Commercial
  
  
  
  
  
  
  
  
  
  
MPattachmentdataPub
7e63c983-6fc8-4004-9500-e7f5ec046b34.aspx
  
2540Abatacept(Orencia®)forInjectionforIntravenousUse08.00.62kPharmacy (08)08.00.62k08.00.627e63c983-6fc8-4004-9500-e7f5ec046b34Abatacept (Orencia®) for Injection for Intravenous UseAbatacept (Orencia®) for Injection for Intravenous Use
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1583Acupuncture (AmeriHealth)Miscellaneous (12)12.00.01f12.00.0185256AA800623D7A8525850D004EBC50Acupuncture (AmeriHealth)Acupuncture (AmeriHealth)
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85256AA800623D7A85258596007CD987.aspx
  
1585Acute Care Facility Inpatient TransfersMiscellaneous (12)12.04.04a12.04.0485256AA800623D7A85258596007CD987Acute Care Facility Inpatient TransfersAcute Care Facility Inpatient Transfers
85256AA800623D7A852583C4005C4617.aspx
  
1656Ado-Trastuzumab Emtansine (Kadcyla®)Pharmacy (08)08.01.11e08.01.1185256AA800623D7A852583C4005C4617Ado-Trastuzumab Emtansine (Kadcyla®)Ado-Trastuzumab Emtansine (Kadcyla®)
{"2240":{"Id":2240,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes and Narratives","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A852583C4005C461D"},}
85256AA800623D7A852585420071736C.aspx
  
1841Agalsidase beta (Fabrazyme®)Pharmacy (08)08.00.69b08.00.6985256AA800623D7A852585420071736CAgalsidase beta (Fabrazyme®)Agalsidase beta (Fabrazyme®)
85256AA800623D7A85258596007D3BA6.aspx
  
1586Air Ambulance ServicesMiscellaneous (12)12.04.03c12.04.0385256AA800623D7A85258596007D3BA6Air Ambulance ServicesAir Ambulance Services
85256AA800623D7A852584EB005B947D.aspx
  
1864Alemtuzumab (Lemtrada®)Pharmacy (08)08.01.22d08.01.2285256AA800623D7A852584EB005B947DAlemtuzumab (Lemtrada®)Alemtuzumab (Lemtrada®)
85256AA800623D7A8525854200710D18.aspx
  
1842Alglucosidase alfa (e.g., Lumizyme®)Pharmacy (08)08.00.72h08.00.7285256AA800623D7A8525854200710D18Alglucosidase alfa (e.g., Lumizyme®)Alglucosidase alfa (e.g., Lumizyme®)
85256AA800623D7A852584E900723F3A.aspx
  
1790Allergy ImmunotherapyMedicine (07)07.00.21i07.00.2185256AA800623D7A852584E900723F3AAllergy ImmunotherapyAllergy Immunotherapy
85256AA800623D7A8525852F00700BD2.aspx
  
1815AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)Pathology and Laboratory (06)06.02.29d06.02.2985256AA800623D7A8525852F00700BD2AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)
C0BF3216424958498525851F0065B493.aspx
  
1803Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)Pharmacy (08)08.00.91d08.00.91C0BF3216424958498525851F0065B493Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)
eb6a7f32-769c-4801-9556-61f87151b480.aspx
  
2600AlwaysBundledProcedureCodes00.01.52jAdministrative (00)00.01.52j00.01.52eb6a7f32-769c-4801-9556-61f87151b480Always Bundled Procedure CodesAlways Bundled Procedure Codes
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85256AA800623D7A8525852700657888.aspx
  
1851Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) DevicesMedicine (07)07.02.09g07.02.0985256AA800623D7A8525852700657888Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) DevicesAmbulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
236c3927-91cd-4f9e-83a1-7da8090f7850.aspx
  
2748AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)Monitoring07.02.21eMedicine (07)07.02.21e07.02.21236c3927-91cd-4f9e-83a1-7da8090f7850Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
85256AA800623D7A8525847900595D5D.aspx
  
