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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)
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4767AcuteCareFacilityInpatientTransfers12.04.04bMiscellaneous (12)12.04.04b12.04.04e30315a0-0657-4f6d-888a-2fa4b0aa46fdAcute Care Facility Inpatient TransfersAcute Care Facility Inpatient Transfers
38d8a45c-488c-48e3-988a-04ec71fc747f.aspx
  
4949Ado-TrastuzumabEmtansine(Kadcyla®)08.01.11hPharmacy (08)08.01.11h08.01.1138d8a45c-488c-48e3-988a-04ec71fc747fAdo-Trastuzumab Emtansine (Kadcyla®)Ado-Trastuzumab Emtansine (Kadcyla®)
{"4950": {"Id":4950,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes and Narratives","MPPolicyAttachmentInternalSourceId":6792,"PolicyAttachmentPageName":"22019f47-888f-4ab7-b554-9fe0c2c91809"},}
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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®)
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5043AirAmbulanceServices12.04.03cMiscellaneous (12)12.04.03c12.04.0314f5591d-8f79-4b62-a760-2e53f042f272Air 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® )
a1de565a-4780-477e-8f16-1cbce906084c.aspx
  
4820AllergyImmunotherapy07.00.21jMedicine (07)07.00.21j07.00.21a1de565a-4780-477e-8f16-1cbce906084cAllergy 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®)
b4c1fd43-8110-4431-8ec1-5eb58bfa6786.aspx
  
5049AlwaysBundledProcedureCodes00.01.52rAdministrative (00)00.01.52r00.01.52b4c1fd43-8110-4431-8ec1-5eb58bfa6786Always Bundled Procedure CodesAlways Bundled Procedure Codes
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4873AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)Devices07.02.09hMedicine (07)07.02.09h07.02.0948fdbbc0-05ed-4ff5-a173-261459ff7c09Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) DevicesAmbulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
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4980AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)Monitoring07.02.21kMedicine (07)07.02.21k07.02.218bd51df3-472e-4025-9b4e-12c5110a60faAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
7d51a925-318f-4d8e-a628-d7270db80137.aspx
  
4628AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagement01.00.12aAnesthesia (01)01.00.12a01.00.127d51a925-318f-4d8e-a628-d7270db80137Anesthesia 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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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
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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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5039AppliedBehaviorAnalysis(ABA)fortheTreatmentofAutismSpectrumDisorders(ASD)14.00.03Behavioral Health (14)14.00.0314.00.035ab4e14d-6b67-4846-85eb-07d9a15c7819Applied Behavior Analysis (ABA) for the Treatment of Autism Spectrum Disorders (ASD)Applied Behavior Analysis (ABA) for the Treatment of Autism Spectrum Disorders (ASD)
b59e539f-57fe-4c9e-97c1-f32cbacecfd4.aspx
  
4993Aprepitant(Cinvanti™),FosaprepitantDimeglumine(Emend®),Granisetron(Sustol®),andRolapitant(Varubi®)08.01.41ePharmacy (08)08.01.41e08.01.41b59e539f-57fe-4c9e-97c1-f32cbacecfd4Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
{"4994": {"Id":4994,"MPAttachmentLetter":"A","Title":"Risk of Emesis Without Prophylaxis: Intravenous and Oral Antineoplastic Agents","MPPolicyAttachmentInternalSourceId":7122,"PolicyAttachmentPageName":"3ba22a0e-77fb-40a0-b6ac-db0a5f7a1f4d"},}
b55c31d5-eb8d-4517-bf3c-eeeb6c9b79a1.aspx
  
