|  | | 2758 | Abatacept(Orencia®)forInjectionforIntravenousUse08.00.62l | Pharmacy (08) | 08.00.62l | 08.00.62 | 79bf2ea2-c896-4994-80c0-11bbe740ef0a | Abatacept (Orencia®) for Injection for Intravenous Use | Abatacept (Orencia®) for Injection for Intravenous Use | {"2759": {"Id":2759,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":4966,"PolicyAttachmentPageName":"f76fa503-86d2-446b-a192-95f717ee8221"},} |
| | | 3219 | Acupuncture(AmeriHealth)12.00.01f | Miscellaneous (12) | 12.00.01f | 12.00.01 | 402ab5b6-7221-4eac-8560-0d1b0f7ca00d | Acupuncture (AmeriHealth) | Acupuncture (AmeriHealth) | {"3220": {"Id":3220,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Acupuncture","MPPolicyAttachmentInternalSourceId":5411,"PolicyAttachmentPageName":"396b54a2-8703-4390-b6a0-35ebb7099b19"},} |
| | | 3303 | AcuteCareFacilityInpatientTransfers12.04.04a | Miscellaneous (12) | 12.04.04a | 12.04.04 | baf2b880-5954-469c-adfe-fcce98d1ed7e | Acute Care Facility Inpatient Transfers | Acute Care Facility Inpatient Transfers | |
| | | 2917 | Ado-TrastuzumabEmtansine(Kadcyla®)08.01.11f | Pharmacy (08) | 08.01.11f | 08.01.11 | 28064e49-a2b7-4f80-ba96-337057e5e541 | Ado-Trastuzumab Emtansine (Kadcyla®) | Ado-Trastuzumab Emtansine (Kadcyla®) | {"2918": {"Id":2918,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes and Narratives","MPPolicyAttachmentInternalSourceId":4967,"PolicyAttachmentPageName":"c4bf9963-de35-4b21-9a8c-4671f09541a4"},} |
| | | 1841 | Agalsidase beta (Fabrazyme®) | Pharmacy (08) | 08.00.69b | 08.00.69 | 85256AA800623D7A852585420071736C | Agalsidase beta (Fabrazyme®) | Agalsidase beta (Fabrazyme®) | |
| | | 3383 | AirAmbulanceServices12.04.03c | Miscellaneous (12) | 12.04.03c | 12.04.03 | c7c932d9-9c5e-4b7d-845e-a6b2b3a53835 | Air Ambulance Services | Air Ambulance Services | |
| | | 3393 | Alemtuzumab(Lemtrada®)08.01.22d | Pharmacy (08) | 08.01.22d | 08.01.22 | 8d15f836-a0d2-4303-acef-f981a139b95c | Alemtuzumab (Lemtrada®) | Alemtuzumab (Lemtrada®) | |
| | | 1842 | Alglucosidase alfa (e.g., Lumizyme®) | Pharmacy (08) | 08.00.72h | 08.00.72 | 85256AA800623D7A8525854200710D18 | Alglucosidase alfa (e.g., Lumizyme®) | Alglucosidase alfa (e.g., Lumizyme®) | |
| | | 3199 | AllergyImmunotherapy07.00.21j | Medicine (07) | 07.00.21j | 07.00.21 | 5bebba01-0b42-45ed-ae07-f386ffcff954 | Allergy Immunotherapy | Allergy Immunotherapy | |
| | | 3210 | AlloMap™MolecularExpressionTestingforHeartTransplantRejection(AmeriHealthAdministrators)06.02.29d | Pathology and Laboratory (06) | 06.02.29d | 06.02.29 | 4961f658-2939-4b42-aba7-40a8e6a01043 | AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators) | AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators) | |
| | | 2927 | Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C®,AralastNP®,Glassia®,Zemaira®)08.00.91e | Pharmacy (08) | 08.00.91e | 08.00.91 | f928229d-392f-46ab-a93c-274ef407aa75 | Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®) | Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®) | |
| | | 3469 | AlwaysBundledProcedureCodes00.01.52m | Administrative (00) | 00.01.52m | 00.01.52 | 279f3e1d-cef8-423c-b11f-86955bd5c7db | Always Bundled Procedure Codes | Always Bundled Procedure Codes | {"3470": {"Id":3470,"MPAttachmentLetter":"A","Title":"Always Bundled Procedures (Indicator B)","MPPolicyAttachmentInternalSourceId":5646,"PolicyAttachmentPageName":"0cd3a1d6-755c-4426-9de7-f2e916bfdd14"},"3471": {"Id":3471,"MPAttachmentLetter":"B","Title":"Procedures/Services Not Eligible for Separate Reimbursement","MPPolicyAttachmentInternalSourceId":5647,"PolicyAttachmentPageName":"e79baeeb-9c92-4448-af0b-e91c4da72554"},"3472": {"Id":3472,"MPAttachmentLetter":"C","Title":"Procedures/Services Not Eligible for Reimbursement","MPPolicyAttachmentInternalSourceId":5648,"PolicyAttachmentPageName":"e06b153a-f993-46b2-9cb3-d716110b45a1"},} |