1674Ankle-Foot/Knee-Ankle-Foot OrthosesDME (05)05.00.39o05.00.3985256AA800623D7A8525847900595D5DAnkle-Foot/Knee-Ankle-Foot OrthosesAnkle-Foot/Knee-Ankle-Foot Orthoses
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1605Apheresis TherapyPathology and Laboratory (06)06.03.04n06.03.0485256AA800623D7A852581E800531E7BApheresis TherapyApheresis Therapy
0820c52b-3435-4ae2-9ea0-c8c776494f41.aspx
  
2674ApplicationandRemovalofTattoos11.08.05gSurgery (11)11.08.05g11.08.050820c52b-3435-4ae2-9ea0-c8c776494f41Application and Removal of TattoosApplication and Removal of Tattoos
85256AA800623D7A8525853E004B8BDF.aspx
  
1843Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)Pharmacy (08)08.01.41c08.01.4185256AA800623D7A8525853E004B8BDFAprepitant (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"},}
9bd8f538-81fe-4c49-bad1-aff8dd64fcb2.aspx
  
2719AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucoma11.05.16iSurgery (11)11.05.16i11.05.169bd8f538-81fe-4c49-bad1-aff8dd64fcb2Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
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A3A0632A8125CAEF85258588005C3C90.aspx
  
1543Artificial Intervertebral Disc InsertionSurgery (11)11.14.19o11.14.19A3A0632A8125CAEF85258588005C3C90Artificial Intervertebral Disc InsertionArtificial Intervertebral Disc Insertion
85256AA800623D7A8525848D004D1680.aspx
  
1739Asparaginase Erwinia Chrysanthemi (Erwinaze®)Pharmacy (08)08.01.35b08.01.3585256AA800623D7A8525848D004D1680Asparaginase Erwinia Chrysanthemi (Erwinaze®)Asparaginase Erwinia Chrysanthemi (Erwinaze®)
85256AA800623D7A852585A4006521E2.aspx
  
1596Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (AmeriHealth Administrators)Pathology and Laboratory (06)06.02.27l06.02.2785256AA800623D7A852585A4006521E2Assays 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)
5fe6dcdc-0b9d-475c-9e40-1df097fb9f2c.aspx
  
2615AssistedReproductiveTechnologyforInfertilityandOocyteCryopreservation07.10.06hMedicine (07)07.10.06h07.10.065fe6dcdc-0b9d-475c-9e40-1df097fb9f2cAssisted Reproductive Technology for Infertility and Oocyte CryopreservationAssisted Reproductive Technology for Infertility and Oocyte Cryopreservation
8470da1f-a6df-49af-b6bb-2f51ee4280db.aspx
  
2500Atezolizumab(Tecentriq®)08.01.69Pharmacy (08)08.01.6908.01.698470da1f-a6df-49af-b6bb-2f51ee4280dbAtezolizumab (Tecentriq®)Atezolizumab (Tecentriq®)
{"2501": {"Id":2501,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":4723,"PolicyAttachmentPageName":"afedffda-6a22-4abb-8108-ba0033e13870"},}
85256AA800623D7A8525849B004313B6.aspx
  
1551Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage LesionsSurgery (11)11.14.06i11.14.0685256AA800623D7A8525849B004313B6Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage LesionsAutologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions
A0450B1CECA727FF852585AB00533565.aspx
  
2426Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)DME (05)05.00.29l05.00.29A0450B1CECA727FF852585AB00533565Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
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85256AA800623D7A85258535005F4262.aspx
  
1561Autonomic Nervous System TestingMedicine (07)07.03.23c07.03.2385256AA800623D7A85258535005F4262Autonomic Nervous System TestingAutonomic Nervous System Testing
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2482Avelumab(Bavencio®)08.01.64Pharmacy (08)08.01.6408.01.64062d4c58-12d3-4969-b37b-8e58d6aef3baAvelumab (Bavencio®)Avelumab (Bavencio®)
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2728BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitis11.16.06jSurgery (11)11.16.06j11.16.06f2e21ee4-7f8d-4194-87e5-9f702fb30cefBalloon Catheter Dilation of Sinus Ostia for Treatment of Chronic RhinosinusitisBalloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
85256AA800623D7A852584E0005DE542.aspx
  
1782Bariatric SurgerySurgery (11)11.03.02s11.03.0285256AA800623D7A852584E0005DE542Bariatric SurgeryBariatric Surgery
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2622Belantamabmafodotin-blmf(Blenrep)08.01.70Pharmacy (08)08.01.7008.01.70a6b86613-83d7-4813-9353-d966deac3c9dBelantamab mafodotin-blmf (Blenrep)Belantamab mafodotin-blmf (Blenrep)
85256AA800623D7A852584EB005DFB48.aspx
  
1534Belimumab (Benlysta®) for Intravenous UsePharmacy (08)08.00.99c08.00.9985256AA800623D7A852584EB005DFB48Belimumab (Benlysta®) for Intravenous UseBelimumab (Benlysta®) for Intravenous Use
6566BD92D37238AE8525856900675D9F.aspx
  
1867Bevacizumab (Avastin®) and Related Biosimilars For Oncologic UsePharmacy (08)08.00.66n08.00.666566BD92D37238AE8525856900675D9FBevacizumab (Avastin®) and Related Biosimilars For Oncologic UseBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
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1969Billing Requirements for Multiple Births for Professional ProvidersAdministrative (00)00.10.38a00.10.3885256AA800623D7A852584B100666803Billing Requirements for Multiple Births for Professional ProvidersBilling Requirements for Multiple Births for Professional Providers
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2630BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampus00.10.39mAdministrative (00)00.10.39m00.10.3977d16a17-98de-496a-b99e-cc44427692bfBilling 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
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2575a0d1-26dc-45aa-81b4-c8c13ea46c73.aspx
  
2685BiofeedbackTherapy07.00.01jMedicine (07)07.00.01j07.00.012575a0d1-26dc-45aa-81b4-c8c13ea46c73Biofeedback TherapyBiofeedback Therapy
85256AA800623D7A852585340044B9F1.aspx
  
1821Bioimpedance for the Detection of LymphedemaMedicine (07)07.06.03b07.06.0385256AA800623D7A852585340044B9F1Bioimpedance for the Detection of LymphedemaBioimpedance for the Detection of Lymphedema
85256AA800623D7A85258336004611B0.aspx
  
1611Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/CanthopexySurgery (11)11.05.02i11.05.0285256AA800623D7A85258336004611B0Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/CanthopexyBlepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
{"2225":{"Id":2225,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258336004611BB"},}
fcb82298-9d09-45e8-ba5b-d51e0894b846.aspx
  
2743Blinatumomab(Blincyto®)08.01.21cPharmacy (08)08.01.21c08.01.21fcb82298-9d09-45e8-ba5b-d51e0894b846Blinatumomab (Blincyto®)Blinatumomab (Blincyto®)
85256AA800623D7A852584B80067B4E4.aspx
  
1804Bone Mineral Density (BMD) TestingRadiology (09)09.00.04k09.00.0485256AA800623D7A852584B80067B4E4Bone Mineral Density (BMD) TestingBone Mineral Density (BMD) Testing
af56d217-5751-42f2-9ded-3b66ff325a7f.aspx
  
2734Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAids11.01.06eSurgery (11)11.01.06e11.01.06af56d217-5751-42f2-9ded-3b66ff325a7fBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing AidsBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
85256AA800623D7A8525838400606BF9.aspx
  
1626Bortezomib (Bortezomib for Injection, Velcade®)Pharmacy (08)08.00.73l08.00.7385256AA800623D7A8525838400606BF9Bortezomib (Bortezomib for Injection, Velcade®)Bortezomib (Bortezomib for Injection, Velcade®)
85256AA800623D7A8525853E005046D3.aspx
  
1537Botulinum Toxin AgentsPharmacy (08)08.00.26w08.00.2685256AA800623D7A8525853E005046D3Botulinum Toxin AgentsBotulinum Toxin Agents
{"2368":{"Id":2368,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525853E005046F5"},}
85256AA800623D7A852583B60065D7FE.aspx
  
1661Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (AmeriHealth Administrators)Radiology (09)09.00.10z09.00.1085256AA800623D7A852583B60065D7FEBrachytherapy 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)
85256AA800623D7A852584C80074166B.aspx
  
1757Breast PumpsDME (05)05.00.76c05.00.7685256AA800623D7A852584C80074166BBreast PumpsBreast Pumps
85256AA800623D7A8525848D004D1008.aspx
  
1755Brentuximab Vedotin (Adcetris®)Pharmacy (08)08.01.13d08.01.1385256AA800623D7A8525848D004D1008Brentuximab Vedotin (Adcetris®)Brentuximab Vedotin (Adcetris®)
{"2311":{"Id":2311,"MPAttachmentLetter":"A","Title":"ICD CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A8525848D004D1011"},}
85256AA800623D7A852585A4005899AC.aspx
  
1601Bronchial ThermoplastySurgery (11)11.16.07b11.16.0785256AA800623D7A852585A4005899ACBronchial ThermoplastyBronchial Thermoplasty
85256AA800623D7A8525847E006E285B.aspx
  
1680Burosumab-twza (Crysvita®)Pharmacy (08)08.01.49a08.01.4985256AA800623D7A8525847E006E285BBurosumab-twza (Crysvita®)Burosumab-twza (Crysvita®)
85256AA800623D7A8525853D005A168F.aspx
  
1590Cabazitaxel (Jevtana®)Pharmacy (08)08.00.96e08.00.9685256AA800623D7A8525853D005A168FCabazitaxel (Jevtana®)Cabazitaxel (Jevtana®)
85256AA800623D7A852585660071B05C.aspx
  
1875Canakinumab (Ilaris®)Pharmacy (08)08.01.5108.01.5185256AA800623D7A852585660071B05CCanakinumab (Ilaris®)Canakinumab (Ilaris®)
847887d0-b38f-484e-80b4-ce36b27acefe.aspx
  
2750CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)Programs10.01.01nRehabilitation Services (10)10.01.01n10.01.01847887d0-b38f-484e-80b4-ce36b27acefeCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) ProgramsCardiac 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"},}
85256AA800623D7A8525847F0061D443.aspx
  
1974Care Management and Care Planning ServicesAdministrative (00)00.01.59f00.01.5985256AA800623D7A8525847F0061D443Care Management and Care Planning ServicesCare Management and Care Planning Services
24c34fb2-6bd5-48be-a2a3-e7136af3f275.aspx
  
2677Carfilzomib(Kyprolis®)08.01.05gPharmacy (08)08.01.05g08.01.0524c34fb2-6bd5-48be-a2a3-e7136af3f275Carfilzomib (Kyprolis®)Carfilzomib (Kyprolis®)
82EF268AB3C7CA1E852581E9005653DB.aspx
  
1932Cast and Splint Applications and Associated Supplies Provided in the Office SettingAdministrative (00)00.10.15c00.10.1582EF268AB3C7CA1E852581E9005653DBCast and Splint Applications and Associated Supplies Provided in the Office SettingCast and Splint Applications and Associated Supplies Provided in the Office Setting
{"2215":{"Id":2215,"MPAttachmentLetter":"A","Title":"No Title","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"4D63E2E2E70A4FA4852581E9005653EC"},}
85256AA800623D7A85258574006D0BB6.aspx
  
1531Cataract SurgerySurgery (11)11.01.07e11.01.0785256AA800623D7A85258574006D0BB6Cataract SurgeryCataract Surgery
{"2364":{"Id":2364,"MPAttachmentLetter":"A","Title":"ICD 10 codes for policy 11.01.07d, Cataract Surgery","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"85256AA800623D7A85258574006D0BFE"},}
2fc0ca5d-07cf-482b-b1aa-64c3dc277478.aspx
  
2691CatheterAblationofCardiacArrhythmias11.02.06mSurgery (11)11.02.06m11.02.062fc0ca5d-07cf-482b-b1aa-64c3dc277478Catheter Ablation of Cardiac ArrhythmiasCatheter Ablation of Cardiac Arrhythmias
85256AA800623D7A8525857A004FE849.aspx
  
2427Cemiplimab-rwlc (LIBTAYO®)Pharmacy (08)08.01.6608.01.6685256AA800623D7A8525857A004FE849Cemiplimab-rwlc (LIBTAYO®)Cemiplimab-rwlc (LIBTAYO®)
85256AA800623D7A8525852F006D7D15.aspx
  
1824Cerliponase alfa (Brineura®)Pharmacy (08)08.01.39c08.01.3985256AA800623D7A8525852F006D7D15Cerliponase alfa (Brineura®)Cerliponase alfa (Brineura®)
2892d91c-09af-4047-9d95-193f41591437.aspx
  
