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ff54db2a-d4c9-4bc1-9852-bd476768943a.aspx
  
8200​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Low-LevelLaserTherapy07.00.14iMedicine (07)07.00.14i07.00.14ff54db2a-d4c9-4bc1-9852-bd476768943a​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Low-Level Laser Therapy​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Low-Level Laser Therapy
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7909Abatacept(Orencia®)forInjectionforIntravenousUse08.00.62rPharmacy (08)08.00.62r08.00.620cdfa197-861f-4507-8f37-a8d7b9435ffbAbatacept (Orencia®) for Injection for Intravenous UseAbatacept (Orencia®) for Injection for Intravenous Use
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8605AblationofLungTumors11.00.16kSurgery (11)11.00.16k11.00.1608354f57-a9df-4cdb-8605-e39818199d3aAblation of Lung TumorsAblation of Lung Tumors
8d8979e8-6906-43bc-8899-2aca3ffdd751.aspx
  
8259Acupuncture12.00.01iMiscellaneous (12)12.00.01i12.00.018d8979e8-6906-43bc-8899-2aca3ffdd751AcupunctureAcupuncture
{"8260": {"Id":8260,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Acupuncture","MPPolicyAttachmentInternalSourceId":10302,"PolicyAttachmentPageName":"8bf9e1dc-64be-48d6-930d-0a52ad405e8e"},}
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7781AcuteCareFacilityInpatientTransfers12.04.04bMiscellaneous (12)12.04.04b12.04.049d5c2f34-6177-4cbe-967c-fc6c80eb5810Acute Care Facility Inpatient TransfersAcute Care Facility Inpatient Transfers
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7519ADAMTS13,recombinant-krhn(Adzynma)08.02.21Pharmacy (08)08.02.2108.02.21fd008533-34c4-4ed3-ba7e-e3a4ac663f0fADAMTS13, recombinant-krhn (Adzynma)ADAMTS13, recombinant-krhn (Adzynma)
1ede2684-4822-4a03-b66b-ed1000fcf81f.aspx
  
7991Ado-TrastuzumabEmtansine(Kadcyla®)08.01.11jPharmacy (08)08.01.11j08.01.111ede2684-4822-4a03-b66b-ed1000fcf81fAdo-Trastuzumab Emtansine (Kadcyla®)Ado-Trastuzumab Emtansine (Kadcyla®)
4758c78a-1e05-4951-8f9d-d374b7d2607e.aspx
  
8346Afamitresgeneautoleucel(Tecelra®)08.02.32aPharmacy (08)08.02.32a08.02.324758c78a-1e05-4951-8f9d-d374b7d2607eAfamitresgene autoleucel (Tecelra®)Afamitresgene autoleucel (Tecelra®)
6ae71c67-4905-4441-9792-103799004bce.aspx
  
8347Agalsidasebeta(Fabrazyme®)andpegunigalsidasealfa-iwxj(Elfabrio)08.00.69dPharmacy (08)08.00.69d08.00.696ae71c67-4905-4441-9792-103799004bceAgalsidase beta (Fabrazyme®) and pegunigalsidase alfa-iwxj (Elfabrio) Agalsidase beta (Fabrazyme®) and pegunigalsidase alfa-iwxj (Elfabrio)
e1ea2509-f318-4875-b48b-fc16bb7c5517.aspx
  
7879AirAmbulanceServices12.04.03dMiscellaneous (12)12.04.03d12.04.03e1ea2509-f318-4875-b48b-fc16bb7c5517Air Ambulance ServicesAir Ambulance Services
f38164fa-91fd-4e3b-a62a-4a24cdfa2a60.aspx
  
7838Alemtuzumab(Lemtrada®)08.01.22ePharmacy (08)08.01.22e08.01.22f38164fa-91fd-4e3b-a62a-4a24cdfa2a60Alemtuzumab (Lemtrada®)Alemtuzumab (Lemtrada®)
f78ee04f-b763-47ec-9b46-8e442c19b589.aspx
  
8473Alglucosidasealfa(e.g.,Lumizyme®),Avalglucosidasealfa-ngpt(Nexviazyme®),Cipaglucosidasealfa-atga(Pombiliti™)08.00.72lPharmacy (08)08.00.72l08.00.72f78ee04f-b763-47ec-9b46-8e442c19b589Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® ), Cipaglucosidase alfa-atga (Pombiliti™ )Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® ), Cipaglucosidase alfa-atga (Pombiliti™ )
53d13a94-5654-4cfd-b1c5-4a656717e2f1.aspx
  
8430AllergyImmunotherapy07.00.21kMedicine (07)07.00.21k07.00.2153d13a94-5654-4cfd-b1c5-4a656717e2f1Allergy ImmunotherapyAllergy Immunotherapy
209dee3a-83a5-45ce-9f57-83defef9b35e.aspx
  
8601AllogeneicProcessedThymusTissue-agdc(Rethymic®)08.01.88bPharmacy (08)08.01.88b08.01.88209dee3a-83a5-45ce-9f57-83defef9b35eAllogeneic Processed Thymus Tissue-agdc (Rethymic®)Allogeneic Processed Thymus Tissue-agdc (Rethymic®)
c638673c-6433-4d3e-85a2-235799915fdd.aspx
  
8338AlloMap™MolecularExpressionTestingforHeartTransplantRejection(AmeriHealthAdministrators)06.02.29gPathology and Laboratory (06)06.02.29g06.02.29c638673c-6433-4d3e-85a2-235799915fddAlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)
26c797a4-e6a5-4143-8587-6242d11c6ad4.aspx
  
8525Alpha-1AntitrypsinTherapy(e.g.,Prolastin-C®,AralastNP®,Glassia®,Zemaira®)08.00.91fPharmacy (08)08.00.91f08.00.9126c797a4-e6a5-4143-8587-6242d11c6ad4Alpha-1 Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)Alpha-1 Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)
f02dd513-baba-4592-8efe-f63835d1ab20.aspx
  
8451AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)Devices07.02.09kMedicine (07)07.02.09k07.02.09f02dd513-baba-4592-8efe-f63835d1ab20Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) DevicesAmbulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
d6e22cf1-f860-4ba4-bd1f-653d6f1d17e0.aspx
  
8600AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)Monitoring07.02.21rMedicine (07)07.02.21r07.02.21d6e22cf1-f860-4ba4-bd1f-653d6f1d17e0Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
4be0de04-e277-4a85-ae2d-b2deb35e8f21.aspx
  
8504Amivantamab-vmjw(Rybrevant®)andAmivantamabandhyaluronidase-lpuj(RybrevantFaspro™)08.01.90cPharmacy (08)08.01.90c08.01.904be0de04-e277-4a85-ae2d-b2deb35e8f21Amivantamab-vmjw (Rybrevant®) and Amivantamab and hyaluronidase-lpuj (Rybrevant Faspro™)Amivantamab-vmjw (Rybrevant®) and Amivantamab and hyaluronidase-lpuj (Rybrevant Faspro™)
fa80afe7-2a2d-4bef-8751-39ae4b420c8f.aspx
  
8316AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagement01.00.12dAnesthesia (01)01.00.12d01.00.12fa80afe7-2a2d-4bef-8751-39ae4b420c8fAnesthesia 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
{"8317": {"Id":8317,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":10365,"PolicyAttachmentPageName":"68840056-6ccf-4e86-9e09-4fbc9b1b12a4"},}
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8533Anifrolumab-fnia(Saphnelo®)08.01.82cPharmacy (08)08.01.82c08.01.82bb14ca28-1d81-4987-92f9-a494abd49a2bAnifrolumab-fnia (Saphnelo®)Anifrolumab-fnia (Saphnelo®)
966bd452-6338-41a9-92af-732491b02dc4.aspx
  