| | | 3042 | AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)Devices07.02.09g | Medicine (07) | 07.02.09g | 07.02.09 | c233d9c4-b48b-4763-a10b-7f4a06ccaad8 | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | |
| | | 3437 | AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)Monitoring07.02.21g | Medicine (07) | 07.02.21g | 07.02.21 | 69c530c0-af3f-468f-ab49-14ba3e754a06 | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | |
| | | 3117 | Ankle-Foot/Knee-Ankle-FootOrthoses05.00.39q | DME (05) | 05.00.39q | 05.00.39 | 6318042c-eefe-416e-aa5f-2e046c59e74c | Ankle-Foot/Knee-Ankle-Foot Orthoses | Ankle-Foot/Knee-Ankle-Foot Orthoses | {"3118": {"Id":3118,"MPAttachmentLetter":"A","Title":"HCPCS Codes","MPPolicyAttachmentInternalSourceId":5396,"PolicyAttachmentPageName":"831b70a7-a3aa-4042-9c2c-62fa34a9d0b8"},} |
| | | 2807 | ApheresisTherapy06.03.04n | Pathology and Laboratory (06) | 06.03.04n | 06.03.04 | b395fd09-303a-4b18-a74c-04bb56dc9226 | Apheresis Therapy | Apheresis Therapy | |
| | | 2674 | ApplicationandRemovalofTattoos11.08.05g | Surgery (11) | 11.08.05g | 11.08.05 | 0820c52b-3435-4ae2-9ea0-c8c776494f41 | Application and Removal of Tattoos | Application and Removal of Tattoos | |
| | | 1843 | Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®) | Pharmacy (08) | 08.01.41c | 08.01.41 | 85256AA800623D7A8525853E004B8BDF | Aprepitant (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"},} |
| | | 3354 | AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucoma11.05.16i | Surgery (11) | 11.05.16i | 11.05.16 | da3b7e49-6fee-4ec5-8f29-9fd0649ed796 | Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | {"3355": {"Id":3355,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":5521,"PolicyAttachmentPageName":"6654b7d9-5901-47ca-b406-a4e1cdc152ca"},} |
| | | 2951 | ArtificialIntervertebralCervicalDiscInsertion(AmerihealthAdministrators)11.14.19p | Surgery (11) | 11.14.19p | 11.14.19 | 3c9c1102-de45-473f-9a0d-e92c3d7b9687 | Artificial Intervertebral Cervical Disc Insertion (Amerihealth Administrators) | Artificial Intervertebral Cervical Disc Insertion (Amerihealth Administrators) | |
| | | 2950 | ArtificialIntervertebralLumbarDiscInsertion11.15.31 | Surgery (11) | 11.15.31 | 11.15.31 | 12d48495-64b9-4f9f-b05b-007bf460da46 | Artificial Intervertebral Lumbar Disc Insertion | Artificial Intervertebral Lumbar Disc Insertion | |
| | | 3017 | AsparaginaseErwiniaChrysanthemi(Erwinaze®)08.01.35c | Pharmacy (08) | 08.01.35c | 08.01.35 | 988495ee-f60a-43f4-841b-2a0794848d76 | Asparaginase Erwinia Chrysanthemi (Erwinaze®) | Asparaginase Erwinia Chrysanthemi (Erwinaze®) | |
| | | 3209 | AssaysofGeneticExpressioninTumorTissueforBreastCancerPrognosis(AmeriHealthAdministrators)06.02.27l | Pathology and Laboratory (06) | 06.02.27l | 06.02.27 | e1743810-56f0-4a50-922d-e70a1d2200d3 | Assays 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) | |
| | | 2877 | AssistedReproductiveTechnologyforInfertilityandOocyteCryopreservation07.10.06i | Medicine (07) | 07.10.06i | 07.10.06 | e20aa7d8-bb05-4110-be2b-f752b6a8d611 | Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation | Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation | |
| | | 2500 | Atezolizumab(Tecentriq®)08.01.69 | Pharmacy (08) | 08.01.69 | 08.01.69 | 8470da1f-a6df-49af-b6bb-2f51ee4280db | Atezolizumab (Tecentriq®) | Atezolizumab (Tecentriq®) | {"2501": {"Id":2501,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":4723,"PolicyAttachmentPageName":"afedffda-6a22-4abb-8108-ba0033e13870"},} |
