|  | | 2454 | Abatacept (Orencia®) for Injection for Intravenous Use | Pharmacy (08) | 08.00.62j | 08.00.62 | 85256AA800623D7A852584EB005E0702 | Abatacept (Orencia®) for Injection for Intravenous Use | Abatacept (Orencia®) For Injection For Intravenous Use | {"2367":{"Id":2367,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584EB005E070C"},} |
| | | 1583 | Acupuncture (AmeriHealth) | Miscellaneous (12) | 12.00.01f | 12.00.01 | 85256AA800623D7A8525850D004EBC50 | Acupuncture (AmeriHealth) | Acupuncture (AmeriHealth) | {"2393":{"Id":2393,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Acupuncture","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525850D004EBC58"},} |
| | | 1585 | Acute Care Facility Inpatient Transfers | Miscellaneous (12) | 12.04.04a | 12.04.04 | 85256AA800623D7A85258596007CD987 | Acute Care Facility Inpatient Transfers | Acute Care Facility Inpatient Transfers | |
| | | 1656 | Ado-Trastuzumab Emtansine (Kadcyla®) | Pharmacy (08) | 08.01.11e | 08.01.11 | 85256AA800623D7A852583C4005C4617 | Ado-Trastuzumab Emtansine (Kadcyla®) | Ado-Trastuzumab Emtansine (Kadcyla®) | {"2240":{"Id":2240,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes and Narratives","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852583C4005C461D"},} |
| | | 1841 | Agalsidase beta (Fabrazyme®) | Pharmacy (08) | 08.00.69b | 08.00.69 | 85256AA800623D7A852585420071736C | Agalsidase beta (Fabrazyme®) | Agalsidase beta (Fabrazyme®) | |
| | | 1586 | Air Ambulance Services | Miscellaneous (12) | 12.04.03c | 12.04.03 | 85256AA800623D7A85258596007D3BA6 | Air Ambulance Services | Air Ambulance Services | |
| | | 1864 | Alemtuzumab (Lemtrada®) | Pharmacy (08) | 08.01.22d | 08.01.22 | 85256AA800623D7A852584EB005B947D | Alemtuzumab (Lemtrada®) | Alemtuzumab (Lemtrada®) | |
| | | 1842 | Alglucosidase alfa (e.g., Lumizyme®) | Pharmacy (08) | 08.00.72h | 08.00.72 | 85256AA800623D7A8525854200710D18 | Alglucosidase alfa (e.g., Lumizyme®) | Alglucosidase alfa (e.g., Lumizyme®) | |
| | | 1790 | Allergy Immunotherapy | Medicine (07) | 07.00.21i | 07.00.21 | 85256AA800623D7A852584E900723F3A | Allergy Immunotherapy | Allergy Immunotherapy | |
| | | 1815 | AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators) | Pathology and Laboratory (06) | 06.02.29d | 06.02.29 | 85256AA800623D7A8525852F00700BD2 | AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators) | AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators) | |
| | | 1803 | Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™) | Pharmacy (08) | 08.00.91d | 08.00.91 | C0BF3216424958498525851F0065B493 | Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™) | Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™) | |
| | | 1971 | Always Bundled Procedure Codes | Administrative (00) | 00.01.52i | 00.01.52 | 85256AA800623D7A852584BE0061748B | Always Bundled Procedure Codes | Always Bundled Procedure Codes | {"2323":{"Id":2323,"MPAttachmentLetter":"A","Title":"CPT Codes and HCPCS Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584BE00617493"},} |
| | | 1851 | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | Medicine (07) | 07.02.09g | 07.02.09 | 85256AA800623D7A8525852700657888 | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | |
| | | 1772 | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | Medicine (07) | 07.02.21e | 07.02.21 | 85256AA800623D7A8525849B0072BC56 | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | |
| | | 1674 | Ankle-Foot/Knee-Ankle-Foot Orthoses | DME (05) | 05.00.39o | 05.00.39 | 85256AA800623D7A8525847900595D5D | Ankle-Foot/Knee-Ankle-Foot Orthoses | Ankle-Foot/Knee-Ankle-Foot Orthoses | {"2250":{"Id":2250,"MPAttachmentLetter":"A","Title":"HCPCS Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525847900595D63"},} |
| | | 1605 | Apheresis Therapy | Pathology and Laboratory (06) | 06.03.04n | 06.03.04 | 85256AA800623D7A852581E800531E7B | Apheresis Therapy | Apheresis Therapy | |
| | | 1676 | Application and Removal of Tattoos | Surgery (11) | 11.08.05g | 11.08.05 | 85256AA800623D7A85258464005D7037 | Application and Removal of Tattoos | Application and Removal of Tattoos | |