2672CervicalTractionDevicesforIn-homeUse05.00.61gDME (05)05.00.61g05.00.612892d91c-09af-4047-9d95-193f41591437Cervical Traction Devices for In-home UseCervical Traction Devices for In-home Use
85256AA800623D7A8525846C00638C9B.aspx
  
1730Cetuximab (Erbitux®)Pharmacy (08)08.00.67l08.00.6785256AA800623D7A8525846C00638C9BCetuximab (Erbitux®)Cetuximab (Erbitux®)
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cfe71410-8201-47ec-aea1-88249ce1763b.aspx
  
2694ChemicalPeels11.08.08gSurgery (11)11.08.08g11.08.08cfe71410-8201-47ec-aea1-88249ce1763bChemical PeelsChemical Peels
85256AA800623D7A852583E500468BCA.aspx
  
1735Chimeric Antigen Receptor (CAR) TherapyPharmacy (08)08.01.43e08.01.4385256AA800623D7A852583E500468BCAChimeric Antigen Receptor (CAR) TherapyChimeric Antigen Receptor (CAR) Therapy
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CD5255F2AD53803E8525856C006F1209.aspx
  
1869Chiropractic Spinal and Extraspinal Manipulation TherapyRehabilitation Services (10)10.02.02j10.02.02CD5255F2AD53803E8525856C006F1209Chiropractic Spinal and Extraspinal Manipulation TherapyChiropractic Spinal and Extraspinal Manipulation Therapy
85256AA800623D7A85258583006910C4.aspx
  
1575Coagulation FactorsPharmacy (08)08.00.92ab08.00.9285256AA800623D7A85258583006910C4Coagulation FactorsCoagulation Factors
85256AA800623D7A852585A4006620E8.aspx
  
1599Cobalamin (Vitamin B12), Folic Acid, and Homocysteine TestingPathology and Laboratory (06)06.02.5406.02.5485256AA800623D7A852585A4006620E8Cobalamin (Vitamin B12), Folic Acid, and Homocysteine TestingCobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
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85256AA800623D7A852584C500591E9D.aspx
  
1778Cochlear ImplantSurgery (11)11.01.02o11.01.0285256AA800623D7A852584C500591E9DCochlear ImplantCochlear Implant
f708376d-a16b-48f1-8f4b-beea8f1a3144.aspx
  
2722Collagenaseclostridiumhistolyticum(Xiaflex®),collagenaseclostridiumhistolyticum-aaes(Qwo™)08.01.71Pharmacy (08)08.01.7108.01.71f708376d-a16b-48f1-8f4b-beea8f1a3144Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™)Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™)
e8fcbf84-816c-410d-ad3b-6d4dfbbecd65.aspx
  
2680ColorectalCancerScreening11.03.12sSurgery (11)11.03.12s11.03.12e8fcbf84-816c-410d-ad3b-6d4dfbbecd65Colorectal Cancer ScreeningColorectal Cancer Screening
B55889244594F1F085258574005DA579.aspx
  
1917Complementary and Integrative Health ServicesMiscellaneous (12)12.00.03g12.00.03B55889244594F1F085258574005DA579Complementary and Integrative Health ServicesComplementary and Integrative Health Services
85256AA800623D7A852585340042F9F6.aspx
  
1820Complete Decongestive Therapy (CDT)Medicine (07)07.06.01b07.06.0185256AA800623D7A852585340042F9F6Complete Decongestive Therapy (CDT)Complete Decongestive Therapy (CDT)
85256AA800623D7A852585380063AE75.aspx
  
1526Composite Tissue Allotransplantation of the Hand(s) and FaceSurgery (11)11.14.3011.14.3085256AA800623D7A852585380063AE75Composite Tissue Allotransplantation of the Hand(s) and FaceComposite Tissue Allotransplantation of the Hand(s) and Face
85256AA800623D7A8525855100776BC6.aspx
  
1582Compression GarmentsDME (05)05.00.37f05.00.3785256AA800623D7A8525855100776BC6Compression GarmentsCompression Garments
85256AA800623D7A852584F2004C9E48.aspx
  
1798Computer-Aided Detection (CAD) System for Use with Chest RadiographsRadiology (09)09.00.42c09.00.4285256AA800623D7A852584F2004C9E48Computer-Aided Detection (CAD) System for Use with Chest RadiographsComputer-Aided Detection (CAD) System for Use with Chest Radiographs
85256AA800623D7A852584E90067043F.aspx
  
1859Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic ProceduresSurgery (11)11.14.17d11.14.1785256AA800623D7A852584E90067043FComputer-Assisted Musculoskeletal Surgical Navigational Orthopedic ProceduresComputer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures
F3BA7DB0E980312B8525854B005EE64C.aspx
  
1986Consultation ServicesAdministrative (00)00.01.6900.01.69F3BA7DB0E980312B8525854B005EE64CConsultation ServicesConsultation Services
8193c86d-b0a9-4cfb-833c-e68d203cf6d6.aspx
  
2681ContactLensesfortheTreatmentofPersistent(Corneal)EpithelialDefects07.13.11jMedicine (07)07.13.11j07.13.118193c86d-b0a9-4cfb-833c-e68d203cf6d6Contact Lenses for the Treatment of Persistent (Corneal) Epithelial DefectsContact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
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85256AA800623D7A852584E900724249.aspx
  
1787Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion PumpAnesthesia (01)01.00.09c01.00.0985256AA800623D7A852584E900724249Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion PumpContinuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump
85256AA800623D7A8525851B005C0BC6.aspx
  
1979Contrast Agents Used in Conjunction with EchocardiographyRadiology (09)09.00.11d09.00.1185256AA800623D7A8525851B005C0BC6Contrast Agents Used in Conjunction with EchocardiographyContrast Agents Used in Conjunction with Echocardiography
eeb622d6-06b3-4b65-b45b-8e30a72cc6fb.aspx
  
2683CornealPachymetryUsingUltrasound07.13.07kMedicine (07)07.13.07k07.13.07eeb622d6-06b3-4b65-b45b-8e30a72cc6fbCorneal Pachymetry Using UltrasoundCorneal Pachymetry Using Ultrasound
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4ed52e3e-0047-438d-8ad9-e328a7daae59.aspx
  
2698CosmeticProcedures12.01.03aMiscellaneous (12)12.01.03a12.01.034ed52e3e-0047-438d-8ad9-e328a7daae59Cosmetic ProceduresCosmetic Procedures
85256AA800623D7A852583F900647246.aspx
  
1953Coverage of Medical DevicesDME (05)05.00.04e05.00.0485256AA800623D7A852583F900647246Coverage of Medical DevicesCoverage of Medical Devices
85256AA800623D7A8525855000697D90.aspx
  
1858Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical BenefitPharmacy (08)08.01.08d08.01.0885256AA800623D7A8525855000697D90Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical BenefitCoverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical Benefit
B359B93517FDEAD385258550007A8C53.aspx
  
1853Cranial Remolding Orthoses (Helmets)DME (05)05.00.25i05.00.25B359B93517FDEAD385258550007A8C53Cranial Remolding Orthoses (Helmets)Cranial Remolding Orthoses (Helmets)
237abae4-3c2e-4ac9-bd1b-670132546eb6.aspx
  
2645CranialElectrotherapyStimulation05.00.80ADME (05)05.00.80A05.00.80237abae4-3c2e-4ac9-bd1b-670132546eb6Cranial Electrotherapy StimulationCranial Electrotherapy Stimulation
85256AA800623D7A852584710058EC0E.aspx
  
1811Criteria for Reimbursement of Emergency Room ServicesAdministrative (00)00.10.03j00.10.0385256AA800623D7A852584710058EC0ECriteria for Reimbursement of Emergency Room ServicesCriteria for Reimbursement of Emergency Room Services
faa50be1-657d-4d20-a6a5-87611074c3ab.aspx
  
2455crizanlizumab-tmca(Adakveo®)08.00.04Pharmacy (08)08.00.0408.00.04faa50be1-657d-4d20-a6a5-87611074c3abcrizanlizumab-tmca (Adakveo®)crizanlizumab-tmca (Adakveo®)
85256AA800623D7A8525853000775E5F.aspx
  
1827Cryosurgical Ablation of the Prostate GlandSurgery (11)11.11.03d11.11.0385256AA800623D7A8525853000775E5FCryosurgical Ablation of the Prostate GlandCryosurgical Ablation of the Prostate Gland
f588715f-2a74-4e26-b498-dddf9c0be50e.aspx
  
