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6337CochlearImplantation11.01.02rSurgery (11)11.01.02r11.01.0285d7a94a-d5ad-4974-87f1-423bc92c9205Cochlear 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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6651ColorectalCancerScreening11.03.12uSurgery (11)11.03.12u11.03.1207e946c3-ede9-491b-a58b-e8bd704ca61dColorectal Cancer ScreeningColorectal Cancer Screening
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6411ComplementaryandIntegrativeHealthServices12.00.03hMiscellaneous (12)12.00.03h12.00.03ba170083-35f9-4f1e-9e58-e68b05aa307aComplementary and Integrative Health ServicesComplementary and Integrative Health Services
2a646409-8ef0-4f1d-a82f-b8255abe7637.aspx
  
6648CompleteDecongestiveTherapy(CDT)07.06.01bMedicine (07)07.06.01b07.06.012a646409-8ef0-4f1d-a82f-b8255abe7637Complete 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
808d9177-9c6a-4134-9a81-abe8964f00a0.aspx
  
6723Computer-AidedDetection(CAD)SystemforUsewithChestRadiographs09.00.42dRadiology (09)09.00.42d09.00.42808d9177-9c6a-4134-9a81-abe8964f00a0Computer-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
1fc8159e-2b1f-42e2-975e-fe9ef1aae41b.aspx
  
6418ConsultationServices00.01.69bAdministrative (00)00.01.69b00.01.691fc8159e-2b1f-42e2-975e-fe9ef1aae41bConsultation ServicesConsultation Services
d6d7e319-5af2-4f69-8fc0-7a90f8d7d80b.aspx
  
6643ContactLensesfortheTreatmentofPersistent(Corneal)EpithelialDefects07.13.11kMedicine (07)07.13.11k07.13.11d6d7e319-5af2-4f69-8fc0-7a90f8d7d80bContact 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
a1f7886c-2785-4dc7-bfaf-eb44b5577a4d.aspx
  
6525CornealPachymetryUsingUltrasound07.13.07lMedicine (07)07.13.07l07.13.07a1f7886c-2785-4dc7-bfaf-eb44b5577a4dCorneal Pachymetry Using UltrasoundCorneal Pachymetry Using Ultrasound
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6304CoronaryArteryCalcium(CAC)TestingUsingComputedTomography(AmeriHealthAdministrators)09.00.58Radiology (09)09.00.5809.00.5895fe317c-cc2c-4f35-be30-a227f8fcb371Coronary 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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7091CoverageofAnticancerPrescriptionOralandInjectableDrugsandBiologicsandSupportiveAgents08.01.08sPharmacy (08)08.01.08s08.01.083bcd8a4a-5cc7-4b63-b452-bd6e235dbadcCoverage 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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6936CoverageofMedicalDevices05.00.04eDME (05)05.00.04e05.00.0421580a78-eec4-4b84-a973-1315467a0db9Coverage of Medical DevicesCoverage of Medical Devices
e6fa1ee9-b65c-4dc7-8cb6-4f43c749322b.aspx
  
6482CranialElectrotherapyStimulation05.00.80dDME (05)05.00.80d05.00.80e6fa1ee9-b65c-4dc7-8cb6-4f43c749322bCranial 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)
185338ad-41d3-418a-8747-c8d402f4c6ff.aspx
  
6989CriteriaforReimbursementofEmergencyRoomServices00.10.03lAdministrative (00)00.10.03l00.10.03185338ad-41d3-418a-8747-c8d402f4c6ffCriteria for Reimbursement of Emergency Room ServicesCriteria for Reimbursement of Emergency Room Services
b13eb749-bcbf-4a49-9865-64e96d61b947.aspx
  
6439crizanlizumab-tmca(Adakveo®)08.00.04aPharmacy (08)08.00.04a08.00.04b13eb749-bcbf-4a49-9865-64e96d61b947crizanlizumab-tmca (Adakveo®)crizanlizumab-tmca (Adakveo®)
aabae9b6-4fc1-47d0-bfdb-a233c71259c4.aspx
  
7061Crovalimab-akkz(Piasky)08.02.31Pharmacy (08)08.02.3108.02.31aabae9b6-4fc1-47d0-bfdb-a233c71259c4Crovalimab-akkz (Piasky)Crovalimab-akkz (Piasky)
7e3fde8b-e5b5-405b-8ce0-009e29458622.aspx
  
6635CryosurgicalAblationoftheProstateGland11.11.03dSurgery (11)11.11.03d11.11.037e3fde8b-e5b5-405b-8ce0-009e29458622Cryosurgical Ablation of the Prostate GlandCryosurgical Ablation of the Prostate Gland
34c27cb0-972d-4a80-b60b-1e81b353d8e9.aspx
  
6679Daratumumab(Darzalex®),DaratumumabandHyaluronidase-fihj(DarzalexFaspro®)08.01.29lPharmacy (08)08.01.29l08.01.2934c27cb0-972d-4a80-b60b-1e81b353d8e9Daratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®)Daratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®)
f51fc115-617f-4fda-adec-b8413749d2b9.aspx
  
6906DayRehabilitation10.00.02cRehabilitation Services (10)10.00.02c10.00.02f51fc115-617f-4fda-adec-b8413749d2b9Day RehabilitationDay Rehabilitation
19d4f8f5-e16c-4aff-9f5a-2a9d99fc69d1.aspx
  
6358DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNails11.08.17kSurgery (11)11.08.17k11.08.1719d4f8f5-e16c-4aff-9f5a-2a9d99fc69d1Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe NailsDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
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6972DeepBrainStimulation(DBS)11.15.20tSurgery (11)11.15.20t11.15.2068047524-e0c8-4220-808d-abb635d1ef30Deep Brain Stimulation (DBS)Deep Brain Stimulation (DBS)
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