| | | 1843 | Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®) | Pharmacy (08) | 08.01.41c | 08.01.41 | 85256AA800623D7A8525853E004B8BDF | Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®) | Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®) | {"2347":{"Id":2347,"MPAttachmentLetter":"A","Title":"Risk of Emesis Without Prophylaxis: Intravenous and Oral Antineoplastic Agents","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525853E004B8C13"},} |
| | | 1660 | Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | Surgery (11) | 11.05.16h | 11.05.16 | 85256AA800623D7A85258397005A3BB6 | Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | {"2242":{"Id":2242,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258397005A3BBF"},} |
| | | 1543 | Artificial Intervertebral Disc Insertion | Surgery (11) | 11.14.19o | 11.14.19 | A3A0632A8125CAEF85258588005C3C90 | Artificial Intervertebral Disc Insertion | Artificial Intervertebral Disc Insertion | |
| | | 1739 | Asparaginase Erwinia Chrysanthemi (Erwinaze®) | Pharmacy (08) | 08.01.35b | 08.01.35 | 85256AA800623D7A8525848D004D1680 | Asparaginase Erwinia Chrysanthemi (Erwinaze®) | Asparaginase Erwinia Chrysanthemi (Erwinaze®) | |
| | | 1596 | Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (AmeriHealth Administrators) | Pathology and Laboratory (06) | 06.02.27l | 06.02.27 | 85256AA800623D7A852585A4006521E2 | Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (AmeriHealth Administrators) | Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (AmeriHealth Administrators) | |
| | | 1779 | Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation | Medicine (07) | 07.10.06h | 07.10.06 | 85256AA800623D7A852584C500591919 | Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation | Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation | |
| | | 1551 | Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions | Surgery (11) | 11.14.06i | 11.14.06 | 85256AA800623D7A8525849B004313B6 | Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions | Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions | |
| | | 2426 | Automatic External Cardioverter Defibrillators (Wearable and Nonwearable) | DME (05) | 05.00.29l | 05.00.29 | A0450B1CECA727FF852585AB00533565 | Automatic External Cardioverter Defibrillators (Wearable and Nonwearable) | Automatic External Cardioverter Defibrillators (Wearable and Nonwearable) | {"2435": {"Id":2435,"MPAttachmentLetter":"B","Title":"ICD-10 codes used to represent the Nonwearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"DE272CF959A83D46852585AB00533585"},"2436": {"Id":2436,"MPAttachmentLetter":"A","Title":"ICD-10 Codes used to represent the Wearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"5080E542121FA54B852585AB0053357F"},} |
| | | 1561 | Autonomic Nervous System Testing | Medicine (07) | 07.03.23c | 07.03.23 | 85256AA800623D7A85258535005F4262 | Autonomic Nervous System Testing | Autonomic Nervous System Testing | |
| | | 2482 | Avelumab(Bavencio®)08.01.64 | Pharmacy (08) | 08.01.64 | 08.01.64 | 062d4c58-12d3-4969-b37b-8e58d6aef3ba | Avelumab (Bavencio®) | Avelumab (Bavencio®) | {"2483": {"Id":2483,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":2486,"PolicyAttachmentPageName":"c8c8c64e-3156-4e08-96fe-46526051edba"},} |
| | | 1768 | Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis | Surgery (11) | 11.16.06j | 11.16.06 | 85256AA800623D7A852584C80048DC59 | Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis | Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis | |
| | | 1782 | Bariatric Surgery | Surgery (11) | 11.03.02s | 11.03.02 | 85256AA800623D7A852584E0005DE542 | Bariatric Surgery | Bariatric Surgery | {"2329":{"Id":2329,"MPAttachmentLetter":"A","Title":"Body Mass Index (BMI) Charts","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584E0005DE54F"},"2330":{"Id":2330,"MPAttachmentLetter":"B","Title":"Tanner Staging System Criteria for Adolescents","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584E0005DE554"},"2331":{"Id":2331,"MPAttachmentLetter":"C","Title":"ICD-10-CM codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584E0005DE558"},} |