2539Daratumumab(Darzalex®),Daratumumab,andHyaluronidase-fihj(DarzalexFaspro™)08.01.29gPharmacy (08)08.01.29g08.01.29f588715f-2a74-4e26-b498-dddf9c0be50eDaratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro™)Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro™)
85256AA800623D7A85258585004BD885.aspx
  
1558Day RehabilitationRehabilitation Services (10)10.00.02c10.00.0285256AA800623D7A85258585004BD885Day RehabilitationDay Rehabilitation
d32a8021-473d-4d01-b269-950e6c35c325.aspx
  
2545DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNails11.08.17jSurgery (11)11.08.17j11.08.17d32a8021-473d-4d01-b269-950e6c35c325Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe NailsDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
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85256AA800623D7A8525842B006B6CC3.aspx
  
1667Deep Brain Stimulation (DBS)Surgery (11)11.15.20o11.15.2085256AA800623D7A8525842B006B6CC3Deep Brain Stimulation (DBS)Deep Brain Stimulation (DBS)
6E54370B49975A5A85258588005CDCC0.aspx
  
1547Denervation of the Spinal Nerves for Chronic PainSurgery (11)11.15.09n11.15.096E54370B49975A5A85258588005CDCC0Denervation of the Spinal Nerves for Chronic PainDenervation of the Spinal Nerves for Chronic Pain
f49857c4-b5fa-4ab2-8175-9106ac943d5a.aspx
  
2608Denosumab(Prolia®,Xgeva®),Romosozumab-aqqg(Evenity™)08.00.94nPharmacy (08)08.00.94n08.00.94f49857c4-b5fa-4ab2-8175-9106ac943d5aDenosumab (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"},}
85256AA800623D7A852585880062FEBF.aspx
  
1572Deoxycholic Acid (Kybella™)Pharmacy (08)08.01.24a08.01.2485256AA800623D7A852585880062FEBFDeoxycholic Acid (Kybella™)Deoxycholic Acid (Kybella™)
85256AA800623D7A85258513005AF2AB.aspx
  
1984Diagnostic Radiology Services Included in CapitationAdministrative (00)00.03.02aa00.03.0285256AA800623D7A85258513005AF2ABDiagnostic Radiology Services Included in CapitationDiagnostic Radiology Services Included in Capitation
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85256AA800623D7A852582CD00532104.aspx
  
1946Direct Access to Obstetrics/Gynecology (OB/GYN) ServicesAdministrative (00)00.09.01f00.09.0185256AA800623D7A852582CD00532104Direct Access to Obstetrics/Gynecology (OB/GYN) ServicesDirect Access to Obstetrics/Gynecology (OB/GYN) Services
85256AA800623D7A852585A40063C332.aspx
  
1600Dofetilide (Tikosyn®) Use in the Inpatient SettingPharmacy (08)08.00.49e08.00.4985256AA800623D7A852585A40063C332Dofetilide (Tikosyn®) Use in the Inpatient SettingDofetilide (Tikosyn®) Use in the Inpatient Setting
bef1b14c-04ab-4591-b6a4-e5d222c3a82c.aspx
  
2669Drug-ElutingBeadsandBlandEmbolizationfortheTreatmentofHepaticMalignancies07.05.07dMedicine (07)07.05.07d07.05.07bef1b14c-04ab-4591-b6a4-e5d222c3a82cDrug-Eluting Beads and Bland Embolization for the Treatment of Hepatic MalignanciesDrug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
85256AA800623D7A8525820B004EC0DE.aspx
  
1704Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Naltrexone Implants, Probuphine Implant, Sublocade Injection, Vivitrol Injection)Pharmacy (08)08.01.37a08.01.3785256AA800623D7A8525820B004EC0DEDrugs 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)
85256AA800623D7A85258360004DAB8C.aspx
  
1941Durable Medical Equipment (DME) Not Subject to a Rental to Purchase MaximumDME (05)05.00.48j05.00.4885256AA800623D7A85258360004DAB8CDurable Medical Equipment (DME) Not Subject to a Rental to Purchase MaximumDurable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
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