|  | | 2540 | Abatacept(Orencia®)forInjectionforIntravenousUse08.00.62k | Pharmacy (08) | 08.00.62k | 08.00.62 | 7e63c983-6fc8-4004-9500-e7f5ec046b34 | Abatacept (Orencia®) for Injection for Intravenous Use | Abatacept (Orencia®) for Injection for Intravenous Use | {"2541": {"Id":2541,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":4835,"PolicyAttachmentPageName":"757c2e1e-e711-42d3-91d8-856aaec0df25"},} |
| | | 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 | |
| | | 2917 | Ado-TrastuzumabEmtansine(Kadcyla®)08.01.11f | Pharmacy (08) | 08.01.11f | 08.01.11 | 28064e49-a2b7-4f80-ba96-337057e5e541 | Ado-Trastuzumab Emtansine (Kadcyla®) | Ado-Trastuzumab Emtansine (Kadcyla®) | {"2918": {"Id":2918,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes and Narratives","MPPolicyAttachmentInternalSourceId":4967,"PolicyAttachmentPageName":"c4bf9963-de35-4b21-9a8c-4671f09541a4"},} |
| | | 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®) | |
| | | 2879 | AllergyImmunotherapy07.00.21j | Medicine (07) | 07.00.21j | 07.00.21 | 97b16c26-2db8-44f7-8e9d-c9e653158d5b | 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) | |
| | | 2927 | Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C®,AralastNP®,Glassia®,Zemaira®)08.00.91e | Pharmacy (08) | 08.00.91e | 08.00.91 | f928229d-392f-46ab-a93c-274ef407aa75 | Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®) | Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®) | |
| | | 3012 | AlwaysBundledProcedureCodes00.01.52k | Administrative (00) | 00.01.52k | 00.01.52 | f32100d3-d483-46c8-9ad9-315ac6f7ba7c | Always Bundled Procedure Codes | Always Bundled Procedure Codes | {"3013": {"Id":3013,"MPAttachmentLetter":"A","Title":"Always Bundled Procedures (Indicator B)","MPPolicyAttachmentInternalSourceId":4769,"PolicyAttachmentPageName":"b0a8e91b-7f96-4844-af96-45a687605dcc"},"3014": {"Id":3014,"MPAttachmentLetter":"B","Title":"Procedures/Services Not Eligible for Separate Reimbursement","MPPolicyAttachmentInternalSourceId":4953,"PolicyAttachmentPageName":"83299f78-9df8-4da3-8402-02002bfc5d16"},"3015": {"Id":3015,"MPAttachmentLetter":"C","Title":"Procedures/Services Not Eligible for Reimbursement","MPPolicyAttachmentInternalSourceId":4954,"PolicyAttachmentPageName":"d1ea4190-4678-4e03-9b92-5f5f8a770ae8"},} |
| | | 3042 | AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)Devices07.02.09g | Medicine (07) | 07.02.09g | 07.02.09 | c233d9c4-b48b-4763-a10b-7f4a06ccaad8 | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | |
| | | 2878 | AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)Monitoring07.02.21f | Medicine (07) | 07.02.21f | 07.02.21 | 6a4f1314-aedb-4e85-ab25-74431b22a079 | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | |
| | | 2993 | Ankle-Foot/Knee-Ankle-FootOrthoses05.00.39p | DME (05) | 05.00.39p | 05.00.39 | b3e048ec-4c3b-4a90-a710-c460b38063ca | Ankle-Foot/Knee-Ankle-Foot Orthoses | Ankle-Foot/Knee-Ankle-Foot Orthoses | {"2994": {"Id":2994,"MPAttachmentLetter":"A","Title":"HCPCS Codes","MPPolicyAttachmentInternalSourceId":5037,"PolicyAttachmentPageName":"ba291425-5caf-4ec1-91a0-fb19d4e01507"},} |
| | | 2807 | ApheresisTherapy06.03.04n | Pathology and Laboratory (06) | 06.03.04n | 06.03.04 | b395fd09-303a-4b18-a74c-04bb56dc9226 | Apheresis Therapy | Apheresis Therapy | |
| | | 2674 | ApplicationandRemovalofTattoos11.08.05g | Surgery (11) | 11.08.05g | 11.08.05 | 0820c52b-3435-4ae2-9ea0-c8c776494f41 | 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"},} |
| | | 2719 | AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucoma11.05.16i | Surgery (11) | 11.05.16i | 11.05.16 | 9bd8f538-81fe-4c49-bad1-aff8dd64fcb2 | Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | {"2720": {"Id":2720,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":4936,"PolicyAttachmentPageName":"0d5dc4d2-0630-4ac2-a103-622629fa04a6"},} |