| | | 1534 | Belimumab (Benlysta®) for Intravenous Use | Pharmacy (08) | 08.00.99c | 08.00.99 | 85256AA800623D7A852584EB005DFB48 | Belimumab (Benlysta®) for Intravenous Use | Belimumab (Benlysta®) for Intravenous Use | |
| | | 1867 | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | Pharmacy (08) | 08.00.66n | 08.00.66 | 6566BD92D37238AE8525856900675D9F | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | {"2354":{"Id":2354,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"22FCB0309FA06CF48525856900675DB5"},} |
| | | 1985 | Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus | Administrative (00) | 00.10.39l | 00.10.39 | 21B5108DBB59C30C8525854B0059E5B9 | Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus | Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus | {"2349":{"Id":2349,"MPAttachmentLetter":"A","Title":"No Title","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"9640A916A3C2C7C98525854B0059E5C9"},} |
| | | 1969 | Billing Requirements for Multiple Births for Professional Providers | Administrative (00) | 00.10.38a | 00.10.38 | 85256AA800623D7A852584B100666803 | Billing Requirements for Multiple Births for Professional Providers | Billing Requirements for Multiple Births for Professional Providers | {"2312":{"Id":2312,"MPAttachmentLetter":"A","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ROUTINE OBSTETRIC (GLOBALE MATERNITY/OBSTETRIC [OB]) CARE WAS PROVIDED","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584B1006EAA44"},"2313":{"Id":2313,"MPAttachmentLetter":"B","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ANETEPARTUM CARE IS NOT PROVIDED","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584B1006EDFF6"},"2314":{"Id":2314,"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":0,"PolicyAttachmentPageName":"85256AA800623D7A852584B1006F0E36"},"2315":{"Id":2315,"MPAttachmentLetter":"D","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF HIGH-ORDER MULTIPLES WHEN ANTEPARTUM CARE IS NOT PROVIDED","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584B1006F364A"},} |
| | | 1762 | Biofeedback Therapy | Medicine (07) | 07.00.01i | 07.00.01 | 85256AA800623D7A852584C800740AEF | Biofeedback Therapy | Biofeedback Therapy | |
| | | 1821 | Bioimpedance for the Detection of Lymphedema | Medicine (07) | 07.06.03b | 07.06.03 | 85256AA800623D7A852585340044B9F1 | Bioimpedance for the Detection of Lymphedema | Bioimpedance for the Detection of Lymphedema | |
| | | 1611 | Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy | Surgery (11) | 11.05.02i | 11.05.02 | 85256AA800623D7A85258336004611B0 | Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy | Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy | {"2225":{"Id":2225,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258336004611BB"},} |
| | | 1636 | Blinatumomab (Blincyto®) | Pharmacy (08) | 08.01.21c | 08.01.21 | 85256AA800623D7A85258401004A12A1 | Blinatumomab (Blincyto®) | Blinatumomab (Blincyto®) | |
| | | 1804 | Bone Mineral Density (BMD) Testing | Radiology (09) | 09.00.04k | 09.00.04 | 85256AA800623D7A852584B80067B4E4 | Bone Mineral Density (BMD) Testing | Bone Mineral Density (BMD) Testing | |
| | | 1648 | Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids | Surgery (11) | 11.01.06e | 11.01.06 | 85256AA800623D7A852583F200496747 | Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids | Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids | |
| | | 1626 | Bortezomib (Bortezomib for Injection, Velcade®) | Pharmacy (08) | 08.00.73l | 08.00.73 | 85256AA800623D7A8525838400606BF9 | Bortezomib (Bortezomib for Injection, Velcade®) | Bortezomib (Bortezomib for Injection, Velcade®) | |
| | | 1537 | Botulinum Toxin Agents | Pharmacy (08) | 08.00.26w | 08.00.26 | 85256AA800623D7A8525853E005046D3 | Botulinum Toxin Agents | Botulinum Toxin Agents | {"2368":{"Id":2368,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525853E005046F5"},} |
