Commercial
  
  
  
  
  
  
  
  
  
  
MPattachmentdataPub
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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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1585Acute Care Facility Inpatient TransfersMiscellaneous (12)12.04.04a12.04.0485256AA800623D7A85258596007CD987Acute Care Facility Inpatient TransfersAcute Care Facility Inpatient Transfers
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2917Ado-TrastuzumabEmtansine(Kadcyla®)08.01.11fPharmacy (08)08.01.11f08.01.1128064e49-a2b7-4f80-ba96-337057e5e541Ado-Trastuzumab Emtansine (Kadcyla®)Ado-Trastuzumab Emtansine (Kadcyla®)
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85256AA800623D7A852585420071736C.aspx
  
1841Agalsidase beta (Fabrazyme®)Pharmacy (08)08.00.69b08.00.6985256AA800623D7A852585420071736CAgalsidase beta (Fabrazyme®)Agalsidase beta (Fabrazyme®)
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1586Air Ambulance ServicesMiscellaneous (12)12.04.03c12.04.0385256AA800623D7A85258596007D3BA6Air Ambulance ServicesAir Ambulance Services
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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®)
97b16c26-2db8-44f7-8e9d-c9e653158d5b.aspx
  
2879AllergyImmunotherapy07.00.21jMedicine (07)07.00.21j07.00.2197b16c26-2db8-44f7-8e9d-c9e653158d5bAllergy 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)
f928229d-392f-46ab-a93c-274ef407aa75.aspx
  
2927Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C®,AralastNP®,Glassia®,Zemaira®)08.00.91ePharmacy (08)08.00.91e08.00.91f928229d-392f-46ab-a93c-274ef407aa75Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)
f32100d3-d483-46c8-9ad9-315ac6f7ba7c.aspx
  
3012AlwaysBundledProcedureCodes00.01.52kAdministrative (00)00.01.52k00.01.52f32100d3-d483-46c8-9ad9-315ac6f7ba7cAlways Bundled Procedure CodesAlways Bundled Procedure Codes
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c233d9c4-b48b-4763-a10b-7f4a06ccaad8.aspx
  
3042AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)Devices07.02.09gMedicine (07)07.02.09g07.02.09c233d9c4-b48b-4763-a10b-7f4a06ccaad8Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) DevicesAmbulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
6a4f1314-aedb-4e85-ab25-74431b22a079.aspx
  
2878AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)Monitoring07.02.21fMedicine (07)07.02.21f07.02.216a4f1314-aedb-4e85-ab25-74431b22a079Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
b3e048ec-4c3b-4a90-a710-c460b38063ca.aspx
  
2993Ankle-Foot/Knee-Ankle-FootOrthoses05.00.39pDME (05)05.00.39p05.00.39b3e048ec-4c3b-4a90-a710-c460b38063caAnkle-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
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®)
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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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3c9c1102-de45-473f-9a0d-e92c3d7b9687.aspx
  
2951ArtificialIntervertebralCervicalDiscInsertion(AmerihealthAdministrators)11.14.19pSurgery (11)11.14.19p11.14.193c9c1102-de45-473f-9a0d-e92c3d7b9687Artificial Intervertebral Cervical Disc Insertion (Amerihealth Administrators)Artificial Intervertebral Cervical Disc Insertion (Amerihealth Administrators)
12d48495-64b9-4f9f-b05b-007bf460da46.aspx
  
2950ArtificialIntervertebralLumbarDiscInsertion11.15.31Surgery (11)11.15.3111.15.3112d48495-64b9-4f9f-b05b-007bf460da46Artificial Intervertebral Lumbar Disc InsertionArtificial Intervertebral Lumbar Disc Insertion
988495ee-f60a-43f4-841b-2a0794848d76.aspx
  
3017AsparaginaseErwiniaChrysanthemi(Erwinaze®)08.01.35cPharmacy (08)08.01.35c08.01.35988495ee-f60a-43f4-841b-2a0794848d76Asparaginase 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)
e20aa7d8-bb05-4110-be2b-f752b6a8d611.aspx
  
2877AssistedReproductiveTechnologyforInfertilityandOocyteCryopreservation07.10.06iMedicine (07)07.10.06i07.10.06e20aa7d8-bb05-4110-be2b-f752b6a8d611Assisted 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"},}
39dafee4-6e6f-4983-b14c-8085c01aeba5.aspx
  
2963AutologousChondrocyteImplantation(ACI)andOtherCell-basedTreatmentsofFocalArticularCartilageLesions(AmerihealthAdministrators)11.14.06jSurgery (11)11.14.06j11.14.0639dafee4-6e6f-4983-b14c-8085c01aeba5Autologous 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)
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
062d4c58-12d3-4969-b37b-8e58d6aef3ba.aspx
  
2482Avelumab(Bavencio®)08.01.64Pharmacy (08)08.01.6408.01.64062d4c58-12d3-4969-b37b-8e58d6aef3baAvelumab (Bavencio®)Avelumab (Bavencio®)
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f2e21ee4-7f8d-4194-87e5-9f702fb30cef.aspx
  
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
deb6788b-9378-4634-bea1-f71971bb7026.aspx
  
2824BariatricSurgery11.03.02tSurgery (11)11.03.02t11.03.02deb6788b-9378-4634-bea1-f71971bb7026Bariatric SurgeryBariatric Surgery
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762b4173-9163-47ba-8d52-1b35cf5b90fd.aspx
  
2946Belantamabmafodotin-blmf(Blenrep)08.01.70aPharmacy (08)08.01.70a08.01.70762b4173-9163-47ba-8d52-1b35cf5b90fdBelantamab 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
e14d5427-e045-4eee-875d-5a1c7e82f214.aspx
  
3018Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUse08.00.66oPharmacy (08)08.00.66o08.00.66e14d5427-e045-4eee-875d-5a1c7e82f214Bevacizumab (Avastin®) and Related Biosimilars For Oncologic UseBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
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85256AA800623D7A852584B100666803.aspx
  
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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2936BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampus00.10.39nAdministrative (00)00.10.39n00.10.39aac783a0-0ef9-4d21-84a0-e1478fdc4bfdBilling 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
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1821Bioimpedance for the Detection of LymphedemaMedicine (07)07.06.03b07.06.0385256AA800623D7A852585340044B9F1Bioimpedance for the Detection of LymphedemaBioimpedance for the Detection of Lymphedema
18f429c4-65be-44ad-b849-f3e29733bbb7.aspx
  
3009Blepharoplasty,RepairofBlepharoptosis,RepairofBrowPtosis,andCanthoplasty/Canthopexy11.05.02jSurgery (11)11.05.02j11.05.0218f429c4-65be-44ad-b849-f3e29733bbb7Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/CanthopexyBlepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
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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
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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)
2d010011-4b3e-446e-b6ca-4467bc6b5d99.aspx
  
2753BreastPumps05.00.76dDME (05)05.00.76d05.00.762d010011-4b3e-446e-b6ca-4467bc6b5d99Breast PumpsBreast Pumps
85256AA800623D7A8525848D004D1008.aspx
  
1755Brentuximab Vedotin (Adcetris®)Pharmacy (08)08.01.13d08.01.1385256AA800623D7A8525848D004D1008Brentuximab Vedotin (Adcetris®)Brentuximab Vedotin (Adcetris®)
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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®)
d28522d7-c8b8-4e7d-a7ae-28920d8964b0.aspx
  
3036Canakinumab(Ilaris®)08.01.51aMiscellaneous (12)08.01.51a08.01.51d28522d7-c8b8-4e7d-a7ae-28920d8964b0Canakinumab (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
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2928CareManagementandCarePlanningServices00.01.59hAdministrative (00)00.01.59h00.01.59dab50f18-23da-4fbc-a6ec-142a67aa94e7Care 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®)
ead5d815-c736-402d-a236-12375fa27c39.aspx
  
2815CastandSplintApplicationsandAssociatedSupplies00.10.15dAdministrative (00)00.10.15d00.10.15ead5d815-c736-402d-a236-12375fa27c39Cast and Splint Applications and Associated SuppliesCast 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"},}
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1531Cataract SurgerySurgery (11)11.01.07e11.01.0785256AA800623D7A85258574006D0BB6Cataract SurgeryCataract Surgery
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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®)
{"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"},}
cfe71410-8201-47ec-aea1-88249ce1763b.aspx
  
2694ChemicalPeels11.08.08gSurgery (11)11.08.08g11.08.08cfe71410-8201-47ec-aea1-88249ce1763bChemical PeelsChemical Peels
d89b4d38-e37b-4495-80fc-acbf653a7e0f.aspx
  
2854ChimericAntigenReceptor(CAR)Therapy08.01.43fPharmacy (08)08.01.43f08.01.43d89b4d38-e37b-4495-80fc-acbf653a7e0fChimeric Antigen Receptor (CAR) TherapyChimeric Antigen Receptor (CAR) Therapy
{"2855": {"Id":2855,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":4713,"PolicyAttachmentPageName":"5d52e64b-d5ca-48d4-864c-79eaa970bb68"},}
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1869Chiropractic Spinal and Extraspinal Manipulation TherapyRehabilitation Services (10)10.02.02j10.02.02CD5255F2AD53803E8525856C006F1209Chiropractic Spinal and Extraspinal Manipulation TherapyChiropractic Spinal and Extraspinal Manipulation Therapy
083b8973-f704-430b-9342-5b06a2044349.aspx
  
2769CoagulationFactors08.00.92acPharmacy (08)08.00.92ac08.00.92083b8973-f704-430b-9342-5b06a2044349Coagulation Factors Coagulation Factors
71eeef1f-3ef6-49f6-bd61-b3ccbe4aff14.aspx
  
2828Cobalamin(VitaminB12),FolicAcid,andHomocysteineTesting06.02.54aPathology and Laboratory (06)06.02.54a06.02.5471eeef1f-3ef6-49f6-bd61-b3ccbe4aff14Cobalamin (Vitamin B12), Folic Acid, and Homocysteine TestingCobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
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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
bca8c37a-6d54-4b51-bf09-5450927cf0e2.aspx
  
2876Computer-assistedMusculoskeletalSurgicalNavigationalOrthopedicProcedure11.14.17eSurgery (11)11.14.17e11.14.17bca8c37a-6d54-4b51-bf09-5450927cf0e2Computer-assisted Musculoskeletal Surgical Navigational Orthopedic ProcedureComputer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
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
{"2682": {"Id":2682,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":4947,"PolicyAttachmentPageName":"546e7e55-6586-4b95-9af6-cb61f6f4bcf3"},}
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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
{"2684": {"Id":2684,"MPAttachmentLetter":"A","Title":"ICD-10-CM codes","MPPolicyAttachmentInternalSourceId":4969,"PolicyAttachmentPageName":"93ce09d2-985c-454f-94b2-f24a4f734a3f"},}
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
237abae4-3c2e-4ac9-bd1b-670132546eb6.aspx
  
2645CranialElectrotherapyStimulation05.00.80ADME (05)05.00.80A05.00.80237abae4-3c2e-4ac9-bd1b-670132546eb6Cranial Electrotherapy StimulationCranial Electrotherapy Stimulation
4c0f9461-3615-42b9-8172-7d831e57933a.aspx
  
3034CranialRemoldingOrthoses(Helmets)05.00.25iDME (05)05.00.25i05.00.254c0f9461-3615-42b9-8172-7d831e57933aCranial Remolding Orthoses (Helmets)Cranial Remolding Orthoses (Helmets)
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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
a4165e6e-9756-4be7-8f91-724258b7636e.aspx
  
2929Daratumumab(Darzalex®),Daratumumab,andHyaluronidase-fihj(DarzalexFaspro™)08.01.29hPharmacy (08)08.01.29h08.01.29a4165e6e-9756-4be7-8f91-724258b7636eDaratumumab (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
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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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7ab9c75e-ec48-47b0-9461-0cfae8b2cce8.aspx
  
2661DeepBrainStimulation(DBS)11.15.20pSurgery (11)11.15.20p11.15.207ab9c75e-ec48-47b0-9461-0cfae8b2cce8Deep Brain Stimulation (DBS)Deep Brain Stimulation (DBS)
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2958DenervationoftheSpinalNervesforChronicPain(AmerihealthAdministrators)11.15.09oSurgery (11)11.15.09o11.15.09a4157456-533f-41b7-af48-b069b8f89828Denervation of the Spinal Nerves for Chronic Pain (Amerihealth Administrators)Denervation of the Spinal Nerves for Chronic Pain (Amerihealth Administrators)
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™)
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2991DiagnosticRadiologyServicesIncludedinCapitation00.03.02abAdministrative (00)00.03.02ab00.03.02e4575742-3afd-4e86-a0f5-24ebba7753f9Diagnostic Radiology Services Included in CapitationDiagnostic Radiology Services Included in Capitation
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2947DirectAccesstoObstetrics/Gynecology(OB/GYN)Services00.09.01hAdministrative (00)00.09.01h00.09.01b1ef5086-c4c5-4583-836b-b89027c587a7Direct Access to Obstetrics/Gynecology (OB/GYN) ServicesDirect Access to Obstetrics/Gynecology (OB/GYN) Services
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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)
8c89e826-a513-41f2-8716-59e9e8adeff6.aspx
  
2896DurableMedicalEquipment(DME)andConsumableMedicalSupplies05.00.21wDME (05)05.00.21w05.00.218c89e826-a513-41f2-8716-59e9e8adeff6Durable Medical Equipment (DME) and Consumable Medical SuppliesDurable Medical Equipment (DME) and Consumable Medical Supplies
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3020DurableMedicalEquipment(DME)NotSubjecttoaRentaltoPurchaseMaximum05.00.48kDME (05)05.00.48k05.00.48bf7c7de8-7799-4645-adb6-e4be539f9bddDurable 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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