| | | 2951 | ArtificialIntervertebralCervicalDiscInsertion(AmerihealthAdministrators)11.14.19p | Surgery (11) | 11.14.19p | 11.14.19 | 3c9c1102-de45-473f-9a0d-e92c3d7b9687 | Artificial Intervertebral Cervical Disc Insertion (Amerihealth Administrators) | Artificial Intervertebral Cervical Disc Insertion (Amerihealth Administrators) | |
| | | 2950 | ArtificialIntervertebralLumbarDiscInsertion11.15.31 | Surgery (11) | 11.15.31 | 11.15.31 | 12d48495-64b9-4f9f-b05b-007bf460da46 | Artificial Intervertebral Lumbar Disc Insertion | Artificial Intervertebral Lumbar Disc Insertion | |
| | | 3017 | AsparaginaseErwiniaChrysanthemi(Erwinaze®)08.01.35c | Pharmacy (08) | 08.01.35c | 08.01.35 | 988495ee-f60a-43f4-841b-2a0794848d76 | 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) | |
| | | 2877 | AssistedReproductiveTechnologyforInfertilityandOocyteCryopreservation07.10.06i | Medicine (07) | 07.10.06i | 07.10.06 | e20aa7d8-bb05-4110-be2b-f752b6a8d611 | Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation | Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation | |
| | | 2500 | Atezolizumab(Tecentriq®)08.01.69 | Pharmacy (08) | 08.01.69 | 08.01.69 | 8470da1f-a6df-49af-b6bb-2f51ee4280db | Atezolizumab (Tecentriq®) | Atezolizumab (Tecentriq®) | {"2501": {"Id":2501,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":4723,"PolicyAttachmentPageName":"afedffda-6a22-4abb-8108-ba0033e13870"},} |
| | | 2963 | AutologousChondrocyteImplantation(ACI)andOtherCell-basedTreatmentsofFocalArticularCartilageLesions(AmerihealthAdministrators)11.14.06j | Surgery (11) | 11.14.06j | 11.14.06 | 39dafee4-6e6f-4983-b14c-8085c01aeba5 | Autologous 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) | |
| | | 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"},} |
| | | 2728 | BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitis11.16.06j | Surgery (11) | 11.16.06j | 11.16.06 | f2e21ee4-7f8d-4194-87e5-9f702fb30cef | Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis | Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis | |
| | | 2824 | BariatricSurgery11.03.02t | Surgery (11) | 11.03.02t | 11.03.02 | deb6788b-9378-4634-bea1-f71971bb7026 | Bariatric Surgery | Bariatric 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"},} |
| | | 2946 | Belantamabmafodotin-blmf(Blenrep)08.01.70a | Pharmacy (08) | 08.01.70a | 08.01.70 | 762b4173-9163-47ba-8d52-1b35cf5b90fd | Belantamab mafodotin-blmf (Blenrep) | Belantamab mafodotin-blmf (Blenrep) | |
| | | 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 | |
| | | 3018 | Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUse08.00.66o | Pharmacy (08) | 08.00.66o | 08.00.66 | e14d5427-e045-4eee-875d-5a1c7e82f214 | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | {"3019": {"Id":3019,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":5036,"PolicyAttachmentPageName":"ee63b08d-1c28-4691-8152-447aec4c24e1"},} |
| | | 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"},} |
| | | 2936 | BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampus00.10.39n | Administrative (00) | 00.10.39n | 00.10.39 | aac783a0-0ef9-4d21-84a0-e1478fdc4bfd | 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 | {"2937": {"Id":2937,"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":5191,"PolicyAttachmentPageName":"8c5aaa02-4928-4e46-ab85-3294a77b4a08"},} |
| | | 2685 | BiofeedbackTherapy07.00.01j | Medicine (07) | 07.00.01j | 07.00.01 | 2575a0d1-26dc-45aa-81b4-c8c13ea46c73 | 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 | |
| | | 3009 | Blepharoplasty,RepairofBlepharoptosis,RepairofBrowPtosis,andCanthoplasty/Canthopexy11.05.02j | Surgery (11) | 11.05.02j | 11.05.02 | 18f429c4-65be-44ad-b849-f3e29733bbb7 | Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy | Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy | {"3010": {"Id":3010,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5006,"PolicyAttachmentPageName":"14701adc-60ac-44c0-b279-538135fdad2b"},} |