| | | 2963 | AutologousChondrocyteImplantation(ACI)andOtherCell-basedTreatmentsofFocalArticularCartilageLesions(AmerihealthAdministrators)11.14.06j | Surgery (11) | 11.14.06j | 11.14.06 | 39dafee4-6e6f-4983-b14c-8085c01aeba5 | Autologous 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) | |
| | | 2426 | Automatic External Cardioverter Defibrillators (Wearable and Nonwearable) | DME (05) | 05.00.29l | 05.00.29 | A0450B1CECA727FF852585AB00533565 | Automatic External Cardioverter Defibrillators (Wearable and Nonwearable) | Automatic External Cardioverter Defibrillators (Wearable and Nonwearable) | {"2435": {"Id":2435,"MPAttachmentLetter":"B","Title":"ICD-10 codes used to represent the Nonwearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"DE272CF959A83D46852585AB00533585"},"2436": {"Id":2436,"MPAttachmentLetter":"A","Title":"ICD-10 Codes used to represent the Wearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"5080E542121FA54B852585AB0053357F"},} |
| | | 3367 | AutonomicNervousSystemTesting07.03.23d | Medicine (07) | 07.03.23d | 07.03.23 | 6887dc50-b389-42c6-b9f3-36ae0110503e | Autonomic Nervous System Testing | Autonomic Nervous System Testing | |
| | | 2482 | Avelumab(Bavencio®)08.01.64 | Pharmacy (08) | 08.01.64 | 08.01.64 | 062d4c58-12d3-4969-b37b-8e58d6aef3ba | Avelumab (Bavencio®) | Avelumab (Bavencio®) | {"2483": {"Id":2483,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":2486,"PolicyAttachmentPageName":"c8c8c64e-3156-4e08-96fe-46526051edba"},} |
| | | 2728 | BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitis11.16.06j | Surgery (11) | 11.16.06j | 11.16.06 | f2e21ee4-7f8d-4194-87e5-9f702fb30cef | Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis | Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis | |
| | | 2824 | BariatricSurgery11.03.02t | Surgery (11) | 11.03.02t | 11.03.02 | deb6788b-9378-4634-bea1-f71971bb7026 | Bariatric Surgery | Bariatric 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"},} |
| | | 3218 | Belantamabmafodotin-blmf(Blenrep)08.01.70b | Pharmacy (08) | 08.01.70b | 08.01.70 | 0c3de023-25fb-4244-9bf2-c75e131b3d05 | Belantamab mafodotin-blmf (Blenrep) | Belantamab mafodotin-blmf (Blenrep) | |
| | | 3073 | Belimumab(Benlysta®)forIntravenousUse08.00.99d | Pharmacy (08) | 08.00.99d | 08.00.99 | 3b05feac-73bb-4236-94ea-6f8bc0cb065c | Belimumab (Benlysta®) for Intravenous Use | Belimumab (Benlysta®) for Intravenous Use | |
| | | 3018 | Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUse08.00.66o | Pharmacy (08) | 08.00.66o | 08.00.66 | e14d5427-e045-4eee-875d-5a1c7e82f214 | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | {"3019": {"Id":3019,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":5036,"PolicyAttachmentPageName":"ee63b08d-1c28-4691-8152-447aec4c24e1"},} |
| | | 2936 | BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampus00.10.39n | Administrative (00) | 00.10.39n | 00.10.39 | aac783a0-0ef9-4d21-84a0-e1478fdc4bfd | Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus | Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus | {"2937": {"Id":2937,"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":5191,"PolicyAttachmentPageName":"8c5aaa02-4928-4e46-ab85-3294a77b4a08"},} |
| | | 3087 | BillingRequirementsforMultipleBirthsforProfessionalProviders00.10.38a | Administrative (00) | 00.10.38a | 00.10.38 | e862bc0b-0289-4661-bf0a-950e2efca6ee | Billing Requirements for Multiple Births for Professional Providers | Billing 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"},} |
| | | 2685 | BiofeedbackTherapy07.00.01j | Medicine (07) | 07.00.01j | 07.00.01 | 2575a0d1-26dc-45aa-81b4-c8c13ea46c73 | Biofeedback Therapy | Biofeedback Therapy | |
