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b59cae2d-57f8-4cdb-b9af-b182573fa7a3.aspx
  
4316Abatacept(Orencia®)forInjectionforIntravenousUse08.00.62nPharmacy (08)08.00.62n08.00.62b59cae2d-57f8-4cdb-b9af-b182573fa7a3Abatacept (Orencia®) for Injection for Intravenous UseAbatacept (Orencia®) for Injection for Intravenous Use
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4562Acupuncture(AmeriHealth)12.00.01gMiscellaneous (12)12.00.01g12.00.01db140092-e4a2-4209-b40c-6aa36c212743Acupuncture (AmeriHealth)Acupuncture (AmeriHealth)
{"4563": {"Id":4563,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Acupuncture","MPPolicyAttachmentInternalSourceId":6539,"PolicyAttachmentPageName":"950b5367-3996-47a3-bfb5-883cefbfa427"},}
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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
4c4e349b-96ae-4b67-8665-e39cf4b971d0.aspx
  
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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4427Aducanumab(Aduhelm)forAlzheimerDisease08.01.93Pharmacy (08)08.01.9308.01.93d9e41786-d397-4077-99ef-24e9b3106343Aducanumab (Aduhelm) for Alzheimer DiseaseAducanumab (Aduhelm) for Alzheimer Disease
6b63a7e1-4463-4e1e-b63d-9246fce9041a.aspx
  
4174Agalsidasebeta(Fabrazyme®)08.00.69cPharmacy (08)08.00.69c08.00.696b63a7e1-4463-4e1e-b63d-9246fce9041aAgalsidase beta (Fabrazyme®)Agalsidase beta (Fabrazyme®)
c7c932d9-9c5e-4b7d-845e-a6b2b3a53835.aspx
  
3383AirAmbulanceServices12.04.03cMiscellaneous (12)12.04.03c12.04.03c7c932d9-9c5e-4b7d-845e-a6b2b3a53835Air Ambulance ServicesAir Ambulance Services
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4304Alemtuzumab(Lemtrada®)08.01.22dPharmacy (08)08.01.22d08.01.2240672c4d-e4fc-4fb0-9cea-cfbd53b89f1cAlemtuzumab (Lemtrada®)Alemtuzumab (Lemtrada®)
db78fe85-fc99-4a2e-abea-24e3940e2471.aspx
  
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® )
5bebba01-0b42-45ed-ae07-f386ffcff954.aspx
  
3199AllergyImmunotherapy07.00.21jMedicine (07)07.00.21j07.00.215bebba01-0b42-45ed-ae07-f386ffcff954Allergy ImmunotherapyAllergy Immunotherapy
3a1f86ae-9d7b-4d18-a99c-b44ed0f6cd73.aspx
  
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®)
ecd32c25-e4fc-44ae-b107-02cd1a65f035.aspx
  
4490AlloMap™MolecularExpressionTestingforHeartTransplantRejection(AmeriHealthAdministrators)06.02.29dPathology and Laboratory (06)06.02.29d06.02.29ecd32c25-e4fc-44ae-b107-02cd1a65f035AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)
610ebc32-c1f7-43c8-9899-232ac2a13716.aspx
  
4305Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C®,AralastNP®,Glassia®,Zemaira®)08.00.91ePharmacy (08)08.00.91e08.00.91610ebc32-c1f7-43c8-9899-232ac2a13716Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)
1c16cded-b770-4aa4-b763-1204e1dc69d5.aspx
  
4207AlwaysBundledProcedureCodes00.01.52pAdministrative (00)00.01.52p00.01.521c16cded-b770-4aa4-b763-1204e1dc69d5Always Bundled Procedure CodesAlways Bundled Procedure Codes
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4517AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)Devices07.02.09gMedicine (07)07.02.09g07.02.0917b4a0fe-371b-4ed1-be41-1801b412a277Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) DevicesAmbulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
566dc299-1d7d-47a0-b25f-8aa0a7df906f.aspx
  
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
980512de-305e-46eb-a71f-bd4469be1e29.aspx
  
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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cce61d28-3be6-4b9a-ac5f-58bb099d245c.aspx
  
4307Anifrolumab-fnia(Saphnelo™)08.01.82bPharmacy (08)08.01.82b08.01.82cce61d28-3be6-4b9a-ac5f-58bb099d245cAnifrolumab-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
{"3457": {"Id":3457,"MPAttachmentLetter":"A","Title":"HCPCS Codes","MPPolicyAttachmentInternalSourceId":5437,"PolicyAttachmentPageName":"5d32ce1c-b867-42d3-b5ce-2492f31a60d6"},}
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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"},}
dded1e10-c31a-4a82-8e28-71bd8f6156a3.aspx
  