| | | 2743 | Blinatumomab(Blincyto®)08.01.21c | Pharmacy (08) | 08.01.21c | 08.01.21 | fcb82298-9d09-45e8-ba5b-d51e0894b846 | 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 | |
| | | 2734 | Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAids11.01.06e | Surgery (11) | 11.01.06e | 11.01.06 | af56d217-5751-42f2-9ded-3b66ff325a7f | 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) | |
| | | 2753 | BreastPumps05.00.76d | DME (05) | 05.00.76d | 05.00.76 | 2d010011-4b3e-446e-b6ca-4467bc6b5d99 | 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®) | |
| | | 3036 | Canakinumab(Ilaris®)08.01.51a | Miscellaneous (12) | 08.01.51a | 08.01.51 | d28522d7-c8b8-4e7d-a7ae-28920d8964b0 | Canakinumab (Ilaris®) | Canakinumab (Ilaris®) | |
| | | 2750 | CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)Programs10.01.01n | Rehabilitation Services (10) | 10.01.01n | 10.01.01 | 847887d0-b38f-484e-80b4-ce36b27acefe | Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs | Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs | {"2751": {"Id":2751,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":4998,"PolicyAttachmentPageName":"7e6f465c-6432-4fbd-807e-abe0a5a98e6c"},} |
| | | 2928 | CareManagementandCarePlanningServices00.01.59h | Administrative (00) | 00.01.59h | 00.01.59 | dab50f18-23da-4fbc-a6ec-142a67aa94e7 | Care Management and Care Planning Services | Care Management and Care Planning Services | |
| | | 2677 | Carfilzomib(Kyprolis®)08.01.05g | Pharmacy (08) | 08.01.05g | 08.01.05 | 24c34fb2-6bd5-48be-a2a3-e7136af3f275 | Carfilzomib (Kyprolis®) | Carfilzomib (Kyprolis®) | |
| | | 2815 | CastandSplintApplicationsandAssociatedSupplies00.10.15d | Administrative (00) | 00.10.15d | 00.10.15 | ead5d815-c736-402d-a236-12375fa27c39 | Cast and Splint Applications and Associated Supplies | Cast and Splint Applications and Associated Supplies | {"2816": {"Id":2816,"MPAttachmentLetter":"A","Title":"Procedure Codes Related to Cast and Splint Applications and Associated Supplies","MPPolicyAttachmentInternalSourceId":4979,"PolicyAttachmentPageName":"8e789d63-630d-4491-95de-91c11ca83242"},} |
| | | 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"},} |
| | | 2691 | CatheterAblationofCardiacArrhythmias11.02.06m | Surgery (11) | 11.02.06m | 11.02.06 | 2fc0ca5d-07cf-482b-b1aa-64c3dc277478 | 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®) | |
| | | 2672 | CervicalTractionDevicesforIn-homeUse05.00.61g | DME (05) | 05.00.61g | 05.00.61 | 2892d91c-09af-4047-9d95-193f41591437 | 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"},} |
| | | 2694 | ChemicalPeels11.08.08g | Surgery (11) | 11.08.08g | 11.08.08 | cfe71410-8201-47ec-aea1-88249ce1763b | Chemical Peels | Chemical Peels | |
| | | 2854 | ChimericAntigenReceptor(CAR)Therapy08.01.43f | Pharmacy (08) | 08.01.43f | 08.01.43 | d89b4d38-e37b-4495-80fc-acbf653a7e0f | Chimeric Antigen Receptor (CAR) Therapy | Chimeric Antigen Receptor (CAR) Therapy | {"2855": {"Id":2855,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":4713,"PolicyAttachmentPageName":"5d52e64b-d5ca-48d4-864c-79eaa970bb68"},} |
| | | 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 | |
| | | 2769 | CoagulationFactors08.00.92ac | Pharmacy (08) | 08.00.92ac | 08.00.92 | 083b8973-f704-430b-9342-5b06a2044349 | Coagulation Factors | Coagulation Factors | |
| | | 2828 | Cobalamin(VitaminB12),FolicAcid,andHomocysteineTesting06.02.54a | Pathology and Laboratory (06) | 06.02.54a | 06.02.54 | 71eeef1f-3ef6-49f6-bd61-b3ccbe4aff14 | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | {"2829": {"Id":2829,"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":4910,"PolicyAttachmentPageName":"9ab9d7e8-1e45-4cc6-8c24-527791b717d5"},} |
| | | 1778 | Cochlear Implant | Surgery (11) | 11.01.02o | 11.01.02 | 85256AA800623D7A852584C500591E9D | Cochlear Implant | Cochlear Implant | |