| | | 3362 | BioimpedencefortheDetectionofLymphedema07.06.03b | Medicine (07) | 07.06.03b | 07.06.03 | cd8cf796-b592-420d-9cab-8d2f79ac5dd4 | Bioimpedence for the Detection of Lymphedema | Bioimpedence for the Detection of Lymphedema | |
| | | 3009 | Blepharoplasty,RepairofBlepharoptosis,RepairofBrowPtosis,andCanthoplasty/Canthopexy11.05.02j | Surgery (11) | 11.05.02j | 11.05.02 | 18f429c4-65be-44ad-b849-f3e29733bbb7 | Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy | Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy | {"3010": {"Id":3010,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5006,"PolicyAttachmentPageName":"14701adc-60ac-44c0-b279-538135fdad2b"},} |
| | | 3329 | Blinatumomab(Blincyto®)08.01.21d | Pharmacy (08) | 08.01.21d | 08.01.21 | 6e7ed1b5-34ce-4ae4-b8dc-de98c39b1693 | Blinatumomab (Blincyto®) | Blinatumomab (Blincyto®) | |
| | | 2734 | Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAids11.01.06e | Surgery (11) | 11.01.06e | 11.01.06 | af56d217-5751-42f2-9ded-3b66ff325a7f | Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids | Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids | |
| | | 3270 | BoneMineralDensity(BMD)Testing09.00.04k | Radiology (09) | 09.00.04k | 09.00.04 | 947be316-7e66-4ef1-a110-29cf455804d7 | Bone Mineral Density (BMD) Testing | Bone Mineral Density (BMD) Testing | |
| | | 3191 | Bortezomib(BortezomibforInjection,Velcade®)08.00.73m | Pharmacy (08) | 08.00.73m | 08.00.73 | 54396ad1-0c63-4e39-b13e-f1c7cd1b44b5 | Bortezomib (Bortezomib for Injection, Velcade®) | Bortezomib (Bortezomib for Injection, Velcade®) | |
| | | 3212 | BotulinumToxinAgents08.00.26x | Pharmacy (08) | 08.00.26x | 08.00.26 | 0a5008a1-ca3f-4c65-9f57-bee0c8cf4d12 | Botulinum Toxin Agents | Botulinum Toxin Agents | {"3213": {"Id":3213,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":5156,"PolicyAttachmentPageName":"adc0b891-cf41-4968-b10d-9fd0bf295a7e"},} |
| | | 3078 | BrachytherapyandAcceleratedWholeBreastIrradiationusingThree-DimensionalConformationRadiationTherapy09.00.10z | Radiology (09) | 09.00.10z | 09.00.10 | 58a9dc62-6d10-446e-83de-88737485a3d1 | Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy | Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy | |
| | | 2753 | BreastPumps05.00.76d | DME (05) | 05.00.76d | 05.00.76 | 2d010011-4b3e-446e-b6ca-4467bc6b5d99 | Breast Pumps | Breast Pumps | |
| | | 3045 | BrentuximabVedotin(Adcetris®)08.01.13e | Pharmacy (08) | 08.01.13e | 08.01.13 | 6a96c1f5-bf57-4736-b68f-d4f3c50a51e6 | Brentuximab Vedotin (Adcetris®) | Brentuximab Vedotin (Adcetris®) | {"3046": {"Id":3046,"MPAttachmentLetter":"A","Title":"ICD CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":5096,"PolicyAttachmentPageName":"329c7063-603b-4db6-895d-eb2d6f4b1d6d"},} |
| | | 1601 | Bronchial Thermoplasty | Surgery (11) | 11.16.07b | 11.16.07 | 85256AA800623D7A852585A4005899AC | Bronchial Thermoplasty | Bronchial Thermoplasty | |
| | | 3071 | Burosumab-twza(Crysvita®)08.01.49b | Pharmacy (08) | 08.01.49b | 08.01.49 | 91c0ca12-9c10-4251-95cb-0d26375505ba | Burosumab-twza (Crysvita®) | Burosumab-twza (Crysvita®) | |
| | | 3036 | Canakinumab(Ilaris®)08.01.51a | Miscellaneous (12) | 08.01.51a | 08.01.51 | d28522d7-c8b8-4e7d-a7ae-28920d8964b0 | Canakinumab (Ilaris®) | Canakinumab (Ilaris®) | |
| | | 2750 | CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)Programs10.01.01n | Rehabilitation Services (10) | 10.01.01n | 10.01.01 | 847887d0-b38f-484e-80b4-ce36b27acefe | Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs | Cardiac 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"},} |