| | | 1661 | Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (AmeriHealth Administrators) | Radiology (09) | 09.00.10z | 09.00.10 | 85256AA800623D7A852583B60065D7FE | Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (AmeriHealth Administrators) | Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (AmeriHealth Administrators) | |
| | | 1757 | Breast Pumps | DME (05) | 05.00.76c | 05.00.76 | 85256AA800623D7A852584C80074166B | Breast Pumps | Breast Pumps | |
| | | 1755 | Brentuximab Vedotin (Adcetris®) | Pharmacy (08) | 08.01.13d | 08.01.13 | 85256AA800623D7A8525848D004D1008 | Brentuximab Vedotin (Adcetris®) | Brentuximab Vedotin (Adcetris®) | {"2311":{"Id":2311,"MPAttachmentLetter":"A","Title":"ICD CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525848D004D1011"},} |
| | | 1601 | Bronchial Thermoplasty | Surgery (11) | 11.16.07b | 11.16.07 | 85256AA800623D7A852585A4005899AC | Bronchial Thermoplasty | Bronchial Thermoplasty | |
| | | 1680 | Burosumab-twza (Crysvita®) | Pharmacy (08) | 08.01.49a | 08.01.49 | 85256AA800623D7A8525847E006E285B | Burosumab-twza (Crysvita®) | Burosumab-twza (Crysvita®) | |
| | | 1590 | Cabazitaxel (Jevtana®) | Pharmacy (08) | 08.00.96e | 08.00.96 | 85256AA800623D7A8525853D005A168F | Cabazitaxel (Jevtana®) | Cabazitaxel (Jevtana®) | |
| | | 1875 | Canakinumab (Ilaris®) | Pharmacy (08) | 08.01.51 | 08.01.51 | 85256AA800623D7A852585660071B05C | Canakinumab (Ilaris®) | Canakinumab (Ilaris®) | |
| | | 1684 | Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs | Rehabilitation Services (10) | 10.01.01n | 10.01.01 | 85256AA800623D7A8525847E006A6590 | Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs | Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs | {"2252":{"Id":2252,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525847E006A6597"},} |
| | | 1974 | Care Management and Care Planning Services | Administrative (00) | 00.01.59f | 00.01.59 | 85256AA800623D7A8525847F0061D443 | Care Management and Care Planning Services | Care Management and Care Planning Services | |
| | | 1654 | Carfilzomib (Kyprolis™) | Pharmacy (08) | 08.01.05f | 08.01.05 | 85256AA800623D7A852583E60043F347 | Carfilzomib (Kyprolis™) | Carfilzomib (Kyprolis™) | |
| | | 1932 | Cast and Splint Applications and Associated Supplies Provided in the Office Setting | Administrative (00) | 00.10.15c | 00.10.15 | 82EF268AB3C7CA1E852581E9005653DB | Cast and Splint Applications and Associated Supplies Provided in the Office Setting | Cast and Splint Applications and Associated Supplies Provided in the Office Setting | {"2215":{"Id":2215,"MPAttachmentLetter":"A","Title":"No Title","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"4D63E2E2E70A4FA4852581E9005653EC"},} |
| | | 1531 | Cataract Surgery | Surgery (11) | 11.01.07e | 11.01.07 | 85256AA800623D7A85258574006D0BB6 | Cataract Surgery | Cataract Surgery | {"2364":{"Id":2364,"MPAttachmentLetter":"A","Title":"ICD 10 codes for policy 11.01.07d, Cataract Surgery","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258574006D0BFE"},} |
| | | 1695 | Catheter Ablation of Cardiac Arrhythmias | Surgery (11) | 11.02.06m | 11.02.06 | 85256AA800623D7A8525847B00611B55 | Catheter Ablation of Cardiac Arrhythmias | Catheter Ablation of Cardiac Arrhythmias | |
| | | 2427 | Cemiplimab-rwlc (LIBTAYO®) | Pharmacy (08) | 08.01.66 | 08.01.66 | 85256AA800623D7A8525857A004FE849 | Cemiplimab-rwlc (LIBTAYO®) | Cemiplimab-rwlc (LIBTAYO®) | |
| | | 1824 | Cerliponase alfa (Brineura®) | Pharmacy (08) | 08.01.39c | 08.01.39 | 85256AA800623D7A8525852F006D7D15 | Cerliponase alfa (Brineura®) | Cerliponase alfa (Brineura®) | |
| | | 1640 | Cervical Traction Devices for In-home Use | DME (05) | 05.00.61f | 05.00.61 | 85256AA800623D7A852583CC0054CDD8 | Cervical Traction Devices for In-home Use | Cervical Traction Devices for In-home Use | |
| | | 1730 | Cetuximab (Erbitux®) | Pharmacy (08) | 08.00.67l | 08.00.67 | 85256AA800623D7A8525846C00638C9B | Cetuximab (Erbitux®) | Cetuximab (Erbitux®) | {"2299":{"Id":2299,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525846C00638CAA"},"2300":{"Id":2300,"MPAttachmentLetter":"B","Title":"ICD-10 Codes for Cetuximab (Erbitux®)","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525846C00638CA4"},} |