4998AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucoma11.05.16lSurgery (11)11.05.16l11.05.16b55c31d5-eb8d-4517-bf3c-eeeb6c9b79a1Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
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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)
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4989ArtificialIntervertebralLumbarDiscInsertion11.15.31bSurgery (11)11.15.31b11.15.31afb41ec7-458d-467b-b4e7-e59d90e2de3dArtificial Intervertebral Lumbar Disc InsertionArtificial Intervertebral Lumbar Disc Insertion
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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)
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4861AssistedReproductiveTechnologyforInfertilityandOocyteCryopreservation07.10.06iMedicine (07)07.10.06i07.10.061957f95b-a5e6-40c1-befd-604f31a47e21Assisted Reproductive Technology for Infertility and Oocyte CryopreservationAssisted Reproductive Technology for Infertility and Oocyte Cryopreservation
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)
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4870AutomaticExternalCardioverterDefibrillators(WearableandNonwearable)05.00.29nDME (05)05.00.29n05.00.293b574e00-b30e-4b42-87e3-f17689845506Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
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4638AutonomicNervousSystemTesting07.03.23fMedicine (07)07.03.23f07.03.235280bd9c-a7a7-4c25-8f2c-ee1aa4539dd7Autonomic Nervous System TestingAutonomic Nervous System Testing
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4958Avelumab(Bavencio®)08.01.64bPharmacy (08)08.01.64b08.01.64f20a2a02-1ded-4005-9bf4-693e1c2fd092Avelumab (Bavencio®)Avelumab (Bavencio®)
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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
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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"},}
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4276Belantamabmafodotin-blmf(Blenrep)08.01.70bPharmacy (08)08.01.70b08.01.70246806c0-46da-409c-b330-cdc5192c284aBelantamab mafodotin-blmf (Blenrep)Belantamab mafodotin-blmf (Blenrep)
e6effbe3-24af-4dcf-9ad1-6faf964ca378.aspx
  
4753Belimumab(Benlysta®)forIntravenousUse08.00.99ePharmacy (08)08.00.99e08.00.99e6effbe3-24af-4dcf-9ad1-6faf964ca378Belimumab (Benlysta®) for Intravenous UseBelimumab (Benlysta®) for Intravenous Use
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4970BetibeglogeneAutotemcel[Beti-Cel(ZYNTEGLO®)]08.01.89Pharmacy (08)08.01.8908.01.89f4038900-116f-45a9-a1d0-49644aa0544dBetibeglogene Autotemcel [Beti-Cel (ZYNTEGLO®)]Betibeglogene Autotemcel [Beti-Cel (ZYNTEGLO®)]
ac115993-2c1c-48ea-8c33-e953d1e8129a.aspx
  
5003Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUse08.00.66sPharmacy (08)08.00.66s08.00.66ac115993-2c1c-48ea-8c33-e953d1e8129aBevacizumab (Avastin®) and Related Biosimilars For Oncologic UseBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
{"5004": {"Id":5004,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":7070,"PolicyAttachmentPageName":"cef71558-23da-47a0-ba8a-9dbcfb729e8b"},}
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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"},}
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3087BillingRequirementsforMultipleBirthsforProfessionalProviders00.10.38aAdministrative (00)00.10.38a00.10.38e862bc0b-0289-4661-bf0a-950e2efca6eeBilling Requirements for Multiple Births for Professional ProvidersBilling Requirements for Multiple Births for Professional Providers
{"3088": {"Id":3088,"MPAttachmentLetter":"A","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ROUTINE OBSTETRIC (GLOBALE MATERNITY/OBSTETRIC [OB]) CARE WAS PROVIDED","MPPolicyAttachmentInternalSourceId":5340,"PolicyAttachmentPageName":"ba5b6730-4f52-4c93-97c1-4ca8f4766879"},"3089": {"Id":3089,"MPAttachmentLetter":"B","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ANETEPARTUM CARE IS NOT PROVIDED","MPPolicyAttachmentInternalSourceId":5341,"PolicyAttachmentPageName":"494d41d3-1fd0-4df8-b729-ad76b6fc2723"},"3090": {"Id":3090,"MPAttachmentLetter":"C","Title":"CODING SCENARIOS FOR REPORTING HIGH-ORDER MULTIPLE (TRIPLETS, QUADRUPLETS, ETC) BIRTHS WHEN ROUTINE OBSTETRIC (GLOBAL MATERNITY/OBSTETRIC [OB]) CARE WAS PROVIDED","MPPolicyAttachmentInternalSourceId":5342,"PolicyAttachmentPageName":"1232f148-ec02-4366-a47a-8917edfa3d73"},"3091": {"Id":3091,"MPAttachmentLetter":"D","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF HIGH-ORDER MULTIPLES WHEN ANTEPARTUM CARE IS NOT PROVIDED","MPPolicyAttachmentInternalSourceId":5343,"PolicyAttachmentPageName":"dee47969-1193-42f8-9cc1-4dabfcc50995"},}
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4394BiofeedbackTherapy07.00.01jMedicine (07)07.00.01j07.00.01704d8479-8073-4f31-8bc7-6b30ae0e1a63Biofeedback TherapyBiofeedback Therapy
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4368BioimpedencefortheDetectionofLymphedema07.06.03bMedicine (07)07.06.03b07.06.034f6901b4-8f19-4b3f-97f5-802d005c75cfBioimpedence for the Detection of LymphedemaBioimpedence for the Detection of Lymphedema
b491f109-dc4e-41fb-906a-5eb04fe2602d.aspx
  