| | | 2928 | CareManagementandCarePlanningServices00.01.59h | Administrative (00) | 00.01.59h | 00.01.59 | dab50f18-23da-4fbc-a6ec-142a67aa94e7 | Care Management and Care Planning Services | Care Management and Care Planning Services | |
| | | 2677 | Carfilzomib(Kyprolis®)08.01.05g | Pharmacy (08) | 08.01.05g | 08.01.05 | 24c34fb2-6bd5-48be-a2a3-e7136af3f275 | Carfilzomib (Kyprolis®) | Carfilzomib (Kyprolis®) | |
| | | 2815 | CastandSplintApplicationsandAssociatedSupplies00.10.15d | Administrative (00) | 00.10.15d | 00.10.15 | ead5d815-c736-402d-a236-12375fa27c39 | Cast and Splint Applications and Associated Supplies | Cast 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"},} |
| | | 3264 | CataractSurgery11.01.07e | Surgery (11) | 11.01.07e | 11.01.07 | cf334ac5-936c-4a2f-a834-5d2bc9e152d2 | Cataract Surgery | Cataract Surgery | {"3265": {"Id":3265,"MPAttachmentLetter":"A","Title":"ICD 10 codes for policy 11.01.07d, Cataract Surgery","MPPolicyAttachmentInternalSourceId":5477,"PolicyAttachmentPageName":"bfb7aea9-1f0d-4a55-8c31-38d0fe0f28bc"},} |
| | | 2691 | CatheterAblationofCardiacArrhythmias11.02.06m | Surgery (11) | 11.02.06m | 11.02.06 | 2fc0ca5d-07cf-482b-b1aa-64c3dc277478 | Catheter Ablation of Cardiac Arrhythmias | Catheter Ablation of Cardiac Arrhythmias | |
| | | 2427 | Cemiplimab-rwlc (LIBTAYO®) | Pharmacy (08) | 08.01.66 | 08.01.66 | 85256AA800623D7A8525857A004FE849 | Cemiplimab-rwlc (LIBTAYO®) | Cemiplimab-rwlc (LIBTAYO®) | |
| | | 3230 | Cerliponasealfa(Brineura®)08.01.39c | Pharmacy (08) | 08.01.39c | 08.01.39 | 7f0fe3cf-38d7-4067-a609-377ca7fdb1bb | Cerliponase alfa (Brineura®) | Cerliponase alfa (Brineura®) | |
| | | 2672 | CervicalTractionDevicesforIn-homeUse05.00.61g | DME (05) | 05.00.61g | 05.00.61 | 2892d91c-09af-4047-9d95-193f41591437 | Cervical Traction Devices for In-home Use | Cervical Traction Devices for In-home Use | |
| | | 1730 | Cetuximab (Erbitux®) | Pharmacy (08) | 08.00.67l | 08.00.67 | 85256AA800623D7A8525846C00638C9B | Cetuximab (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"},} |
| | | 2694 | ChemicalPeels11.08.08g | Surgery (11) | 11.08.08g | 11.08.08 | cfe71410-8201-47ec-aea1-88249ce1763b | Chemical Peels | Chemical Peels | |
| | | 3407 | ChimericAntigenReceptor(CAR)Therapy08.01.43h | Pharmacy (08) | 08.01.43h | 08.01.43 | 307351f3-8163-4488-b5ef-b93252a74fa9 | Chimeric Antigen Receptor (CAR) Therapy | Chimeric Antigen Receptor (CAR) Therapy | {"3408": {"Id":3408,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":5617,"PolicyAttachmentPageName":"b0270997-f44d-42f6-8558-386d987382fc"},} |
| | | 3311 | ChiropracticSpinalandExtraspinalManipulationTherapy10.02.02j | Rehabilitation Services (10) | 10.02.02j | 10.02.02 | 79223218-5ff1-491f-aae1-eb232d8fa401 | Chiropractic Spinal and Extraspinal Manipulation Therapy | Chiropractic Spinal and Extraspinal Manipulation Therapy | |
| | | 2769 | CoagulationFactors08.00.92ac | Pharmacy (08) | 08.00.92ac | 08.00.92 | 083b8973-f704-430b-9342-5b06a2044349 | Coagulation Factors | Coagulation Factors | |
| | | 2828 | Cobalamin(VitaminB12),FolicAcid,andHomocysteineTesting06.02.54a | Pathology and Laboratory (06) | 06.02.54a | 06.02.54 | 71eeef1f-3ef6-49f6-bd61-b3ccbe4aff14 | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | {"2829": {"Id":2829,"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":4910,"PolicyAttachmentPageName":"9ab9d7e8-1e45-4cc6-8c24-527791b717d5"},} |
| | | 3164 | CochlearImplant11.01.02p | Surgery (11) | 11.01.02p | 11.01.02 | e4d1c502-60ae-4c63-8021-a778a10a3c5d | Cochlear Implant | Cochlear Implant | |
