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d5348acb-dad2-4abe-aba8-f51b4839d7b7.aspx
  
5752Abatacept(Orencia®)forInjectionforIntravenousUse08.00.62oPharmacy (08)08.00.62o08.00.62d5348acb-dad2-4abe-aba8-f51b4839d7b7Abatacept (Orencia®) for Injection for Intravenous UseAbatacept (Orencia®) for Injection for Intravenous Use
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5669Acupuncture12.00.01hMiscellaneous (12)12.00.01h12.00.0177df5bd1-45ad-4977-b7aa-e48b58521792AcupunctureAcupuncture
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5536AcuteCareFacilityInpatientTransfers12.04.04bMiscellaneous (12)12.04.04b12.04.041cfcdcfa-8618-4278-b580-4cb85d35ce0cAcute Care Facility Inpatient TransfersAcute Care Facility Inpatient Transfers
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4949Ado-TrastuzumabEmtansine(Kadcyla®)08.01.11hPharmacy (08)08.01.11h08.01.1138d8a45c-488c-48e3-988a-04ec71fc747fAdo-Trastuzumab Emtansine (Kadcyla®)Ado-Trastuzumab Emtansine (Kadcyla®)
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5163Agalsidasebeta(Fabrazyme®)08.00.69cPharmacy (08)08.00.69c08.00.69b8b27d69-62ab-4921-9ae8-f074ee40c9dcAgalsidase beta (Fabrazyme®)Agalsidase beta (Fabrazyme®)
54421f21-0a89-4d2b-b568-b43c51393668.aspx
  
5440AirAmbulanceServices12.04.03cMiscellaneous (12)12.04.03c12.04.0354421f21-0a89-4d2b-b568-b43c51393668Air Ambulance ServicesAir Ambulance Services
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5305Alemtuzumab(Lemtrada®)08.01.22dPharmacy (08)08.01.22d08.01.22253c8671-81ff-425d-9d8e-309011c90aa0Alemtuzumab (Lemtrada®)Alemtuzumab (Lemtrada®)
8efb377e-0527-4def-a962-5f79e0b36912.aspx
  
5359Alglucosidasealfa(e.g.,Lumizyme®),Avalglucosidasealfa-ngpt(Nexviazyme®)08.00.72kPharmacy (08)08.00.72k08.00.728efb377e-0527-4def-a962-5f79e0b36912Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® )Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® )
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4820AllergyImmunotherapy07.00.21jMedicine (07)07.00.21j07.00.21a1de565a-4780-477e-8f16-1cbce906084cAllergy ImmunotherapyAllergy Immunotherapy
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5178AllogeneicProcessedThymusTissue-agdc(Rethymic®)08.01.88Pharmacy (08)08.01.8808.01.88b94000e7-dd84-4ae8-b8f9-3712a52d80daAllogeneic Processed Thymus Tissue-agdc (Rethymic®)Allogeneic Processed Thymus Tissue-agdc (Rethymic®)
79251573-4f96-4f72-96e8-6488e1cc8797.aspx
  
5224AlloMap™MolecularExpressionTestingforHeartTransplantRejection(AmeriHealthAdministrators)06.02.29dPathology and Laboratory (06)06.02.29d06.02.2979251573-4f96-4f72-96e8-6488e1cc8797AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)
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5230Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C®,AralastNP®,Glassia®,Zemaira®)08.00.91ePharmacy (08)08.00.91e08.00.9189deaeea-96aa-4381-9a71-4bc587fb08c9Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)
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5524AlwaysBundledProcedureCodes00.01.52sAdministrative (00)00.01.52s00.01.524dbd90d3-e8eb-4791-8ebf-3170964d453fAlways Bundled Procedure CodesAlways Bundled Procedure Codes
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5674AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)Devices07.02.09iMedicine (07)07.02.09i07.02.0960934549-b89d-4621-9139-ae8356ccea80Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) DevicesAmbulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
9ce53a68-591b-4581-9875-fd5cbd286ed7.aspx
  
5682AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)Monitoring07.02.21mMedicine (07)07.02.21m07.02.219ce53a68-591b-4581-9875-fd5cbd286ed7Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
2d5afb71-f0c1-41d0-9ac2-8547f69eeced.aspx
  
5678AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagement01.00.12bAnesthesia (01)01.00.12b01.00.122d5afb71-f0c1-41d0-9ac2-8547f69eecedAnesthesia 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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5431Anifrolumab-fnia(Saphnelo®)08.01.82bPharmacy (08)08.01.82b08.01.827f881bbb-9ecf-4690-b6b8-6f5cb234c8f7Anifrolumab-fnia (Saphnelo®)Anifrolumab-fnia (Saphnelo®)
9fe524ee-227c-45ca-894a-d481fa0fef99.aspx
  
5159Ankle-Foot/Knee-Ankle-FootOrthoses05.00.39sDME (05)05.00.39s05.00.399fe524ee-227c-45ca-894a-d481fa0fef99Ankle-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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5107ApplicationandRemovalofTattoos11.08.05gSurgery (11)11.08.05g11.08.0540adc8e6-69c1-4b04-9492-4dde285906f2Application 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)
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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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5311ArtificialIntervertebralCervicalDiscInsertion(AmerihealthAdministrators)11.14.19pSurgery (11)11.14.19p11.14.19bc52c9e0-2f80-4074-92f6-4627d2247b46Artificial 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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5453AsparaginaseErwiniaChrysanthemi(Erwinaze®),asparaginaseerwiniachrysanthemi(recombinant)-rywn(Rylaze®)08.01.35gPharmacy (08)08.01.35g08.01.3545eea1e5-d113-4c3c-a874-49b1e3d094b0Asparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze®)Asparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze®)
9df36788-e9f1-4d47-a9c2-21f112f4b6b4.aspx
  
5557AssaysofGeneticExpressioninTumorTissueforBreastCancerPrognosis(AmeriHealthAdministrators)06.02.27nPathology and Laboratory (06)06.02.27n06.02.279df36788-e9f1-4d47-a9c2-21f112f4b6b4Assays 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
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5120Atezolizumab(Tecentriq®)08.01.69cPharmacy (08)08.01.69c08.01.693692eb86-55ea-4cdd-a607-efd8374b8545Atezolizumab (Tecentriq®)Atezolizumab (Tecentriq®)
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5239AutologousChondrocyteImplantation(ACI)andOtherCell-basedTreatmentsofFocalArticularCartilageLesions(AmerihealthAdministrators)11.14.06jSurgery (11)11.14.06j11.14.062128d5d8-b7a4-4ff5-9a1a-9608698cc0ebAutologous 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)
a590a8dc-f63a-4148-bbaf-c1db550f4901.aspx
  
5683AutomaticExternalCardioverterDefibrillators(WearableandNonwearable)05.00.29oDME (05)05.00.29o05.00.29a590a8dc-f63a-4148-bbaf-c1db550f4901Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
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5340AutonomicNervousSystemTesting07.03.23fMedicine (07)07.03.23f07.03.23b393d397-a419-44af-9b52-d0c610c1ee8cAutonomic 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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5096BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitis11.16.06jSurgery (11)11.16.06j11.16.06e6e1f2fb-cb7d-4b62-b88c-93f6f4dbaaa6Balloon 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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5303Belimumab(Benlysta®)forIntravenousUse08.00.99ePharmacy (08)08.00.99e08.00.9948faca03-d3ad-4abd-af51-f1fdd06652c8Belimumab (Benlysta®) for Intravenous UseBelimumab (Benlysta®) for Intravenous Use
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5611BeremageneGeperpavec(Vyjuvek™)08.02.10Pharmacy (08)08.02.1008.02.1087c3f070-2bb4-4558-8c27-bb164294d05aBeremagene Geperpavec (Vyjuvek™)Beremagene Geperpavec (Vyjuvek™)
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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®)]
5e39b1ae-f374-4b43-a5f0-9444ff939207.aspx
  
5394Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUse08.00.66uPharmacy (08)08.00.66u08.00.665e39b1ae-f374-4b43-a5f0-9444ff939207Bevacizumab (Avastin®) and Related Biosimilars For Oncologic UseBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
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5080BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampus00.10.39pAdministrative (00)00.10.39p00.10.39974307f4-0c12-4fca-a95c-49747a501e32Billing 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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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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5671BiofeedbackTherapy07.00.01kMedicine (07)07.00.01k07.00.019a1be15a-6a08-4a47-bb7e-fc09a9695011Biofeedback TherapyBiofeedback Therapy
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5632BioimpedencefortheDetectionofLymphedema07.06.03bMedicine (07)07.06.03b07.06.03a832cdcc-2c89-40af-9e43-1102d942a08dBioimpedence 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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5114Blinatumomab(Blincyto®)08.01.21fPharmacy (08)08.01.21f08.01.21b306af6e-813e-493c-8a8b-b57d5995a5e4Blinatumomab (Blincyto®)Blinatumomab (Blincyto®)
dcc2f693-5197-49ab-bec1-9281eb137d18.aspx
  
5600Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAids11.01.06gSurgery (11)11.01.06g11.01.06dcc2f693-5197-49ab-bec1-9281eb137d18Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing AidsBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
0dbfab1f-4412-4d17-9957-9d7dec231199.aspx
  
5521BoneMineralDensity(BMD)Testing09.00.04nRadiology (09)09.00.04n09.00.040dbfab1f-4412-4d17-9957-9d7dec231199Bone Mineral Density (BMD) TestingBone Mineral Density (BMD) Testing
3e360ca0-6fe9-4af4-b906-30218d56a8f4.aspx
  
5742Bortezomib(BortezomibforInjection,Velcade®)08.00.73pPharmacy (08)08.00.73p08.00.733e360ca0-6fe9-4af4-b906-30218d56a8f4Bortezomib (Bortezomib for Injection, Velcade®)Bortezomib (Bortezomib for Injection, Velcade®)
{"5743": {"Id":5743,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":7708,"PolicyAttachmentPageName":"62519bd9-92ee-47a8-8ddd-7fdade4cb835"},}
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5748BotulinumToxinAgents08.00.26abPharmacy (08)08.00.26ab08.00.26d2645ebf-b782-4091-8c20-1c86b49c10adBotulinum Toxin AgentsBotulinum Toxin Agents
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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
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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"},}
2bab9fa4-c748-4063-85c4-82ade8f0220a.aspx
  
5537BronchialValves11.16.09Surgery (11)11.16.0911.16.092bab9fa4-c748-4063-85c4-82ade8f0220aBronchial ValvesBronchial Valves
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5360Burosumab-twza(Crysvita®)08.01.49bPharmacy (08)08.01.49b08.01.497086f118-eb42-44a3-8a89-e86e5c88d9cdBurosumab-twza (Crysvita®)Burosumab-twza (Crysvita®)
38c73bef-e52a-4cb7-a01c-656e866406c9.aspx
  
5367Canakinumab(Ilaris®)08.01.51bPharmacy (08)08.01.51b08.01.5138c73bef-e52a-4cb7-a01c-656e866406c9Canakinumab (Ilaris®)Canakinumab (Ilaris®)
094e8580-65c3-46fd-b661-804c2ab5e189.aspx
  
5692CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)Programs10.01.01pRehabilitation Services (10)10.01.01p10.01.01094e8580-65c3-46fd-b661-804c2ab5e189Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) ProgramsCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
{"5693": {"Id":5693,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":7736,"PolicyAttachmentPageName":"ac655044-8cea-403c-b80e-7826290a05c8"},}
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5082CareManagementandCarePlanningServices00.01.59mAdministrative (00)00.01.59m00.01.591a75e5b2-239b-4d8f-ba0c-f6af7246660eCare 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"},}
999dab46-d26f-4042-bdec-44679dace028.aspx
  
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"},}
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5689CatheterAblationofCardiacArrhythmias11.02.06qSurgery (11)11.02.06q11.02.069eccdc4b-79a3-4f95-8e04-651c93549127Catheter Ablation of Cardiac ArrhythmiasCatheter Ablation of Cardiac Arrhythmias
b06a7d38-c9e9-4610-916b-190365fe9fd8.aspx
  
5565Cemiplimab-rwlc(Libtayo®)08.01.66cPharmacy (08)08.01.66c08.01.66b06a7d38-c9e9-4610-916b-190365fe9fd8Cemiplimab-rwlc (Libtayo®)Cemiplimab-rwlc (Libtayo®)
c81b22ec-3ec7-4a91-85c1-70af8b7cf771.aspx
  
5344Cerliponasealfa(Brineura®)08.01.39cPharmacy (08)08.01.39c08.01.39c81b22ec-3ec7-4a91-85c1-70af8b7cf771Cerliponase alfa (Brineura®)Cerliponase alfa (Brineura®)
aff2b094-ca8b-410b-96e4-4a9c0c4fecbb.aspx
  
5183CervicalTractionDevicesforIn-homeUse05.00.61gDME (05)05.00.61g05.00.61aff2b094-ca8b-410b-96e4-4a9c0c4fecbbCervical 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®)
{"5020": {"Id":5020,"MPAttachmentLetter":"B","Title":"ICD-10 Codes for Cetuximab (Erbitux®)","MPPolicyAttachmentInternalSourceId":7025,"PolicyAttachmentPageName":"9d4dd3a8-871d-43d3-8ff6-7f310fde867d"},"5021": {"Id":5021,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":7026,"PolicyAttachmentPageName":"aaa3078f-4999-485c-8564-30acef316ee7"},}
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
d880288d-e445-4a8e-b601-541a53daee72.aspx
  
5495CoagulationFactors08.00.92afPharmacy (08)08.00.92af08.00.92d880288d-e445-4a8e-b601-541a53daee72Coagulation 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"},}
4ee164ea-941e-469a-b9c0-41335b1bb8bd.aspx
  
5535CochlearImplantation11.01.02qSurgery (11)11.01.02q11.01.024ee164ea-941e-469a-b9c0-41335b1bb8bdCochlear ImplantationCochlear Implantation
52fa70dc-94af-4f67-8cb5-471700f2dbd4.aspx
  
5144Collagenaseclostridiumhistolyticum(Xiaflex®),collagenaseclostridiumhistolyticum-aaes(Qwo™)08.01.71Pharmacy (08)08.01.7108.01.7152fa70dc-94af-4f67-8cb5-471700f2dbd4Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™)Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™)
544ced3a-6c13-4171-8a56-94bd7fdaaa81.aspx
  
5450ColorectalCancerScreening11.03.12tSurgery (11)11.03.12t11.03.12544ced3a-6c13-4171-8a56-94bd7fdaaa81Colorectal 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
cd8eb507-7b90-4fb0-9ad4-8a3d1338f17c.aspx
  
5484CompleteDecongestiveTherapy(CDT)07.06.01bMedicine (07)07.06.01b07.06.01cd8eb507-7b90-4fb0-9ad4-8a3d1338f17cComplete Decongestive Therapy (CDT)Complete Decongestive Therapy (CDT)
6c8a40e6-70ca-4754-af6a-14bd7b400f2a.aspx
  
5093CompositeTissueAllotransplantationoftheHand(s)andFace11.14.30Surgery (11)11.14.3011.14.306c8a40e6-70ca-4754-af6a-14bd7b400f2aComposite Tissue Allotransplantation of the Hand(s) and FaceComposite Tissue Allotransplantation of the Hand(s) and Face
0b35e902-f311-4dd7-8f3b-a7219d7413c3.aspx
  
5249CompressionGarments05.00.37gDME (05)05.00.37g05.00.370b35e902-f311-4dd7-8f3b-a7219d7413c3Compression GarmentsCompression Garments
b9742429-a8a1-4644-8b1c-2d8a9c69cbbb.aspx
  
5106Computer-AidedDetection(CAD)SystemforUsewithChestRadiographs09.00.42cRadiology (09)09.00.42c09.00.42b9742429-a8a1-4644-8b1c-2d8a9c69cbbbComputer-Aided Detection (CAD) System for Use with Chest RadiographsComputer-Aided Detection (CAD) System for Use with Chest Radiographs
55481cd2-1b4b-4a4f-abf8-325c47863fc0.aspx
  
5076Computer-assistedMusculoskeletalSurgicalNavigationalOrthopedicProcedure11.14.17eSurgery (11)11.14.17e11.14.1755481cd2-1b4b-4a4f-abf8-325c47863fc0Computer-assisted Musculoskeletal Surgical Navigational Orthopedic ProcedureComputer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
fa3b31f7-c0c1-46d2-9619-2f49ae0825f7.aspx
  
5083ConsultationServices00.01.69bAdministrative (00)00.01.69b00.01.69fa3b31f7-c0c1-46d2-9619-2f49ae0825f7Consultation ServicesConsultation Services
59bf419b-18ab-4008-accf-9b541d9bdb26.aspx
  
5140ContactLensesfortheTreatmentofPersistent(Corneal)EpithelialDefects07.13.11kMedicine (07)07.13.11k07.13.1159bf419b-18ab-4008-accf-9b541d9bdb26Contact Lenses for the Treatment of Persistent (Corneal) Epithelial DefectsContact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
{"5141": {"Id":5141,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":7217,"PolicyAttachmentPageName":"8be86c4f-061e-4c60-8520-fdeb5207de44"},}
12ca4dc2-6f5b-4375-a86a-975789fb3469.aspx
  
5138ContrastAgentsUsedinConjunctionwithEchocardiography09.00.11eRadiology (09)09.00.11e09.00.1112ca4dc2-6f5b-4375-a86a-975789fb3469Contrast Agents Used in Conjunction with EchocardiographyContrast Agents Used in Conjunction with Echocardiography
b3f30839-15d7-4589-9655-435e53e6412c.aspx
  
5581CornealPachymetryUsingUltrasound07.13.07lMedicine (07)07.13.07l07.13.07b3f30839-15d7-4589-9655-435e53e6412cCorneal Pachymetry Using UltrasoundCorneal Pachymetry Using Ultrasound
{"5582": {"Id":5582,"MPAttachmentLetter":"A","Title":"ICD-10-CM codes","MPPolicyAttachmentInternalSourceId":7544,"PolicyAttachmentPageName":"ca7b96c8-3b6c-4c3e-8ef8-3ee9505c2b80"},}
77482876-6f27-4ea1-b0ec-3cc52520d7b6.aspx
  
5538CoronaryArteryCalcium(CAC)TestingUsingComputedTomography(AmeriHealthAdministrators)09.00.58Radiology (09)09.00.5809.00.5877482876-6f27-4ea1-b0ec-3cc52520d7b6Coronary Artery Calcium (CAC) Testing Using Computed Tomography (AmeriHealth Administrators)Coronary Artery Calcium (CAC) Testing Using Computed Tomography (AmeriHealth Administrators)
ce92180b-3b91-4668-af51-0aa525646307.aspx
  
5390CosmeticProcedures12.01.03bMiscellaneous (12)12.01.03b12.01.03ce92180b-3b91-4668-af51-0aa525646307Cosmetic ProceduresCosmetic Procedures
f7ae692a-ba80-454f-ba92-3c7635a5dbcf.aspx
  
5737CoverageofAnticancerPrescriptionOralandInjectableDrugsandBiologicsandSupportiveAgents08.01.08nPharmacy (08)08.01.08n08.01.08f7ae692a-ba80-454f-ba92-3c7635a5dbcfCoverage 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
da959899-1ad2-4f8a-baf2-baa16d2f1d26.aspx
  
5601CranialElectrotherapyStimulation05.00.80cDME (05)05.00.80c05.00.80da959899-1ad2-4f8a-baf2-baa16d2f1d26Cranial Electrotherapy StimulationCranial Electrotherapy Stimulation
0d9aa219-e1dd-4046-88e4-f538aed7afe8.aspx
  
5681CranialRemoldingOrthoses(Helmets)05.00.25jDME (05)05.00.25j05.00.250d9aa219-e1dd-4046-88e4-f538aed7afe8Cranial 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
177478c4-a9ce-4845-b972-98a5a3cf3df6.aspx
  
5727crizanlizumab-tmca(Adakveo®)08.00.04aPharmacy (08)08.00.04a08.00.04177478c4-a9ce-4845-b972-98a5a3cf3df6crizanlizumab-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®)
803d7702-4e64-481a-a856-89a699b735d9.aspx
  
5378DayRehabilitation10.00.02cRehabilitation Services (10)10.00.02c10.00.02803d7702-4e64-481a-a856-89a699b735d9Day RehabilitationDay Rehabilitation
d42f70a6-a972-422f-9fc4-142aa04bdff1.aspx
  
5125DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNails11.08.17kSurgery (11)11.08.17k11.08.17d42f70a6-a972-422f-9fc4-142aa04bdff1Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe NailsDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
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5718DeepBrainStimulation(DBS)11.15.20sSurgery (11)11.15.20s11.15.2042481246-b90c-4838-ad70-3c7e4d01879dDeep Brain Stimulation (DBS)Deep Brain Stimulation (DBS)
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5240DenervationoftheSpinalNervesforChronicPain(AmerihealthAdministrators)11.15.09pSurgery (11)11.15.09p11.15.097ad193a1-4356-4c00-8be7-6d555ca8dceeDenervation of the Spinal Nerves for Chronic Pain (Amerihealth Administrators)Denervation of the Spinal Nerves for Chronic Pain (Amerihealth Administrators)
57bda5d7-15fe-46b5-a899-86ca6605e4b3.aspx
  
5746Denosumab(Prolia®,Xgeva®),Romosozumab-aqqg(Evenity®)08.00.94qPharmacy (08)08.00.94q08.00.9457bda5d7-15fe-46b5-a899-86ca6605e4b3Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)
{"5747": {"Id":5747,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes","MPPolicyAttachmentInternalSourceId":7711,"PolicyAttachmentPageName":"3f4108f4-df79-4a2b-8350-997ae2afe344"},}
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5643DermabrasionforRhinophyma,Septoplasty,Rhinoplasty,andSeptorhinoplasty11.16.01kSurgery (11)11.16.01k11.16.01eb0d2a2d-0772-49af-aa74-3b8d38e08143Dermabrasion 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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