4845Blepharoplasty,RepairofBlepharoptosis,RepairofBrowPtosis,andCanthoplasty/Canthopexy11.05.02jSurgery (11)11.05.02j11.05.02b491f109-dc4e-41fb-906a-5eb04fe2602dBlepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/CanthopexyBlepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
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4375Blinatumomab(Blincyto®)08.01.21ePharmacy (08)08.01.21e08.01.2101f91949-1097-4a9e-9302-81f23de23bffBlinatumomab (Blincyto®)Blinatumomab (Blincyto®)
e1490bfd-d6ac-4b00-a8c1-314c46c78d8f.aspx
  
5030Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAids11.01.06gSurgery (11)11.01.06g11.01.06e1490bfd-d6ac-4b00-a8c1-314c46c78d8fBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing AidsBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
f7005cd1-2e6a-4135-bcfe-9b67820a0fab.aspx
  
4981BoneMineralDensity(BMD)Testing09.00.04mRadiology (09)09.00.04m09.00.04f7005cd1-2e6a-4135-bcfe-9b67820a0fabBone Mineral Density (BMD) TestingBone Mineral Density (BMD) Testing
ec8ad7b9-59e3-4bd1-b521-dc205fe47298.aspx
  
5023Bortezomib(BortezomibforInjection,Velcade®)08.00.73oPharmacy (08)08.00.73o08.00.73ec8ad7b9-59e3-4bd1-b521-dc205fe47298Bortezomib (Bortezomib for Injection, Velcade®)Bortezomib (Bortezomib for Injection, Velcade®)
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4636BotulinumToxinAgents08.00.26zPharmacy (08)08.00.26z08.00.26262b8af6-c42b-4bee-8d1d-5b377356ef16Botulinum Toxin AgentsBotulinum Toxin Agents
{"4637": {"Id":4637,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":6760,"PolicyAttachmentPageName":"313ddfb1-5ecb-4cbc-b75e-8f69a484a88d"},}
f581558f-daff-4a3d-8a3f-4a5256e1bf06.aspx
  
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
7e4c86e0-e560-421c-8463-60b4239e18fa.aspx
  
5033BreastPumps05.00.76gDME (05)05.00.76g05.00.767e4c86e0-e560-421c-8463-60b4239e18faBreast PumpsBreast Pumps
2f4b8bc7-824b-4bd1-bffe-bc24075eb16a.aspx
  
4607BrentuximabVedotin(Adcetris®)08.01.13hPharmacy (08)08.01.13h08.01.132f4b8bc7-824b-4bd1-bffe-bc24075eb16aBrentuximab Vedotin (Adcetris®)Brentuximab Vedotin (Adcetris®)
{"4608": {"Id":4608,"MPAttachmentLetter":"A","Title":"ICD CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":6762,"PolicyAttachmentPageName":"4ef59e2f-b124-4e39-bc83-d921fc98d944"},}
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4141BronchialValves11.16.09Surgery (11)11.16.0911.16.0952cbba4a-1c34-44f4-852c-2aa2af748210Bronchial ValvesBronchial Valves
7af88e8b-93a3-4f90-8d3c-0784954a941b.aspx
  
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®)
cabc1c75-7431-49cc-9530-91eb57207d0f.aspx
  
4619CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)Programs10.01.01oRehabilitation Services (10)10.01.01o10.01.01cabc1c75-7431-49cc-9530-91eb57207d0fCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) ProgramsCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
{"4620": {"Id":4620,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":6701,"PolicyAttachmentPageName":"494bab88-d0fd-4cf6-8e31-f39da209b9f6"},}
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4691CareManagementandCarePlanningServices00.01.59lAdministrative (00)00.01.59l00.01.594a13780b-3cf6-457e-9645-6bbee7fd3bc4Care Management and Care Planning ServicesCare Management and Care Planning Services
154ae50d-be6c-4132-ac0e-cd0daae0016c.aspx
  
4813Carfilzomib(Kyprolis®)08.01.05iPharmacy (08)08.01.05i08.01.05154ae50d-be6c-4132-ac0e-cd0daae0016cCarfilzomib (Kyprolis®)Carfilzomib (Kyprolis®)
3d5103bb-27d5-4963-bd34-f6ba67f1076b.aspx
  