| | | 2722 | Collagenaseclostridiumhistolyticum(Xiaflex®),collagenaseclostridiumhistolyticum-aaes(Qwo™)08.01.71 | Pharmacy (08) | 08.01.71 | 08.01.71 | f708376d-a16b-48f1-8f4b-beea8f1a3144 | Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™) | Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™) | |
| | | 2680 | ColorectalCancerScreening11.03.12s | Surgery (11) | 11.03.12s | 11.03.12 | e8fcbf84-816c-410d-ad3b-6d4dfbbecd65 | 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 | |
| | | 2876 | Computer-assistedMusculoskeletalSurgicalNavigationalOrthopedicProcedure11.14.17e | Surgery (11) | 11.14.17e | 11.14.17 | bca8c37a-6d54-4b51-bf09-5450927cf0e2 | Computer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure | Computer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure | |
| | | 1986 | Consultation Services | Administrative (00) | 00.01.69 | 00.01.69 | F3BA7DB0E980312B8525854B005EE64C | Consultation Services | Consultation Services | |
| | | 2681 | ContactLensesfortheTreatmentofPersistent(Corneal)EpithelialDefects07.13.11j | Medicine (07) | 07.13.11j | 07.13.11 | 8193c86d-b0a9-4cfb-833c-e68d203cf6d6 | Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects | Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects | {"2682": {"Id":2682,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":4947,"PolicyAttachmentPageName":"546e7e55-6586-4b95-9af6-cb61f6f4bcf3"},} |
| | | 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 | |
| | | 2683 | CornealPachymetryUsingUltrasound07.13.07k | Medicine (07) | 07.13.07k | 07.13.07 | eeb622d6-06b3-4b65-b45b-8e30a72cc6fb | Corneal Pachymetry Using Ultrasound | Corneal Pachymetry Using Ultrasound | {"2684": {"Id":2684,"MPAttachmentLetter":"A","Title":"ICD-10-CM codes","MPPolicyAttachmentInternalSourceId":4969,"PolicyAttachmentPageName":"93ce09d2-985c-454f-94b2-f24a4f734a3f"},} |
| | | 2698 | CosmeticProcedures12.01.03a | Miscellaneous (12) | 12.01.03a | 12.01.03 | 4ed52e3e-0047-438d-8ad9-e328a7daae59 | 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 | |
| | | 2645 | CranialElectrotherapyStimulation05.00.80A | DME (05) | 05.00.80A | 05.00.80 | 237abae4-3c2e-4ac9-bd1b-670132546eb6 | Cranial Electrotherapy Stimulation | Cranial Electrotherapy Stimulation | |
| | | 3034 | CranialRemoldingOrthoses(Helmets)05.00.25i | DME (05) | 05.00.25i | 05.00.25 | 4c0f9461-3615-42b9-8172-7d831e57933a | 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 | |
| | | 2455 | crizanlizumab-tmca(Adakveo®)08.00.04 | Pharmacy (08) | 08.00.04 | 08.00.04 | faa50be1-657d-4d20-a6a5-87611074c3ab | crizanlizumab-tmca (Adakveo®) | crizanlizumab-tmca (Adakveo®) | |
| | | 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 | |
| | | 2929 | Daratumumab(Darzalex®),Daratumumab,andHyaluronidase-fihj(DarzalexFaspro™)08.01.29h | Pharmacy (08) | 08.01.29h | 08.01.29 | a4165e6e-9756-4be7-8f91-724258b7636e | 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 | |
| | | 2545 | DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNails11.08.17j | Surgery (11) | 11.08.17j | 11.08.17 | d32a8021-473d-4d01-b269-950e6c35c325 | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | {"2546": {"Id":2546,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (A30.0 -E10.21)","MPPolicyAttachmentInternalSourceId":4872,"PolicyAttachmentPageName":"7fb485c2-cd94-4478-b5a0-8819b04f1db3"},"2547": {"Id":2547,"MPAttachmentLetter":"B","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E10.22 - E13.3512), Continued","MPPolicyAttachmentInternalSourceId":4873,"PolicyAttachmentPageName":"6592deac-6f1b-4af8-adaf-90e79d97a6ea"},"2548": {"Id":2548,"MPAttachmentLetter":"C","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E13.3513 - I87.093), Continued","MPPolicyAttachmentInternalSourceId":4874,"PolicyAttachmentPageName":"95abcbf9-d224-4ef3-9b95-3355236bcfb6"},"2549": {"Id":2549,"MPAttachmentLetter":"E","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (S86.892A - Z79.01), Continued","MPPolicyAttachmentInternalSourceId":4875,"PolicyAttachmentPageName":"3ef91a71-fa72-454c-886c-700553073108"},"2550": {"Id":2550,"MPAttachmentLetter":"D","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (I87.099 - S86.891S), Continued","MPPolicyAttachmentInternalSourceId":4876,"PolicyAttachmentPageName":"7473c2a0-b915-4bb1-a6db-689855c4df11"},} |