7778Ankle-Foot/Knee-Ankle-FootOrthoses05.00.39vDME (05)05.00.39v05.00.39966bd452-6338-41a9-92af-732491b02dc4Ankle-Foot/Knee-Ankle-Foot OrthosesAnkle-Foot/Knee-Ankle-Foot Orthoses
{"7779": {"Id":7779,"MPAttachmentLetter":"A","Title":"HCPCS Codes","MPPolicyAttachmentInternalSourceId":10050,"PolicyAttachmentPageName":"a9a20411-76a0-4e64-939d-66d5b2da8b70"},}
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8370ApheresisTherapy06.03.04pPathology and Laboratory (06)06.03.04p06.03.04165b3086-cdfc-4bf5-b4db-0692080dd2f9Apheresis TherapyApheresis Therapy
67425cc3-07be-4535-8f98-aa782aed6207.aspx
  
8082Apos®biomechanicalshoesystem05.00.84DME (05)05.00.8405.00.8467425cc3-07be-4535-8f98-aa782aed6207Apos® biomechanical shoe systemApos® biomechanical shoe system
2dbac49d-cffb-48cb-ae51-d478c1803762.aspx
  
8319ApplicationandRemovalofTattoos11.08.05gSurgery (11)11.08.05g11.08.052dbac49d-cffb-48cb-ae51-d478c1803762Application and Removal of TattoosApplication and Removal of Tattoos
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8121AppliedBehaviorAnalysis(ABA)fortheTreatmentofAutismSpectrumDisorder(ASD)14.00.03bBehavioral Health (14)14.00.03b14.00.03df5a4d4b-0bc7-4458-844b-0a350f6cb8b0Applied Behavior Analysis (ABA) for the Treatment of Autism Spectrum Disorder (ASD)Applied Behavior Analysis (ABA) for the Treatment of Autism Spectrum Disorder (ASD)
27d52305-5f49-4a7a-9192-b9f44905dbd6.aspx
  
7785AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucoma11.05.16mSurgery (11)11.05.16m11.05.1627d52305-5f49-4a7a-9192-b9f44905dbd6Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
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7479ArtificialIntervertebralCervicalDiscInsertion(AmeriHealthAdministrators)11.14.19pSurgery (11)11.14.19p11.14.1935245b24-5bf6-4802-9442-902d406c9e67Artificial Intervertebral Cervical Disc Insertion (AmeriHealth Administrators)Artificial Intervertebral Cervical Disc Insertion (AmeriHealth Administrators)
c32128a7-4f5b-4e57-975b-151084683596.aspx
  
8541AsparaginaseErwiniaChrysanthemi(recombinant)-rywn(Rylaze®)08.01.35kPharmacy (08)08.01.35k08.01.35c32128a7-4f5b-4e57-975b-151084683596Asparaginase Erwinia Chrysanthemi (recombinant)-rywn (Rylaze®)Asparaginase Erwinia Chrysanthemi (recombinant)-rywn (Rylaze®)
56cacc55-1d7c-498d-927b-8a69cac0aca7.aspx
  
7261AssaysofGeneticExpressioninTumorTissueforBreastCancerPrognosis(AmeriHealthAdministrators)06.02.27pPathology and Laboratory (06)06.02.27p06.02.2756cacc55-1d7c-498d-927b-8a69cac0aca7Assays 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)
6f3e894a-05bc-4cd3-bdef-f6cbc845ef41.aspx
  
6631AssistedReproductiveTechnologyforInfertilityandOocyteCryopreservation07.10.06jMedicine (07)07.10.06j07.10.066f3e894a-05bc-4cd3-bdef-f6cbc845ef41Assisted Reproductive Technology for Infertility and Oocyte CryopreservationAssisted Reproductive Technology for Infertility and Oocyte Cryopreservation
992f3189-6d0f-4926-9bac-58206601cacc.aspx
  
7701Atezolizumab(Tecentriq®)andAtezolizumabwithHyaluronidase-tqjs(TecentriqHybreza™)08.01.69fPharmacy (08)08.01.69f08.01.69992f3189-6d0f-4926-9bac-58206601caccAtezolizumab (Tecentriq®) and Atezolizumab with Hyaluronidase-tqjs (Tecentriq Hybreza™)Atezolizumab (Tecentriq®) and Atezolizumab with Hyaluronidase-tqjs (Tecentriq Hybreza™)
2b1b1765-a231-4988-a244-9ccb24ccbfcf.aspx
  
7534Atidarsageneautotemcel(Lenmeldy)08.02.24Pharmacy (08)08.02.2408.02.242b1b1765-a231-4988-a244-9ccb24ccbfcfAtidarsagene autotemcel (Lenmeldy)Atidarsagene autotemcel (Lenmeldy)
67c56876-fd07-4da6-8475-885f05f5d615.aspx
  
8567AuricularProstheses05.00.82DME (05)05.00.8205.00.8267c56876-fd07-4da6-8475-885f05f5d615Auricular ProsthesesAuricular Prostheses
2df99a15-e872-4a2a-a4a5-442c6c4fa4da.aspx
  
8597AutologousChondrocyteImplantation(ACI)andOtherCell-basedTreatmentsofFocalArticularCartilageLesions(AmerihealthAdministrators)11.14.06jSurgery (11)11.14.06j11.14.062df99a15-e872-4a2a-a4a5-442c6c4fa4daAutologous 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)
b070d704-cac3-4d95-a688-af44923ad4c7.aspx
  
7358AutomaticExternalCardioverterDefibrillators(WearableandNonwearable)05.00.29oDME (05)05.00.29o05.00.29b070d704-cac3-4d95-a688-af44923ad4c7Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
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8335AutonomicNervousSystemTesting07.03.23hMedicine (07)07.03.23h07.03.235bc6bc6c-9e83-4835-b48d-e28ef61d1f82Autonomic Nervous System TestingAutonomic Nervous System Testing
2424724c-1f94-42dd-ad72-c1bf210b7b93.aspx
  
8113Avelumab(Bavencio®)08.01.64ePharmacy (08)08.01.64e08.01.642424724c-1f94-42dd-ad72-c1bf210b7b93Avelumab (Bavencio®)Avelumab (Bavencio®)
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8435Axatilimab-csfr(Niktimvo™)forIntravenousUse08.02.34Pharmacy (08)08.02.3408.02.3473be2894-abe5-401d-8e57-3269b6d8e68bAxatilimab-csfr (Niktimvo™) for Intravenous UseAxatilimab-csfr (Niktimvo™) for Intravenous Use
9999fe02-c4cf-48bc-82cc-4ce3045f0ad8.aspx
  
7335BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitisorRecurrentAcuteRhinosinusitis11.16.06kSurgery (11)11.16.06k11.16.069999fe02-c4cf-48bc-82cc-4ce3045f0ad8Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis or Recurrent Acute RhinosinusitisBalloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis or Recurrent Acute Rhinosinusitis
446fd623-e591-4f59-8c9d-70741e333774.aspx
  
8088BariatricSurgery11.03.02xSurgery (11)11.03.02x11.03.02446fd623-e591-4f59-8c9d-70741e333774Bariatric SurgeryBariatric Surgery
{"8089": {"Id":8089,"MPAttachmentLetter":"B","Title":"Tanner Staging System Criteria for Adolescents","MPPolicyAttachmentInternalSourceId":10120,"PolicyAttachmentPageName":"9fcd9d05-43a3-4c43-a472-6e465bfeb378"},"8090": {"Id":8090,"MPAttachmentLetter":"A","Title":"Body Mass Index (BMI) Charts","MPPolicyAttachmentInternalSourceId":10121,"PolicyAttachmentPageName":"1f1f186c-15dd-4394-9733-9b4fb88b2036"},}
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8517Belantamabmafodotin-blmf(Blenrep)08.02.53Pharmacy (08)08.02.5308.02.53fe2c5777-01fe-4e36-b4df-0eafeab95c46Belantamab mafodotin-blmf (Blenrep)Belantamab mafodotin-blmf (Blenrep)
b2ee0b0f-5fe4-4e5e-8728-9b6ea3d508dd.aspx
  
7531Belimumab(Benlysta®)forIntravenousUse08.00.99ePharmacy (08)08.00.99e08.00.99b2ee0b0f-5fe4-4e5e-8728-9b6ea3d508ddBelimumab (Benlysta®) for Intravenous UseBelimumab (Benlysta®) for Intravenous Use
e4dc72b0-021c-45ca-8da8-946b4b5692fc.aspx
  
8095BeremageneGeperpavec(Vyjuvek™)08.02.10bPharmacy (08)08.02.10b08.02.10e4dc72b0-021c-45ca-8da8-946b4b5692fcBeremagene Geperpavec (Vyjuvek™)Beremagene Geperpavec (Vyjuvek™)
fc30b8b9-db7c-4141-a327-57e532d8259c.aspx
  
7518BetibeglogeneAutotemcel[Beti-Cel(ZYNTEGLO®)]08.01.89aPharmacy (08)08.01.89a08.01.89fc30b8b9-db7c-4141-a327-57e532d8259cBetibeglogene Autotemcel [Beti-Cel (ZYNTEGLO®)]Betibeglogene Autotemcel [Beti-Cel (ZYNTEGLO®)]
460ade68-9fc2-4458-9c8d-6cb709778838.aspx
  
8493Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUse08.00.66xPharmacy (08)08.00.66x08.00.66460ade68-9fc2-4458-9c8d-6cb709778838Bevacizumab (Avastin®) and Related Biosimilars For Oncologic UseBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
{"8494": {"Id":8494,"MPAttachmentLetter":"A","Title":"ICD 10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":10203,"PolicyAttachmentPageName":"f4810066-c22a-4d76-9e03-0beab38cdae8"},}
9c766e44-e195-4f55-8f8a-df1e202967cc.aspx
  
8233BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampus00.10.39rAdministrative (00)00.10.39r00.10.399c766e44-e195-4f55-8f8a-df1e202967ccBilling 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
{"8234": {"Id":8234,"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":10318,"PolicyAttachmentPageName":"7100a278-181d-40b1-88e4-0cf1d3e576d0"},}
9be43eff-6b64-4e0b-a426-ef73f2537ec3.aspx
  
6405BillingRequirementsforMultipleBirthsforProfessionalProviders00.10.38aAdministrative (00)00.10.38a00.10.389be43eff-6b64-4e0b-a426-ef73f2537ec3Billing Requirements for Multiple Births for Professional ProvidersBilling Requirements for Multiple Births for Professional Providers
{"6406": {"Id":6406,"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":8677,"PolicyAttachmentPageName":"8f6b9a74-008f-4e82-8be7-60a9d2b4131a"},"6407": {"Id":6407,"MPAttachmentLetter":"A","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ROUTINE OBSTETRIC (GLOBALE MATERNITY/OBSTETRIC [OB]) CARE WAS PROVIDED","MPPolicyAttachmentInternalSourceId":8678,"PolicyAttachmentPageName":"b5c1c52a-6755-40e1-89ab-106d03f7d9d6"},"6408": {"Id":6408,"MPAttachmentLetter":"D","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF HIGH-ORDER MULTIPLES WHEN ANTEPARTUM CARE IS NOT PROVIDED","MPPolicyAttachmentInternalSourceId":8679,"PolicyAttachmentPageName":"5ae8f316-7805-4e4c-ac92-1e147d896d76"},"6409": {"Id":6409,"MPAttachmentLetter":"B","Title":"MULTIPLE BIRTH CODING SCENARIOS FOR DELIVERY OF TWINS WHEN ANETEPARTUM CARE IS NOT PROVIDED","MPPolicyAttachmentInternalSourceId":8680,"PolicyAttachmentPageName":"1aace5b3-ccc4-4d23-9916-fd982ce3e6ab"},}
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8422BiofeedbackTherapy07.00.01nMedicine (07)07.00.01n07.00.013d434731-e65e-42c5-8464-72950cf4e61fBiofeedback TherapyBiofeedback Therapy
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8006BioimpedancefortheDetectionofLymphedema07.06.03cMedicine (07)07.06.03c07.06.0353dd50f9-76e1-4658-9cb7-47d83a8f3a09Bioimpedance for the Detection of LymphedemaBioimpedance for the Detection of Lymphedema
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7944Blinatumomab(Blincyto®)08.01.21hPharmacy (08)08.01.21h08.01.217177f741-41cb-4ce0-851b-6c9601b97a5cBlinatumomab (Blincyto®)Blinatumomab (Blincyto®)
3fd23412-a86e-48d8-bfd5-0dc5d2919e14.aspx
  