| | | 1689 | Chemical Peels | Surgery (11) | 11.08.08g | 11.08.08 | 85256AA800623D7A85258464005D7623 | Chemical Peels | Chemical Peels | |
| | | 1735 | Chimeric Antigen Receptor (CAR) Therapy | Pharmacy (08) | 08.01.43e | 08.01.43 | 85256AA800623D7A852583E500468BCA | Chimeric Antigen Receptor (CAR) Therapy | Chimeric Antigen Receptor (CAR) Therapy | {"2302":{"Id":2302,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852583E500468BD0"},} |
| | | 1869 | Chiropractic Spinal and Extraspinal Manipulation Therapy | Rehabilitation Services (10) | 10.02.02j | 10.02.02 | CD5255F2AD53803E8525856C006F1209 | Chiropractic Spinal and Extraspinal Manipulation Therapy | Chiropractic Spinal and Extraspinal Manipulation Therapy | |
| | | 1575 | Coagulation Factors | Pharmacy (08) | 08.00.92ab | 08.00.92 | 85256AA800623D7A85258583006910C4 | Coagulation Factors | Coagulation Factors | |
| | | 1599 | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | Pathology and Laboratory (06) | 06.02.54 | 06.02.54 | 85256AA800623D7A852585A4006620E8 | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | {"2401":{"Id":2401,"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":0,"PolicyAttachmentPageName":"85256AA800623D7A852585A400662115"},} |
| | | 1778 | Cochlear Implant | Surgery (11) | 11.01.02o | 11.01.02 | 85256AA800623D7A852584C500591E9D | Cochlear Implant | Cochlear Implant | |
| | | 1834 | Colorectal Cancer Screening | Surgery (11) | 11.03.12s | 11.03.12 | 85256AA800623D7A85258538004FBB12 | Colorectal Cancer Screening | Colorectal Cancer Screening | |
| | | 1917 | Complementary and Integrative Health Services | Miscellaneous (12) | 12.00.03g | 12.00.03 | B55889244594F1F085258574005DA579 | Complementary and Integrative Health Services | Complementary and Integrative Health Services | |
| | | 1820 | Complete Decongestive Therapy (CDT) | Medicine (07) | 07.06.01b | 07.06.01 | 85256AA800623D7A852585340042F9F6 | Complete Decongestive Therapy (CDT) | Complete Decongestive Therapy (CDT) | |
| | | 1526 | Composite Tissue Allotransplantation of the Hand(s) and Face | Surgery (11) | 11.14.30 | 11.14.30 | 85256AA800623D7A852585380063AE75 | Composite Tissue Allotransplantation of the Hand(s) and Face | Composite Tissue Allotransplantation of the Hand(s) and Face | |
| | | 1582 | Compression Garments | DME (05) | 05.00.37f | 05.00.37 | 85256AA800623D7A8525855100776BC6 | Compression Garments | Compression Garments | |
| | | 1798 | Computer-Aided Detection (CAD) System for Use with Chest Radiographs | Radiology (09) | 09.00.42c | 09.00.42 | 85256AA800623D7A852584F2004C9E48 | Computer-Aided Detection (CAD) System for Use with Chest Radiographs | Computer-Aided Detection (CAD) System for Use with Chest Radiographs | |
| | | 1859 | Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures | Surgery (11) | 11.14.17d | 11.14.17 | 85256AA800623D7A852584E90067043F | Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures | Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures | |
| | | 1986 | Consultation Services | Administrative (00) | 00.01.69 | 00.01.69 | F3BA7DB0E980312B8525854B005EE64C | Consultation Services | Consultation Services | |
| | | 1724 | Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects | Medicine (07) | 07.13.11i | 07.13.11 | 85256AA800623D7A852584B600729006 | Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects | Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects | {"2298":{"Id":2298,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584B60072900D"},} |
| | | 1787 | Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump | Anesthesia (01) | 01.00.09c | 01.00.09 | 85256AA800623D7A852584E900724249 | Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump | Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump | |
| | | 1979 | Contrast Agents Used in Conjunction with Echocardiography | Radiology (09) | 09.00.11d | 09.00.11 | 85256AA800623D7A8525851B005C0BC6 | Contrast Agents Used in Conjunction with Echocardiography | Contrast Agents Used in Conjunction with Echocardiography | |
| | | 1721 | Corneal Pachymetry Using Ultrasound | Medicine (07) | 07.13.07j | 07.13.07 | 85256AA800623D7A852584B6006FCA09 | Corneal Pachymetry Using Ultrasound | Corneal Pachymetry Using Ultrasound | {"2295":{"Id":2295,"MPAttachmentLetter":"A","Title":"ICD-10-CM codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584B6006FCA0F"},} |
| | | 1631 | Cosmetic Procedures | Miscellaneous (12) | 12.01.03 | 12.01.03 | 85256AA800623D7A852583CC0054C214 | Cosmetic Procedures | Cosmetic Procedures | |
| | | 1953 | Coverage of Medical Devices | DME (05) | 05.00.04e | 05.00.04 | 85256AA800623D7A852583F900647246 | Coverage of Medical Devices | Coverage of Medical Devices | |
| | | 1858 | Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical Benefit | Pharmacy (08) | 08.01.08d | 08.01.08 | 85256AA800623D7A8525855000697D90 | Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical Benefit | Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical Benefit | |
| | | 1763 | Cranial Electrotherapy Stimulation | DME (05) | 05.00.80a | 05.00.80 | 85256AA800623D7A852584C80048E9C1 | Cranial Electrotherapy Stimulation | Cranial Electrotherapy Stimulation | |
| | | 1853 | Cranial Remolding Orthoses (Helmets) | DME (05) | 05.00.25i | 05.00.25 | B359B93517FDEAD385258550007A8C53 | Cranial Remolding Orthoses (Helmets) | Cranial Remolding Orthoses (Helmets) | |
| | | 1811 | Criteria for Reimbursement of Emergency Room Services | Administrative (00) | 00.10.03j | 00.10.03 | 85256AA800623D7A852584710058EC0E | Criteria for Reimbursement of Emergency Room Services | Criteria for Reimbursement of Emergency Room Services | |
| | | 1827 | Cryosurgical Ablation of the Prostate Gland | Surgery (11) | 11.11.03d | 11.11.03 | 85256AA800623D7A8525853000775E5F | Cryosurgical Ablation of the Prostate Gland | Cryosurgical Ablation of the Prostate Gland | |
| | | 2428 | Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro™) | Pharmacy (08) | 08.01.29f | 08.01.29 | 85256AA800623D7A8525856F00681F27 | Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro™) | Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro™) | |
| | | 1558 | Day Rehabilitation | Rehabilitation Services (10) | 10.00.02c | 10.00.02 | 85256AA800623D7A85258585004BD885 | Day Rehabilitation | Day Rehabilitation | |
| | | 1837 | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | Surgery (11) | 11.08.17i | 11.08.17 | 85256AA800623D7A85258527006587B4 | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | {"2341":{"Id":2341,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (A30.0 -E10.21)","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258527006587BF"},"2342":{"Id":2342,"MPAttachmentLetter":"B","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E10.22 - E13.3512), Continued","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258527006587C7"},"2343":{"Id":2343,"MPAttachmentLetter":"C","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E13.3513 - I87.093), Continued","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258527006587CD"},"2344":{"Id":2344,"MPAttachmentLetter":"D","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (I87.099 - S86.891S), Continued","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258527006587D3"},"2345":{"Id":2345,"MPAttachmentLetter":"E","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (S86.892A - Z79.01), Continued","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258527006587DB"},} |
| | | 1667 | Deep Brain Stimulation (DBS) | Surgery (11) | 11.15.20o | 11.15.20 | 85256AA800623D7A8525842B006B6CC3 | Deep Brain Stimulation (DBS) | Deep Brain Stimulation (DBS) | |
| | | 1547 | Denervation of the Spinal Nerves for Chronic Pain | Surgery (11) | 11.15.09n | 11.15.09 | 6E54370B49975A5A85258588005CDCC0 | Denervation of the Spinal Nerves for Chronic Pain | Denervation of the Spinal Nerves for Chronic Pain | |
| | | 1693 | Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™) | Pharmacy (08) | 08.00.94m | 08.00.94 | 85256AA800623D7A8525847A0047A1F9 | Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™) | Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™) | {"2258":{"Id":2258,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525847A0047A20C"},} |
| | | 1572 | Deoxycholic Acid (Kybella™) | Pharmacy (08) | 08.01.24a | 08.01.24 | 85256AA800623D7A852585880062FEBF | Deoxycholic Acid (Kybella™) | Deoxycholic Acid (Kybella™) | |
| | | 1984 | Diagnostic Radiology Services Included in Capitation | Administrative (00) | 00.03.02aa | 00.03.02 | 85256AA800623D7A85258513005AF2AB | Diagnostic Radiology Services Included in Capitation | Diagnostic Radiology Services Included in Capitation | {"2340":{"Id":2340,"MPAttachmentLetter":"A","Title":"Diagnostic Radiology Procedure Codes Included in Capitation for Pennsylvania (PA) Health Maintenance Organization (HMO) Members","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258513005AF2BC"},} |
| | | 1946 | Direct Access to Obstetrics/Gynecology (OB/GYN) Services | Administrative (00) | 00.09.01f | 00.09.01 | 85256AA800623D7A852582CD00532104 | Direct Access to Obstetrics/Gynecology (OB/GYN) Services | Direct Access to Obstetrics/Gynecology (OB/GYN) Services | |
| | | 1600 | Dofetilide (Tikosyn®) Use in the Inpatient Setting | Pharmacy (08) | 08.00.49e | 08.00.49 | 85256AA800623D7A852585A40063C332 | Dofetilide (Tikosyn®) Use in the Inpatient Setting | Dofetilide (Tikosyn®) Use in the Inpatient Setting | |
| | | 1737 | Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies | Medicine (07) | 07.05.07d | 07.05.07 | 85256AA800623D7A852584A300472C57 | Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies | Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies | |
| | | 1704 | Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Naltrexone Implants, Probuphine Implant, Sublocade Injection, Vivitrol Injection) | Pharmacy (08) | 08.01.37a | 08.01.37 | 85256AA800623D7A8525820B004EC0DE | Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Naltrexone Implants, Probuphine Implant, Sublocade Injection, Vivitrol Injection) | Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Naltrexone Implants, Probuphine Implant, Sublocade Injection, Vivitrol Injection) | |
| | | 1975 | Durable Medical Equipment (DME) and Consumable Medical Supplies | DME (05) | 05.00.21u | 05.00.21 | 85256AA800623D7A852584D60053CD80 | Durable Medical Equipment (DME) and Consumable Medical Supplies | Durable Medical Equipment (DME) and Consumable Medical Supplies | {"2326":{"Id":2326,"MPAttachmentLetter":"A1","Title":"Equipment that Meets the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584D60053CD90"},"2327":{"Id":2327,"MPAttachmentLetter":"A2","Title":"Equipment that Meets the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584D60053CD98"},"2328":{"Id":2328,"MPAttachmentLetter":"B","Title":"Items that Do Not Meet the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852584D60053CD9E"},} |
| | | 1941 | Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum | DME (05) | 05.00.48j | 05.00.48 | 85256AA800623D7A85258360004DAB8C | Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum | Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum | |
| | | 2486 | Durvalumab(Imfinzi™)08.01.65 | Pharmacy (08) | 08.01.65 | 08.01.65 | 35200c6e-75e7-45ff-a1dc-769aff532e6d | Durvalumab (Imfinzi™) | Durvalumab (Imfinzi™) | {"2487": {"Id":2487,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":2495,"PolicyAttachmentPageName":"122a9150-af00-4a8d-a3af-8b56690fc3c4"},} |
| | | 1854 | Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris®) | Pharmacy (08) | 08.00.84g | 08.00.84 | 85256AA800623D7A852584C80066FE64 | Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris®) | Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris®) | |
| | | 2473 | Edaravone(Radicava™)08.01.42a | Pharmacy (08) | 08.01.42a | 08.01.42 | 58ca4b55-1c1c-4eae-ad44-453f84d3f0b8 | Edaravone (Radicava™) | Edaravone (Radicava™) | |