| | | 2661 | DeepBrainStimulation(DBS)11.15.20p | Surgery (11) | 11.15.20p | 11.15.20 | 7ab9c75e-ec48-47b0-9461-0cfae8b2cce8 | Deep Brain Stimulation (DBS) | Deep Brain Stimulation (DBS) | |
| | | 2958 | DenervationoftheSpinalNervesforChronicPain(AmerihealthAdministrators)11.15.09o | Surgery (11) | 11.15.09o | 11.15.09 | a4157456-533f-41b7-af48-b069b8f89828 | Denervation of the Spinal Nerves for Chronic Pain (Amerihealth Administrators) | Denervation of the Spinal Nerves for Chronic Pain (Amerihealth Administrators) | |
| | | 2608 | Denosumab(Prolia®,Xgeva®),Romosozumab-aqqg(Evenity™)08.00.94n | Pharmacy (08) | 08.00.94n | 08.00.94 | f49857c4-b5fa-4ab2-8175-9106ac943d5a | Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™) | Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™) | {"2609": {"Id":2609,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes","MPPolicyAttachmentInternalSourceId":4828,"PolicyAttachmentPageName":"7ccfeda7-c1f0-4cb6-8fe0-5ca12e1ca4ba"},} |
| | | 2991 | DiagnosticRadiologyServicesIncludedinCapitation00.03.02ab | Administrative (00) | 00.03.02ab | 00.03.02 | e4575742-3afd-4e86-a0f5-24ebba7753f9 | Diagnostic Radiology Services Included in Capitation | Diagnostic Radiology Services Included in Capitation | {"2992": {"Id":2992,"MPAttachmentLetter":"A","Title":"Diagnostic Radiology Procedure Codes Included in Capitation for Pennsylvania (PA) Health Maintenance Organization (HMO) Members","MPPolicyAttachmentInternalSourceId":5246,"PolicyAttachmentPageName":"f4d52604-4f86-4003-9801-9124156c63f4"},} |
| | | 2947 | DirectAccesstoObstetrics/Gynecology(OB/GYN)Services00.09.01h | Administrative (00) | 00.09.01h | 00.09.01 | b1ef5086-c4c5-4583-836b-b89027c587a7 | Direct Access to Obstetrics/Gynecology (OB/GYN) Services | Direct Access to Obstetrics/Gynecology (OB/GYN) Services | {"2948": {"Id":2948,"MPAttachmentLetter":"A","Title":"Procedure Codes for Direct Access OB/GYN","MPPolicyAttachmentInternalSourceId":5193,"PolicyAttachmentPageName":"c130de01-b6cd-4054-9f74-0db4b63876db"},} |
| | | 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 | |
| | | 2669 | Drug-ElutingBeadsandBlandEmbolizationfortheTreatmentofHepaticMalignancies07.05.07d | Medicine (07) | 07.05.07d | 07.05.07 | bef1b14c-04ab-4591-b6a4-e5d222c3a82c | 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) | |
| | | 2896 | DurableMedicalEquipment(DME)andConsumableMedicalSupplies05.00.21w | DME (05) | 05.00.21w | 05.00.21 | 8c89e826-a513-41f2-8716-59e9e8adeff6 | Durable Medical Equipment (DME) and Consumable Medical Supplies | Durable Medical Equipment (DME) and Consumable Medical Supplies | {"2897": {"Id":2897,"MPAttachmentLetter":"A2","Title":"Equipment that Meets the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":5039,"PolicyAttachmentPageName":"4763f27a-c1e3-40a9-aa14-eee652b855b4"},"2898": {"Id":2898,"MPAttachmentLetter":"B","Title":"Items that Do Not Meet the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":5040,"PolicyAttachmentPageName":"689285e4-6b6e-47e8-b7f3-27f289ba2d7e"},"2899": {"Id":2899,"MPAttachmentLetter":"A1","Title":"Equipment that Meets the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":5041,"PolicyAttachmentPageName":"8c9e1a3b-3fd2-4ee4-9ef2-467464f2a2e9"},} |
| | | 3020 | DurableMedicalEquipment(DME)NotSubjecttoaRentaltoPurchaseMaximum05.00.48k | DME (05) | 05.00.48k | 05.00.48 | bf7c7de8-7799-4645-adb6-e4be539f9bdd | Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum | Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum | |