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8320BoneMineralDensity(BMD)Testing09.00.04oRadiology (09)09.00.04o09.00.0476fd8a04-7dba-4a01-8f7c-c8b036be1fa3Bone Mineral Density (BMD) TestingBone Mineral Density (BMD) Testing
cfa61371-54dc-46c2-8906-306bcd492f8c.aspx
  
8016BotulinumToxinAgents08.00.26aePharmacy (08)08.00.26ae08.00.26cfa61371-54dc-46c2-8906-306bcd492f8cBotulinum Toxin AgentsBotulinum Toxin Agents
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7745BreastPumps05.00.76iDME (05)05.00.76i05.00.76e70095f6-c867-4c3b-9f96-707c3d28eb89Breast PumpsBreast Pumps
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8241BundledProcedureCodes00.01.52zAdministrative (00)00.01.52z00.01.525c7664e8-beec-499d-bb46-36274a82dfe6Bundled Procedure CodesBundled Procedure Codes
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7522Burosumab-twza(Crysvita®)08.01.49bPharmacy (08)08.01.49b08.01.4990bde7e8-8725-49ce-b0b6-0d9746fc6827Burosumab-twza (Crysvita®)Burosumab-twza (Crysvita®)
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8497CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)Programs10.01.01rRehabilitation Services (10)10.01.01r10.01.01491ed4ee-c053-45a5-b431-3c73f00c7eacCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) ProgramsCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
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8239CareManagementandCarePlanningServices00.01.59pAdministrative (00)00.01.59p00.01.593b542224-8db8-4cad-84ea-ee0cb5482fa6Care Management and Care Planning ServicesCare Management and Care Planning Services
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8004Carfilzomib(Kyprolis®)08.01.05mPharmacy (08)08.01.05m08.01.05b6aef6df-ce54-40c9-8e78-94170c6dc59fCarfilzomib (Kyprolis®)Carfilzomib (Kyprolis®)
6485c996-b386-4a16-8a4d-f7ce3beb8cae.aspx
  
8542Casgevy™(exagamglogeneautotemcel)08.02.14aPharmacy (08)08.02.14a08.02.146485c996-b386-4a16-8a4d-f7ce3beb8caeCasgevy™ (exagamglogene autotemcel)Casgevy™ (exagamglogene autotemcel)
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6738CastandSplintApplicationsandAssociatedSupplies00.10.15dAdministrative (00)00.10.15d00.10.15ff41fdec-319e-4608-be2d-eee15f3bec86Cast and Splint Applications and Associated SuppliesCast and Splint Applications and Associated Supplies
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8575CataractSurgery11.01.07gSurgery (11)11.01.07g11.01.070bc270da-8255-40f5-a455-696f7d2724daCataract SurgeryCataract Surgery
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8614CatheterAblationofCardiacArrhythmias11.02.06rSurgery (11)11.02.06r11.02.06c9a12f9d-ad89-45d1-96c7-86a63f28a068Catheter Ablation of Cardiac ArrhythmiasCatheter Ablation of Cardiac Arrhythmias
11d7da82-48d4-4e14-8cc6-7c28d229e130.aspx
  
8141Cemiplimab-rwlc(Libtayo®)08.01.66ePharmacy (08)08.01.66e08.01.6611d7da82-48d4-4e14-8cc6-7c28d229e130Cemiplimab-rwlc (Libtayo®)Cemiplimab-rwlc (Libtayo®)
90b30eda-a568-415f-bb16-b6b07bb92be1.aspx
  
8084Cerliponasealfa(Brineura®)08.01.39dPharmacy (08)08.01.39d08.01.3990b30eda-a568-415f-bb16-b6b07bb92be1Cerliponase alfa (Brineura®)Cerliponase alfa (Brineura®)
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8083CervicalTractionDevicesforIn-homeUse05.00.61hDME (05)05.00.61h05.00.61b9ddf003-4f8f-42e7-9fc6-76de1f37b76dCervical Traction Devices for In-home UseCervical Traction Devices for In-home Use
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8336ChemicalPeels11.08.08hSurgery (11)11.08.08h11.08.0812d32814-2f47-4360-958d-2ff7f760c0bcChemical PeelsChemical Peels
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a61acc7b-d9b3-46f0-a7bc-ad7ac57c0075.aspx
  
7689ChiropracticSpinalandExtraspinalManipulationTherapy10.02.02kRehabilitation Services (10)10.02.02k10.02.02a61acc7b-d9b3-46f0-a7bc-ad7ac57c0075Chiropractic Spinal and Extraspinal Manipulation TherapyChiropractic Spinal and Extraspinal Manipulation Therapy
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8203CoagulationFactors08.00.92akPharmacy (08)08.00.92ak08.00.92bd646084-b825-424c-893e-93c594321e15Coagulation FactorsCoagulation Factors
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8105Cobalamin(VitaminB12),FolicAcid,andHomocysteineTesting06.02.54dPathology and Laboratory (06)06.02.54d06.02.5453adf5d8-86bb-4c20-9ace-bfa03628c82eCobalamin (Vitamin B12), Folic Acid, and Homocysteine TestingCobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
{"8106": {"Id":8106,"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":10212,"PolicyAttachmentPageName":"ec2c2d38-1ed4-491f-a1c8-f55d1a5b7892"},}
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7529Collagenaseclostridiumhistolyticum(Xiaflex®),collagenaseclostridiumhistolyticum-aaes(Qwo®)08.01.71Pharmacy (08)08.01.7108.01.71757a5c90-a2ba-46a4-8874-38c9ccf90021Collagenase clostridium histolyticum (Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo®)Collagenase clostridium histolyticum (Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo®)
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6411ComplementaryandIntegrativeHealthServices12.00.03hMiscellaneous (12)12.00.03h12.00.03ba170083-35f9-4f1e-9e58-e68b05aa307aComplementary and Integrative Health ServicesComplementary and Integrative Health Services
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8400CompressionGarments05.00.37kDME (05)05.00.37k05.00.37a5238b05-8582-4e67-9f71-859028737a5bCompression GarmentsCompression Garments
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7959Computer-AidedDetection(CAD)SystemforUsewithChestRadiographs09.00.42dRadiology (09)09.00.42d09.00.42b1fa1dff-ec77-46cc-82ba-6cbc54778492Computer-Aided Detection (CAD) System for Use with Chest RadiographsComputer-Aided Detection (CAD) System for Use with Chest Radiographs
11e14a76-9399-4836-894b-2e02f5997046.aspx
  
8311Computer-assistedMusculoskeletalSurgicalNavigationalOrthopedicProcedure11.14.17eSurgery (11)11.14.17e11.14.1711e14a76-9399-4836-894b-2e02f5997046Computer-assisted Musculoskeletal Surgical Navigational Orthopedic ProcedureComputer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
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8070ContactLensesfortheTreatmentofPersistent(Corneal)EpithelialDefects07.13.11kMedicine (07)07.13.11k07.13.11dca4af06-9e87-4c02-85b8-c4538b873975Contact Lenses for the Treatment of Persistent (Corneal) Epithelial DefectsContact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
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c5fd2062-89b8-4c22-a99b-47e4398d8af6.aspx
  