4360CastandSplintApplicationsandAssociatedSupplies00.10.15dAdministrative (00)00.10.15d00.10.153d5103bb-27d5-4963-bd34-f6ba67f1076bCast and Splint Applications and Associated SuppliesCast and Splint Applications and Associated Supplies
{"4361": {"Id":4361,"MPAttachmentLetter":"A","Title":"Procedure Codes Related to Cast and Splint Applications and Associated Supplies","MPPolicyAttachmentInternalSourceId":6421,"PolicyAttachmentPageName":"4af8b16b-794b-4533-a048-5413712cbe65"},}
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4854CataractSurgery11.01.07fSurgery (11)11.01.07f11.01.07999dab46-d26f-4042-bdec-44679dace028Cataract SurgeryCataract Surgery
{"4855": {"Id":4855,"MPAttachmentLetter":"A","Title":"ICD 10 codes for policy 11.01.07d, Cataract Surgery","MPPolicyAttachmentInternalSourceId":6668,"PolicyAttachmentPageName":"705428a5-5a31-40d0-a0d2-354e451b3896"},}
8adec0f3-a1ab-492b-af21-07ab6d6aae6a.aspx
  
4621CatheterAblationofCardiacArrhythmias11.02.06oSurgery (11)11.02.06o11.02.068adec0f3-a1ab-492b-af21-07ab6d6aae6aCatheter Ablation of Cardiac ArrhythmiasCatheter Ablation of Cardiac Arrhythmias
5376605a-e682-418c-82d3-0e7b9a0df081.aspx
  
4956Cemiplimab-rwlc(Libtayo®)08.01.66bPharmacy (08)08.01.66b08.01.665376605a-e682-418c-82d3-0e7b9a0df081Cemiplimab-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
7a91e8d9-4bfe-4deb-978d-8f088449f615.aspx
  
5019Cetuximab(Erbitux®)08.00.67nPharmacy (08)08.00.67n08.00.677a91e8d9-4bfe-4deb-978d-8f088449f615Cetuximab (Erbitux®)Cetuximab (Erbitux®)
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db5a3ccb-3f8a-411e-b545-f3ba973de1c5.aspx
  
4602ChemicalPeels11.08.08hSurgery (11)11.08.08h11.08.08db5a3ccb-3f8a-411e-b545-f3ba973de1c5Chemical PeelsChemical Peels
828baa5b-e049-4764-b88b-528d65afed34.aspx
  
4605ChimericAntigenReceptor(CAR)Therapy08.01.43kPharmacy (08)08.01.43k08.01.43828baa5b-e049-4764-b88b-528d65afed34Chimeric Antigen Receptor (CAR) TherapyChimeric Antigen Receptor (CAR) Therapy
{"4606": {"Id":4606,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":6560,"PolicyAttachmentPageName":"c3da6cc6-10d3-42cd-afb6-fd746f9885a5"},}
41b59432-3402-4af7-aced-f58e3d7ff391.aspx
  
4819ChiropracticSpinalandExtraspinalManipulationTherapy10.02.02jRehabilitation Services (10)10.02.02j10.02.0241b59432-3402-4af7-aced-f58e3d7ff391Chiropractic Spinal and Extraspinal Manipulation TherapyChiropractic Spinal and Extraspinal Manipulation Therapy
5f61fef5-37e8-456e-bf9c-5b59e89362c1.aspx
  
4803CoagulationFactors08.00.92aePharmacy (08)08.00.92ae08.00.925f61fef5-37e8-456e-bf9c-5b59e89362c1Coagulation FactorsCoagulation Factors
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5066Cobalamin(VitaminB12),FolicAcid,andHomocysteineTesting06.02.54cPathology and Laboratory (06)06.02.54c06.02.54359a2377-9b04-4dee-a8be-027bdc97c9b8Cobalamin (Vitamin B12), Folic Acid, and Homocysteine TestingCobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
{"5067": {"Id":5067,"MPAttachmentLetter":"A","Title":"MEDICALLY NECESSARY ICD 10 CODES FOR COBALAMIN (VITAMIN B12) AND/OR FOLIC ACID TESTING (CPT CODES 82607, 82608, 82746, AND 82747)","MPPolicyAttachmentInternalSourceId":7156,"PolicyAttachmentPageName":"9555cfd8-5d27-439f-98b9-f8ac99996c49"},}
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™)
0290a952-ce69-44dd-b858-8c2d138066db.aspx
  