4380AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucoma11.05.16kSurgery (11)11.05.16k11.05.16dded1e10-c31a-4a82-8e28-71bd8f6156a3Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
{"4381": {"Id":4381,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":6349,"PolicyAttachmentPageName":"a369496c-21f6-451d-ad7b-d1e2b6444335"},}
9140ddf8-1261-4329-91de-d8a3307362e0.aspx
  
4438ArtificialIntervertebralCervicalDiscInsertion(AmerihealthAdministrators)11.14.19pSurgery (11)11.14.19p11.14.199140ddf8-1261-4329-91de-d8a3307362e0Artificial Intervertebral Cervical Disc Insertion (Amerihealth Administrators)Artificial Intervertebral Cervical Disc Insertion (Amerihealth Administrators)
a8188232-a8c3-452b-b969-c8204227e8c1.aspx
  
4467ArtificialIntervertebralLumbarDiscInsertion11.15.31aSurgery (11)11.15.31a11.15.31a8188232-a8c3-452b-b969-c8204227e8c1Artificial Intervertebral Lumbar Disc InsertionArtificial Intervertebral Lumbar Disc Insertion
84cbb299-b398-41f9-8fca-e8636350d26e.aspx
  
4552AsparaginaseErwiniaChrysanthemi(Erwinaze®),asparaginaseerwiniachrysanthemi(recombinant)-rywn(Rylaze™)08.01.35fPharmacy (08)08.01.35f08.01.3584cbb299-b398-41f9-8fca-e8636350d26eAsparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze™)Asparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze™)
409b7171-d1a6-4ae0-9438-21770a53e0fb.aspx
  
4489AssaysofGeneticExpressioninTumorTissueforBreastCancerPrognosis(AmeriHealthAdministrators)06.02.27nPathology and Laboratory (06)06.02.27n06.02.27409b7171-d1a6-4ae0-9438-21770a53e0fbAssays 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)
79b13a12-1743-4991-8438-7312e26bd409.aspx
  
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
82b3e9e5-7ed1-47c0-813a-b54b0f5797a6.aspx
  
4114Atezolizumab(Tecentriq®)08.01.69bPharmacy (08)08.01.69b08.01.6982b3e9e5-7ed1-47c0-813a-b54b0f5797a6Atezolizumab (Tecentriq®)Atezolizumab (Tecentriq®)
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cfa96a75-c968-44fb-9c95-1f89049557bc.aspx
  
4439AutologousChondrocyteImplantation(ACI)andOtherCell-basedTreatmentsofFocalArticularCartilageLesions(AmerihealthAdministrators)11.14.06jSurgery (11)11.14.06j11.14.06cfa96a75-c968-44fb-9c95-1f89049557bcAutologous 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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4337AutonomicNervousSystemTesting07.03.23eMedicine (07)07.03.23e07.03.2306b9390d-72af-4986-9dd1-029d8eb4a124Autonomic Nervous System TestingAutonomic Nervous System Testing
434a7d30-72aa-4ef4-ab31-7dfb73669346.aspx
  
4013Avelumab(Bavencio®)08.01.64aPharmacy (08)08.01.64a08.01.64434a7d30-72aa-4ef4-ab31-7dfb73669346Avelumab (Bavencio®)Avelumab (Bavencio®)
{"4014": {"Id":4014,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":6026,"PolicyAttachmentPageName":"e759f4b7-37b6-43d6-a60d-a1d1b5f94081"},}
926a095e-bacc-47d8-9382-4a5601a1aa8a.aspx
  
4372BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitis11.16.06jSurgery (11)11.16.06j11.16.06926a095e-bacc-47d8-9382-4a5601a1aa8aBalloon Catheter Dilation of Sinus Ostia for Treatment of Chronic RhinosinusitisBalloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
deb6788b-9378-4634-bea1-f71971bb7026.aspx
  
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"},}
246806c0-46da-409c-b330-cdc5192c284a.aspx
  
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
5062db65-0522-438f-ace1-ea10b9a34423.aspx
  
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"},}
e862bc0b-0289-4661-bf0a-950e2efca6ee.aspx
  
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"},}
704d8479-8073-4f31-8bc7-6b30ae0e1a63.aspx
  
4394BiofeedbackTherapy07.00.01jMedicine (07)07.00.01j07.00.01704d8479-8073-4f31-8bc7-6b30ae0e1a63Biofeedback TherapyBiofeedback Therapy
4f6901b4-8f19-4b3f-97f5-802d005c75cf.aspx
  
4368BioimpedencefortheDetectionofLymphedema07.06.03bMedicine (07)07.06.03b07.06.034f6901b4-8f19-4b3f-97f5-802d005c75cfBioimpedence 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"},}
01f91949-1097-4a9e-9302-81f23de23bff.aspx
  
4375Blinatumomab(Blincyto®)08.01.21ePharmacy (08)08.01.21e08.01.2101f91949-1097-4a9e-9302-81f23de23bffBlinatumomab (Blincyto®)Blinatumomab (Blincyto®)
997f0eec-1c84-4f92-8c99-9f71ba9eff70.aspx
  
4535Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAids11.01.06fSurgery (11)11.01.06f11.01.06997f0eec-1c84-4f92-8c99-9f71ba9eff70Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing AidsBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
1b72f027-1432-4772-bb35-79b0aaf2d704.aspx
  
4548BoneMineralDensity(BMD)Testing09.00.04lRadiology (09)09.00.04l09.00.041b72f027-1432-4772-bb35-79b0aaf2d704Bone 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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4418BotulinumToxinAgents08.00.26yPharmacy (08)08.00.26y08.00.268b797281-0cdf-4bcb-945c-86e366e26c73Botulinum Toxin AgentsBotulinum Toxin Agents
{"4419": {"Id":4419,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":6206,"PolicyAttachmentPageName":"ff03e2e1-9558-4c32-8fc8-89904d728032"},}
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4495BrachytherapyandAcceleratedWholeBreastIrradiationusingThree-DimensionalConformationRadiationTherapy09.00.10zRadiology (09)09.00.10z09.00.10f581558f-daff-4a3d-8a3f-4a5256e1bf06Brachytherapy 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
5d83e546-8121-41f2-8b1c-cd63329365f6.aspx
  
4373BrentuximabVedotin(Adcetris®)08.01.13gPharmacy (08)08.01.13g08.01.135d83e546-8121-41f2-8b1c-cd63329365f6Brentuximab Vedotin (Adcetris®)Brentuximab Vedotin (Adcetris®)
{"4374": {"Id":4374,"MPAttachmentLetter":"A","Title":"ICD CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":6279,"PolicyAttachmentPageName":"be3b8439-79ca-41d3-9294-cd5dfed42add"},}
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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®)
e134070f-ecb7-4fbb-a722-4ce215467b1e.aspx
  
4410CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)Programs10.01.01nRehabilitation Services (10)10.01.01n10.01.01e134070f-ecb7-4fbb-a722-4ce215467b1eCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) ProgramsCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
{"4411": {"Id":4411,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":6426,"PolicyAttachmentPageName":"4f3bbe2e-cb25-42fa-bb2a-9a04826c0808"},}
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4303CareManagementandCarePlanningServices00.01.59kAdministrative (00)00.01.59k00.01.59e4e11105-47c0-4727-8422-789680c20fa0Care 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®)
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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3990CataractSurgery11.01.07fSurgery (11)11.01.07f11.01.070127f7e1-d5a9-4dff-a9de-d30cca593715Cataract SurgeryCataract Surgery
{"3991": {"Id":3991,"MPAttachmentLetter":"A","Title":"ICD 10 codes for policy 11.01.07d, Cataract Surgery","MPPolicyAttachmentInternalSourceId":6072,"PolicyAttachmentPageName":"4401bd85-8ea3-4169-aca4-37ff08cf69f3"},}
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4460CatheterAblationofCardiacArrhythmias11.02.06nSurgery (11)11.02.06n11.02.06846d1219-299e-4dee-95d1-a5d2c31744f1Catheter 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
97676303-7d9b-4fac-b144-cbb4ef0f89d2.aspx
  
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
{"3980": {"Id":3980,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":6115,"PolicyAttachmentPageName":"3cd16772-be0e-4e1a-91fc-4d425322b6dd"},}
79223218-5ff1-491f-aae1-eb232d8fa401.aspx
  
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™)
21915e7a-f45a-4006-aab9-6b31af07abe7.aspx
  
3897ColorectalCancerScreening11.03.12tSurgery (11)11.03.12t11.03.1221915e7a-f45a-4006-aab9-6b31af07abe7Colorectal Cancer ScreeningColorectal Cancer Screening
78256c85-c80a-49b2-a307-d5efd4b20b60.aspx
  
4362ComplementaryandIntegrativeHealthServices12.00.03gMiscellaneous (12)12.00.03g12.00.0378256c85-c80a-49b2-a307-d5efd4b20b60Complementary and Integrative Health ServicesComplementary and Integrative Health Services
548dc3c9-5890-41ab-9876-91c5c8624a2a.aspx
  
4367CompleteDecongestiveTherapy(CDT)07.06.01bMedicine (07)07.06.01b07.06.01548dc3c9-5890-41ab-9876-91c5c8624a2aComplete Decongestive Therapy (CDT)Complete Decongestive Therapy (CDT)
a42ccacb-d5a0-4c70-a25e-f5bd64c12a9d.aspx
  
4397CompositeTissueAllotransplantationoftheHand(s)andFace11.14.30Surgery (11)11.14.3011.14.30a42ccacb-d5a0-4c70-a25e-f5bd64c12a9dComposite Tissue Allotransplantation of the Hand(s) and FaceComposite Tissue Allotransplantation of the Hand(s) and Face
5380975a-b823-4c68-a242-ddbeb70ce277.aspx
  
4391CompressionGarments05.00.37fDME (05)05.00.37f05.00.375380975a-b823-4c68-a242-ddbeb70ce277Compression GarmentsCompression Garments
e456d809-ee47-437a-9b1d-5125ba6cc561.aspx
  
4458Computer-AidedDetection(CAD)SystemforUsewithChestRadiographs09.00.42cRadiology (09)09.00.42c09.00.42e456d809-ee47-437a-9b1d-5125ba6cc561Computer-Aided Detection (CAD) System for Use with Chest RadiographsComputer-Aided Detection (CAD) System for Use with Chest Radiographs
38daba5e-1856-49a3-aa83-ad18bb5ba2ce.aspx
  
4351Computer-assistedMusculoskeletalSurgicalNavigationalOrthopedicProcedure11.14.17eSurgery (11)11.14.17e11.14.1738daba5e-1856-49a3-aa83-ad18bb5ba2ceComputer-assisted Musculoskeletal Surgical Navigational Orthopedic ProcedureComputer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
3186b005-9972-4b7a-9585-4e09e7c6e6dc.aspx
  
4325ConsultationServices00.01.69aAdministrative (00)00.01.69a00.01.693186b005-9972-4b7a-9585-4e09e7c6e6dcConsultation 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
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4382CornealPachymetryUsingUltrasound07.13.07lMedicine (07)07.13.07l07.13.07abc9baf4-9e1b-4c13-bb6f-f5f65d443558Corneal 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
8edfe7eb-dfcc-448f-ac70-e594d9a36f31.aspx
  
4431CoverageofAnticancerPrescriptionOralandInjectableDrugsandBiologicsandSupportiveAgents08.01.08iPharmacy (08)08.01.08i08.01.088edfe7eb-dfcc-448f-ac70-e594d9a36f31Coverage 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)
85256AA800623D7A852584710058EC0E.aspx
  
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®)
f1cff10d-b7bc-40e7-b5db-a6fe5f3bf3f2.aspx
  
4370CryosurgicalAblationoftheProstateGland11.11.03dSurgery (11)11.11.03d11.11.03f1cff10d-b7bc-40e7-b5db-a6fe5f3bf3f2Cryosurgical Ablation of the Prostate GlandCryosurgical Ablation of the Prostate Gland
bac83114-7a60-4245-84f3-bd19dc5948d3.aspx
  
4558Daratumumab(Darzalex®),Daratumumab,andHyaluronidase-fihj(DarzalexFaspro®)08.01.29jPharmacy (08)08.01.29j08.01.29bac83114-7a60-4245-84f3-bd19dc5948d3Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®)Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®)
4f48cc01-773e-4a32-8967-91fb9b6a67c8.aspx
  
4579DayRehabilitation10.00.02cRehabilitation Services (10)10.00.02c10.00.024f48cc01-773e-4a32-8967-91fb9b6a67c8Day RehabilitationDay Rehabilitation
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4461DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNails11.08.17kSurgery (11)11.08.17k11.08.17bcecfc79-5868-4b61-a23c-84617b4e8ce0Debridement 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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4440DenervationoftheSpinalNervesforChronicPain(AmerihealthAdministrators)11.15.09pSurgery (11)11.15.09p11.15.09c640021e-dceb-4c7f-8b99-bce3299e1a43Denervation 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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4311Dofetilide(Tikosyn®)UseintheInpatientSetting08.00.49ePharmacy (08)08.00.49e08.00.49629348a3-2cb6-4acb-a446-4830710627b9Dofetilide (Tikosyn®) Use in the Inpatient SettingDofetilide (Tikosyn®) Use in the Inpatient Setting
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