7259ContrastAgentsUsedinConjunctionwithEchocardiography09.00.11eRadiology (09)09.00.11e09.00.11c5fd2062-89b8-4c22-a99b-47e4398d8af6Contrast Agents Used in Conjunction with EchocardiographyContrast Agents Used in Conjunction with Echocardiography
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7859CornealPachymetryUsingUltrasound07.13.07mMedicine (07)07.13.07m07.13.074db2bfde-0860-4406-bcd3-e3dabdf21d02Corneal Pachymetry Using UltrasoundCorneal Pachymetry Using Ultrasound
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534ecc67-d1e0-45be-b1ca-a5d9b61f83de.aspx
  
7803CoronaryArteryCalcium(CAC)TestingUsingComputedTomography(AmeriHealthAdministrators)09.00.58aRadiology (09)09.00.58a09.00.58534ecc67-d1e0-45be-b1ca-a5d9b61f83deCoronary Artery Calcium (CAC) Testing Using Computed Tomography (AmeriHealth Administrators)Coronary Artery Calcium (CAC) Testing Using Computed Tomography (AmeriHealth Administrators)
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8590Cosibelimab-ipdl(Unloxcyt™)08.02.40aPharmacy (08)08.02.40a08.02.40a8618648-4fd5-4cd1-b405-1d0ce673ab07Cosibelimab-ipdl (Unloxcyt™)Cosibelimab-ipdl (Unloxcyt™)
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7171CosmeticProcedures12.01.03bMiscellaneous (12)12.01.03b12.01.031b0c4dbc-22e1-4cf2-a8bd-43a74b3675fbCosmetic ProceduresCosmetic Procedures
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8254CoverageofAnticancerPrescriptionOralandInjectableDrugsandBiologicsandSupportiveAgents08.01.08vPharmacy (08)08.01.08v08.01.08901403c5-1f07-40cf-8a9b-91b77219cd04Coverage 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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6936CoverageofMedicalDevices05.00.04eDME (05)05.00.04e05.00.0421580a78-eec4-4b84-a973-1315467a0db9Coverage of Medical DevicesCoverage of Medical Devices
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8091CranialElectrotherapyStimulation05.00.80dDME (05)05.00.80d05.00.80d49f3a0d-b1b8-4bfc-a38f-820b6574df5eCranial Electrotherapy StimulationCranial Electrotherapy Stimulation
2a1d0d80-f17d-466f-8df1-4a5da9d707b3.aspx
  
8568CranialRemoldingOrthoses(Helmets)05.00.25kDME (05)05.00.25k05.00.252a1d0d80-f17d-466f-8df1-4a5da9d707b3Cranial Remolding Orthoses (Helmets)Cranial Remolding Orthoses (Helmets)
218e477c-e785-44d2-b69d-cce973f7e4c8.aspx
  
7666crizanlizumab-tmca(Adakveo®)08.00.04bPharmacy (08)08.00.04b08.00.04218e477c-e785-44d2-b69d-cce973f7e4c8crizanlizumab-tmca (Adakveo®)crizanlizumab-tmca (Adakveo®)
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8263CryosurgicalAblationoftheProstateGland11.11.03dSurgery (11)11.11.03d11.11.038bb9f7de-f753-4689-a82b-7889d45672ccCryosurgical Ablation of the Prostate GlandCryosurgical Ablation of the Prostate Gland
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7737Daratumumab(Darzalex®),DaratumumabandHyaluronidase-fihj(DarzalexFaspro®)08.01.29mPharmacy (08)08.01.29m08.01.294cdc8ed3-6af8-4e8f-8cb6-e5420b00b644Daratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®)Daratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®)
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