| | | 2722 | Collagenaseclostridiumhistolyticum(Xiaflex®),collagenaseclostridiumhistolyticum-aaes(Qwo™)08.01.71 | Pharmacy (08) | 08.01.71 | 08.01.71 | f708376d-a16b-48f1-8f4b-beea8f1a3144 | Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™) | Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™) | |
| | | 3401 | ColorectalCancerScreening11.03.12t | Surgery (11) | 11.03.12t | 11.03.12 | 25a66d22-ffc8-4c6d-b207-353c23c84b2e | Colorectal Cancer Screening | Colorectal Cancer Screening | |
| | | 1917 | Complementary and Integrative Health Services | Miscellaneous (12) | 12.00.03g | 12.00.03 | B55889244594F1F085258574005DA579 | Complementary and Integrative Health Services | Complementary and Integrative Health Services | |
| | | 3371 | CompleteDecongestiveTherapy(CDT)07.06.01b | Medicine (07) | 07.06.01b | 07.06.01 | 335f806f-5741-4098-9952-55b12dc1e476 | Complete Decongestive Therapy (CDT) | Complete Decongestive Therapy (CDT) | |
| | | 3239 | CompositeTissueAllotransplantationoftheHand(s)andFace11.14.30 | Surgery (11) | 11.14.30 | 11.14.30 | c4cb29d5-a6d2-451f-9cb0-66bc9d495580 | Composite Tissue Allotransplantation of the Hand(s) and Face | Composite Tissue Allotransplantation of the Hand(s) and Face | |
| | | 3237 | CompressionGarments05.00.37f | DME (05) | 05.00.37f | 05.00.37 | d7412bfb-d233-41cb-abab-b9e378c4702b | Compression Garments | Compression Garments | |
| | | 1798 | Computer-Aided Detection (CAD) System for Use with Chest Radiographs | Radiology (09) | 09.00.42c | 09.00.42 | 85256AA800623D7A852584F2004C9E48 | Computer-Aided Detection (CAD) System for Use with Chest Radiographs | Computer-Aided Detection (CAD) System for Use with Chest Radiographs | |
| | | 3241 | Computer-assistedMusculoskeletalSurgicalNavigationalOrthopedicProcedure11.14.17e | Surgery (11) | 11.14.17e | 11.14.17 | cea741ca-e1f5-411d-8d34-6af7ac2699a5 | Computer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure | Computer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure | |
| | | 1986 | Consultation Services | Administrative (00) | 00.01.69 | 00.01.69 | F3BA7DB0E980312B8525854B005EE64C | Consultation Services | Consultation Services | |
| | | 2681 | ContactLensesfortheTreatmentofPersistent(Corneal)EpithelialDefects07.13.11j | Medicine (07) | 07.13.11j | 07.13.11 | 8193c86d-b0a9-4cfb-833c-e68d203cf6d6 | Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects | Contact 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"},} |
| | | 3132 | ContrastAgentsUsedinConjunctionwithEchocardiography09.00.11e | Radiology (09) | 09.00.11e | 09.00.11 | 6559b183-cc4e-4272-9c94-1515a87d738a | Contrast Agents Used in Conjunction with Echocardiography | Contrast Agents Used in Conjunction with Echocardiography | |
| | | 2683 | CornealPachymetryUsingUltrasound07.13.07k | Medicine (07) | 07.13.07k | 07.13.07 | eeb622d6-06b3-4b65-b45b-8e30a72cc6fb | Corneal Pachymetry Using Ultrasound | Corneal Pachymetry Using Ultrasound | {"2684": {"Id":2684,"MPAttachmentLetter":"A","Title":"ICD-10-CM codes","MPPolicyAttachmentInternalSourceId":4969,"PolicyAttachmentPageName":"93ce09d2-985c-454f-94b2-f24a4f734a3f"},} |
| | | 3370 | CosmeticProcedures12.01.03a | Miscellaneous (12) | 12.01.03a | 12.01.03 | 3fbb0f4b-f2c3-4e5e-8f16-ed646b2faaaf | Cosmetic Procedures | Cosmetic Procedures | |
| | | 1953 | Coverage of Medical Devices | DME (05) | 05.00.04e | 05.00.04 | 85256AA800623D7A852583F900647246 | Coverage of Medical Devices | Coverage of Medical Devices | |
| | | 3377 | CoverageofAnticancerPrescriptionOralandInjectableDrugsandBiologicsandSupportiveAgents08.01.08e | Pharmacy (08) | 08.01.08e | 08.01.08 | 5d36c57b-fdf1-46c1-8593-fcd0e160f46d | Coverage of Anticancer Prescription Oral and Injectable Drugs and Biologics and Supportive Agents | Coverage of Anticancer Prescription Oral and Injectable Drugs and Biologics and Supportive Agents | {} |
| | | 2645 | CranialElectrotherapyStimulation05.00.80A | DME (05) | 05.00.80A | 05.00.80 | 237abae4-3c2e-4ac9-bd1b-670132546eb6 | Cranial Electrotherapy Stimulation | Cranial Electrotherapy Stimulation | |
| | | 3034 | CranialRemoldingOrthoses(Helmets)05.00.25i | DME (05) | 05.00.25i | 05.00.25 | 4c0f9461-3615-42b9-8172-7d831e57933a | Cranial Remolding Orthoses (Helmets) | Cranial Remolding Orthoses (Helmets) | |
| | | 1811 | Criteria for Reimbursement of Emergency Room Services | Administrative (00) | 00.10.03j | 00.10.03 | 85256AA800623D7A852584710058EC0E | Criteria for Reimbursement of Emergency Room Services | Criteria for Reimbursement of Emergency Room Services | |
| | | 3217 | crizanlizumab-tmca(Adakveo®)08.00.04 | Pharmacy (08) | 08.00.04 | 08.00.04 | 53d97f91-f6e4-42d5-b65b-9b2b85479a07 | crizanlizumab-tmca (Adakveo®) | crizanlizumab-tmca (Adakveo®) | |
| | | 3245 | CryosurgicalAblationoftheProstateGland11.11.03d | Surgery (11) | 11.11.03d | 11.11.03 | f8864ad8-763e-4de5-b347-c1e53faf3f62 | Cryosurgical Ablation of the Prostate Gland | Cryosurgical Ablation of the Prostate Gland | |
| | | 3331 | Daratumumab(Darzalex®),Daratumumab,andHyaluronidase-fihj(DarzalexFaspro®)08.01.29i | Pharmacy (08) | 08.01.29i | 08.01.29 | caddc052-448d-47ed-ab6a-9038bbc469d3 | Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®) | Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®) | |
| | | 3395 | DayRehabilitation10.00.02c | Rehabilitation Services (10) | 10.00.02c | 10.00.02 | d93acb77-0d6c-4707-bd4a-443705511a77 | Day Rehabilitation | Day Rehabilitation | |
| | | 3063 | DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNails11.08.17j | Surgery (11) | 11.08.17j | 11.08.17 | 466b892b-732c-4128-a97c-383817a0164e | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | {"3064": {"Id":3064,"MPAttachmentLetter":"E","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (S86.892A - Z79.01), Continued","MPPolicyAttachmentInternalSourceId":5296,"PolicyAttachmentPageName":"37b01041-bc21-4849-a379-e6e1f6da8e61"},"3065": {"Id":3065,"MPAttachmentLetter":"D","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (I87.099 - S86.891S), Continued","MPPolicyAttachmentInternalSourceId":5297,"PolicyAttachmentPageName":"4e4f0aeb-a698-46ef-963f-fa889a0e5b50"},"3066": {"Id":3066,"MPAttachmentLetter":"B","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E10.22 - E13.3512), Continued","MPPolicyAttachmentInternalSourceId":5298,"PolicyAttachmentPageName":"b363793a-c736-4797-8f61-e297a5f5c34c"},"3067": {"Id":3067,"MPAttachmentLetter":"C","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E13.3513 - I87.093), Continued","MPPolicyAttachmentInternalSourceId":5299,"PolicyAttachmentPageName":"63b71387-48d4-4252-b3d7-6a7c0a0ad6a4"},"3068": {"Id":3068,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (A30.0 -E10.21)","MPPolicyAttachmentInternalSourceId":5300,"PolicyAttachmentPageName":"b7a771a4-6d44-4e95-adde-1c8eb8c85282"},} |
| | | 2661 | DeepBrainStimulation(DBS)11.15.20p | Surgery (11) | 11.15.20p | 11.15.20 | 7ab9c75e-ec48-47b0-9461-0cfae8b2cce8 | Deep Brain Stimulation (DBS) | Deep Brain Stimulation (DBS) | |
| | | 2958 | DenervationoftheSpinalNervesforChronicPain(AmerihealthAdministrators)11.15.09o | Surgery (11) | 11.15.09o | 11.15.09 | a4157456-533f-41b7-af48-b069b8f89828 | Denervation of the Spinal Nerves for Chronic Pain (Amerihealth Administrators) | Denervation of the Spinal Nerves for Chronic Pain (Amerihealth Administrators) | |