4879ColorectalCancerScreening11.03.12tSurgery (11)11.03.12t11.03.120290a952-ce69-44dd-b858-8c2d138066dbColorectal 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"},}
6559b183-cc4e-4272-9c94-1515a87d738a.aspx
  
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
abc9baf4-9e1b-4c13-bb6f-f5f65d443558.aspx
  
4382CornealPachymetryUsingUltrasound07.13.07lMedicine (07)07.13.07l07.13.07abc9baf4-9e1b-4c13-bb6f-f5f65d443558Corneal Pachymetry Using UltrasoundCorneal Pachymetry Using Ultrasound
{"4383": {"Id":4383,"MPAttachmentLetter":"A","Title":"ICD-10-CM codes","MPPolicyAttachmentInternalSourceId":6351,"PolicyAttachmentPageName":"d6fb930e-4bdf-47c7-afb2-9a67e3a91d0b"},}
b9702be8-f4d4-41a6-bbe6-b60213ba8e7d.aspx
  
4858CosmeticProcedures12.01.03aMiscellaneous (12)12.01.03a12.01.03b9702be8-f4d4-41a6-bbe6-b60213ba8e7dCosmetic ProceduresCosmetic Procedures
2b2115cd-247d-4564-9ceb-79dc1d741c9f.aspx
  
4968CoverageofAnticancerPrescriptionOralandInjectableDrugsandBiologicsandSupportiveAgents08.01.08kPharmacy (08)08.01.08k08.01.082b2115cd-247d-4564-9ceb-79dc1d741c9fCoverage 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
8a359129-cc17-465a-8d22-11ea6180520f.aspx
  
4764CranialElectrotherapyStimulation05.00.80cDME (05)05.00.80c05.00.808a359129-cc17-465a-8d22-11ea6180520fCranial 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)
cde76797-199e-4918-9e43-897124bfa2c4.aspx
  
5034CriteriaforReimbursementofEmergencyRoomServices00.10.03kAdministrative (00)00.10.03k00.10.03cde76797-199e-4918-9e43-897124bfa2c4Criteria for Reimbursement of Emergency Room ServicesCriteria for Reimbursement of Emergency Room Services
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
bcecfc79-5868-4b61-a23c-84617b4e8ce0.aspx
  
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
{"4462": {"Id":4462,"MPAttachmentLetter":"E","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (S86.892A - Z79.01), Continued","MPPolicyAttachmentInternalSourceId":6444,"PolicyAttachmentPageName":"631ca1da-1bab-4e79-b523-1f83d76a4b61"},"4463": {"Id":4463,"MPAttachmentLetter":"D","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (I87.099 - S86.891S), Continued","MPPolicyAttachmentInternalSourceId":6445,"PolicyAttachmentPageName":"b3dd08d0-e9bf-4a4b-9115-7e7650ecd00d"},"4464": {"Id":4464,"MPAttachmentLetter":"C","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E13.3513 - I87.093), Continued","MPPolicyAttachmentInternalSourceId":6446,"PolicyAttachmentPageName":"4941a0cb-9b2b-4bd0-ad5b-aab9f279c51a"},"4465": {"Id":4465,"MPAttachmentLetter":"B","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E10.22 - E13.3512), Continued","MPPolicyAttachmentInternalSourceId":6447,"PolicyAttachmentPageName":"05c6ef53-95e9-4a0e-a9d7-f0c48cb8bbff"},"4466": {"Id":4466,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (A30.0 -E10.21)","MPPolicyAttachmentInternalSourceId":6448,"PolicyAttachmentPageName":"cb12558c-d46d-4970-a93c-28a59a8eb702"},}
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4772DeepBrainStimulation(DBS)11.15.20qSurgery (11)11.15.20q11.15.2020127810-2b58-439b-9b5e-579d724dfb7eDeep 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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5000DermabrasionforRhinophyma,Septoplasty,Rhinoplasty,andSeptorhinoplasty11.16.01jSurgery (11)11.16.01j11.16.012952bd67-7274-4c9d-adf0-b1cfb5131637Dermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and SeptorhinoplastyDermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and Septorhinoplasty
34cffd2e-5f5c-447d-95c6-4f2546aea666.aspx
  
5005DiagnosticRadiologyServicesIncludedinCapitation00.03.02adAdministrative (00)00.03.02ad00.03.0234cffd2e-5f5c-447d-95c6-4f2546aea666Diagnostic Radiology Services Included in CapitationDiagnostic Radiology Services Included in Capitation
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