| | | 3227 | Denosumab(Prolia®,Xgeva®),Romosozumab-aqqg(Evenity®)08.00.94o | Pharmacy (08) | 08.00.94o | 08.00.94 | 4f5f5b87-4b5c-46af-874f-cc8c1c7548e9 | Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®) | Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®) | {"3228": {"Id":3228,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes","MPPolicyAttachmentInternalSourceId":5349,"PolicyAttachmentPageName":"7cf342ce-385b-422b-8605-7224112bbe67"},} |
| | | 2991 | DiagnosticRadiologyServicesIncludedinCapitation00.03.02ab | Administrative (00) | 00.03.02ab | 00.03.02 | e4575742-3afd-4e86-a0f5-24ebba7753f9 | Diagnostic Radiology Services Included in Capitation | Diagnostic Radiology Services Included in Capitation | {"2992": {"Id":2992,"MPAttachmentLetter":"A","Title":"Diagnostic Radiology Procedure Codes Included in Capitation for Pennsylvania (PA) Health Maintenance Organization (HMO) Members","MPPolicyAttachmentInternalSourceId":5246,"PolicyAttachmentPageName":"f4d52604-4f86-4003-9801-9124156c63f4"},} |
| | | 2947 | DirectAccesstoObstetrics/Gynecology(OB/GYN)Services00.09.01h | Administrative (00) | 00.09.01h | 00.09.01 | b1ef5086-c4c5-4583-836b-b89027c587a7 | Direct Access to Obstetrics/Gynecology (OB/GYN) Services | Direct Access to Obstetrics/Gynecology (OB/GYN) Services | {"2948": {"Id":2948,"MPAttachmentLetter":"A","Title":"Procedure Codes for Direct Access OB/GYN","MPPolicyAttachmentInternalSourceId":5193,"PolicyAttachmentPageName":"c130de01-b6cd-4054-9f74-0db4b63876db"},} |
| | | 3252 | Dofetilide(Tikosyn®)UseintheInpatientSetting08.00.49e | Pharmacy (08) | 08.00.49e | 08.00.49 | 46492617-4cbd-442b-a4e2-b29e7eee784d | Dofetilide (Tikosyn®) Use in the Inpatient Setting | Dofetilide (Tikosyn®) Use in the Inpatient Setting | |
| | | 3479 | Dostarlimab-gxly(Jemperli)08.01.79 | Pharmacy (08) | 08.01.79 | 08.01.79 | 6c536481-39e1-4537-a9b3-9cf8eb3442e4 | Dostarlimab-gxly (Jemperli) | Dostarlimab-gxly (Jemperli) | |
| | | 2669 | Drug-ElutingBeadsandBlandEmbolizationfortheTreatmentofHepaticMalignancies07.05.07d | Medicine (07) | 07.05.07d | 07.05.07 | bef1b14c-04ab-4591-b6a4-e5d222c3a82c | Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies | Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies | |
| | | 1704 | Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Naltrexone Implants, Probuphine Implant, Sublocade Injection, Vivitrol Injection) | Pharmacy (08) | 08.01.37a | 08.01.37 | 85256AA800623D7A8525820B004EC0DE | Drugs 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) | |
| | | 3150 | DurableMedicalEquipment(DME)andConsumableMedicalSupplies05.00.21x | DME (05) | 05.00.21x | 05.00.21 | bf3906eb-45a9-479b-a72a-76bce9660789 | Durable Medical Equipment (DME) and Consumable Medical Supplies | Durable Medical Equipment (DME) and Consumable Medical Supplies | {"3151": {"Id":3151,"MPAttachmentLetter":"A2","Title":"Equipment that Meets the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":5441,"PolicyAttachmentPageName":"1ce5df51-3d85-4dc7-8d8a-ef8410b47def"},"3152": {"Id":3152,"MPAttachmentLetter":"B","Title":"Items that Do Not Meet the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":5442,"PolicyAttachmentPageName":"222d3133-c39a-4404-a049-2b843e92c969"},"3153": {"Id":3153,"MPAttachmentLetter":"A1","Title":"Equipment that Meets the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":5443,"PolicyAttachmentPageName":"3c504dc7-4afd-4e30-9e41-742bdbdde979"},} |
| | | 3020 | DurableMedicalEquipment(DME)NotSubjecttoaRentaltoPurchaseMaximum05.00.48k | DME (05) | 05.00.48k | 05.00.48 | bf7c7de8-7799-4645-adb6-e4be539f9bdd | Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum | Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum | |
