Commercial
  
  
  
  
  
  
  
  
  
  
MPattachmentdataPub
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3594Abatacept(Orencia®)forInjectionforIntravenousUse08.00.62mPharmacy (08)08.00.62m08.00.62834bcbbf-eb2a-49a9-a954-5a4398bc345cAbatacept (Orencia®) for Injection for Intravenous UseAbatacept (Orencia®) for Injection for Intravenous Use
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3677Acupuncture(AmeriHealth)12.00.01gMiscellaneous (12)12.00.01g12.00.0169738b74-5838-4194-b77b-19438159b0a8Acupuncture (AmeriHealth)Acupuncture (AmeriHealth)
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3303AcuteCareFacilityInpatientTransfers12.04.04aMiscellaneous (12)12.04.04a12.04.04baf2b880-5954-469c-adfe-fcce98d1ed7eAcute Care Facility Inpatient TransfersAcute Care Facility Inpatient Transfers
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2917Ado-TrastuzumabEmtansine(Kadcyla®)08.01.11fPharmacy (08)08.01.11f08.01.1128064e49-a2b7-4f80-ba96-337057e5e541Ado-Trastuzumab Emtansine (Kadcyla®)Ado-Trastuzumab Emtansine (Kadcyla®)
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3561Agalsidasebeta(Fabrazyme®)08.00.69cPharmacy (08)08.00.69c08.00.69ef92af72-44ab-4053-832a-c246d0294937Agalsidase beta (Fabrazyme®)Agalsidase beta (Fabrazyme®)
c7c932d9-9c5e-4b7d-845e-a6b2b3a53835.aspx
  
3383AirAmbulanceServices12.04.03cMiscellaneous (12)12.04.03c12.04.03c7c932d9-9c5e-4b7d-845e-a6b2b3a53835Air Ambulance ServicesAir Ambulance Services
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3393Alemtuzumab(Lemtrada®)08.01.22dPharmacy (08)08.01.22d08.01.228d15f836-a0d2-4303-acef-f981a139b95cAlemtuzumab (Lemtrada®)Alemtuzumab (Lemtrada®)
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3731Alglucosidasealfa(e.g.,Lumizyme®),Avalglucosidasealfa-ngpt(Nexviazyme®)08.00.72iPharmacy (08)08.00.72i08.00.727b1ae6c7-594f-4607-b839-4a10049ca4f6Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® )Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® )
5bebba01-0b42-45ed-ae07-f386ffcff954.aspx
  
3199AllergyImmunotherapy07.00.21jMedicine (07)07.00.21j07.00.215bebba01-0b42-45ed-ae07-f386ffcff954Allergy ImmunotherapyAllergy Immunotherapy
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3210AlloMap™MolecularExpressionTestingforHeartTransplantRejection(AmeriHealthAdministrators)06.02.29dPathology and Laboratory (06)06.02.29d06.02.294961f658-2939-4b42-aba7-40a8e6a01043AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)
f928229d-392f-46ab-a93c-274ef407aa75.aspx
  
2927Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C®,AralastNP®,Glassia®,Zemaira®)08.00.91ePharmacy (08)08.00.91e08.00.91f928229d-392f-46ab-a93c-274ef407aa75Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)
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3744AlwaysBundledProcedureCodes00.01.52nAdministrative (00)00.01.52n00.01.52cd20f2c3-6a69-47e0-94eb-6791cacc51dcAlways Bundled Procedure CodesAlways Bundled Procedure Codes
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3042AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)Devices07.02.09gMedicine (07)07.02.09g07.02.09c233d9c4-b48b-4763-a10b-7f4a06ccaad8Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) DevicesAmbulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
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3589AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)Monitoring07.02.21gMedicine (07)07.02.21g07.02.2131a4bfcd-283c-4a94-bded-f16316543081Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
ec509307-9989-4a80-b1f1-e5d5eae25831.aspx
  
3456Ankle-Foot/Knee-Ankle-FootOrthoses05.00.39rDME (05)05.00.39r05.00.39ec509307-9989-4a80-b1f1-e5d5eae25831Ankle-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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2674ApplicationandRemovalofTattoos11.08.05gSurgery (11)11.08.05g11.08.050820c52b-3435-4ae2-9ea0-c8c776494f41Application and Removal of TattoosApplication and Removal of Tattoos
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3520Aprepitant(Cinvanti™),FosaprepitantDimeglumine(Emend®),Granisetron(Sustol®),andRolapitant(Varubi®)08.01.41cPharmacy (08)08.01.41c08.01.4144db3f87-de94-4415-b8cf-8c8f3b56bd72Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
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3354AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucoma11.05.16iSurgery (11)11.05.16i11.05.16da3b7e49-6fee-4ec5-8f29-9fd0649ed796Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
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3758ArtificialIntervertebralCervicalDiscInsertion(AmerihealthAdministrators)11.14.19pSurgery (11)11.14.19p11.14.196ab357b1-349e-429e-bdfe-ec87420c4790Artificial Intervertebral Cervical Disc Insertion (Amerihealth Administrators)Artificial Intervertebral Cervical Disc Insertion (Amerihealth Administrators)
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3721ArtificialIntervertebralLumbarDiscInsertion11.15.31Surgery (11)11.15.3111.15.316e26e848-ee5d-4b42-8215-06fa20219584Artificial Intervertebral Lumbar Disc InsertionArtificial Intervertebral Lumbar Disc Insertion
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3580AsparaginaseErwiniaChrysanthemi(Erwinaze®),asparaginaseerwiniachrysanthemi(recombinant)-rywn(Rylaze™)08.01.35dPharmacy (08)08.01.35d08.01.350f7bfa2d-07d2-4c37-8f28-84d9a60943d1Asparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze™)Asparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze™)
e1743810-56f0-4a50-922d-e70a1d2200d3.aspx
  
3209AssaysofGeneticExpressioninTumorTissueforBreastCancerPrognosis(AmeriHealthAdministrators)06.02.27lPathology and Laboratory (06)06.02.27l06.02.27e1743810-56f0-4a50-922d-e70a1d2200d3Assays 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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2877AssistedReproductiveTechnologyforInfertilityandOocyteCryopreservation07.10.06iMedicine (07)07.10.06i07.10.06e20aa7d8-bb05-4110-be2b-f752b6a8d611Assisted Reproductive Technology for Infertility and Oocyte CryopreservationAssisted Reproductive Technology for Infertility and Oocyte Cryopreservation
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3559Atezolizumab(Tecentriq®)08.01.69aPharmacy (08)08.01.69a08.01.6949664097-e0c6-43f4-b821-dc72c256bf00Atezolizumab (Tecentriq®)Atezolizumab (Tecentriq®)
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2963AutologousChondrocyteImplantation(ACI)andOtherCell-basedTreatmentsofFocalArticularCartilageLesions(AmerihealthAdministrators)11.14.06jSurgery (11)11.14.06j11.14.0639dafee4-6e6f-4983-b14c-8085c01aeba5Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions (Amerihealth Administrators)Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions (Amerihealth Administrators)
373f2389-2605-4718-bf5b-aeacb92edb77.aspx
  
3543AutomaticExternalCardioverterDefibrillators(WearableandNonwearable)05.00.29lDME (05)05.00.29l05.00.29373f2389-2605-4718-bf5b-aeacb92edb77Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
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3367AutonomicNervousSystemTesting07.03.23dMedicine (07)07.03.23d07.03.236887dc50-b389-42c6-b9f3-36ae0110503eAutonomic Nervous System TestingAutonomic Nervous System Testing
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2482Avelumab(Bavencio®)08.01.64Pharmacy (08)08.01.6408.01.64062d4c58-12d3-4969-b37b-8e58d6aef3baAvelumab (Bavencio®)Avelumab (Bavencio®)
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2728BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitis11.16.06jSurgery (11)11.16.06j11.16.06f2e21ee4-7f8d-4194-87e5-9f702fb30cefBalloon Catheter Dilation of Sinus Ostia for Treatment of Chronic RhinosinusitisBalloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
deb6788b-9378-4634-bea1-f71971bb7026.aspx
  
2824BariatricSurgery11.03.02tSurgery (11)11.03.02t11.03.02deb6788b-9378-4634-bea1-f71971bb7026Bariatric SurgeryBariatric Surgery
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3218Belantamabmafodotin-blmf(Blenrep)08.01.70bPharmacy (08)08.01.70b08.01.700c3de023-25fb-4244-9bf2-c75e131b3d05Belantamab mafodotin-blmf (Blenrep)Belantamab mafodotin-blmf (Blenrep)
3b05feac-73bb-4236-94ea-6f8bc0cb065c.aspx
  
3073Belimumab(Benlysta®)forIntravenousUse08.00.99dPharmacy (08)08.00.99d08.00.993b05feac-73bb-4236-94ea-6f8bc0cb065cBelimumab (Benlysta®) for Intravenous UseBelimumab (Benlysta®) for Intravenous Use
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3604Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUse08.00.66pPharmacy (08)08.00.66p08.00.66562b2f0a-b880-48c9-a8f5-de2c08045153Bevacizumab (Avastin®) and Related Biosimilars For Oncologic UseBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
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2936BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampus00.10.39nAdministrative (00)00.10.39n00.10.39aac783a0-0ef9-4d21-84a0-e1478fdc4bfdBilling for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility CampusBilling for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
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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
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e2f75216-10d2-49bf-80f5-c9cd836a8ff0.aspx
  
3724BiofeedbackTherapy07.00.01jMedicine (07)07.00.01j07.00.01e2f75216-10d2-49bf-80f5-c9cd836a8ff0Biofeedback TherapyBiofeedback Therapy
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3362BioimpedencefortheDetectionofLymphedema07.06.03bMedicine (07)07.06.03b07.06.03cd8cf796-b592-420d-9cab-8d2f79ac5dd4Bioimpedence for the Detection of LymphedemaBioimpedence for the Detection of Lymphedema
18f429c4-65be-44ad-b849-f3e29733bbb7.aspx
  
3009Blepharoplasty,RepairofBlepharoptosis,RepairofBrowPtosis,andCanthoplasty/Canthopexy11.05.02jSurgery (11)11.05.02j11.05.0218f429c4-65be-44ad-b849-f3e29733bbb7Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/CanthopexyBlepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
{"3010": {"Id":3010,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5006,"PolicyAttachmentPageName":"14701adc-60ac-44c0-b279-538135fdad2b"},}
6e7ed1b5-34ce-4ae4-b8dc-de98c39b1693.aspx
  
3329Blinatumomab(Blincyto®)08.01.21dPharmacy (08)08.01.21d08.01.216e7ed1b5-34ce-4ae4-b8dc-de98c39b1693Blinatumomab (Blincyto®)Blinatumomab (Blincyto®)
af56d217-5751-42f2-9ded-3b66ff325a7f.aspx
  
2734Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAids11.01.06eSurgery (11)11.01.06e11.01.06af56d217-5751-42f2-9ded-3b66ff325a7fBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing AidsBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
947be316-7e66-4ef1-a110-29cf455804d7.aspx
  
3270BoneMineralDensity(BMD)Testing09.00.04kRadiology (09)09.00.04k09.00.04947be316-7e66-4ef1-a110-29cf455804d7Bone Mineral Density (BMD) TestingBone Mineral Density (BMD) Testing
54396ad1-0c63-4e39-b13e-f1c7cd1b44b5.aspx
  
3191Bortezomib(BortezomibforInjection,Velcade®)08.00.73mPharmacy (08)08.00.73m08.00.7354396ad1-0c63-4e39-b13e-f1c7cd1b44b5Bortezomib (Bortezomib for Injection, Velcade®)Bortezomib (Bortezomib for Injection, Velcade®)
0a5008a1-ca3f-4c65-9f57-bee0c8cf4d12.aspx
  
3212BotulinumToxinAgents08.00.26xPharmacy (08)08.00.26x08.00.260a5008a1-ca3f-4c65-9f57-bee0c8cf4d12Botulinum Toxin AgentsBotulinum Toxin Agents
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3078BrachytherapyandAcceleratedWholeBreastIrradiationusingThree-DimensionalConformationRadiationTherapy09.00.10zRadiology (09)09.00.10z09.00.1058a9dc62-6d10-446e-83de-88737485a3d1Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation TherapyBrachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy
2d010011-4b3e-446e-b6ca-4467bc6b5d99.aspx
  
2753BreastPumps05.00.76dDME (05)05.00.76d05.00.762d010011-4b3e-446e-b6ca-4467bc6b5d99Breast PumpsBreast Pumps
b1114295-dcd2-4db2-9f0b-05fb8b724540.aspx
  
3602BrentuximabVedotin(Adcetris®)08.01.13fPharmacy (08)08.01.13f08.01.13b1114295-dcd2-4db2-9f0b-05fb8b724540Brentuximab Vedotin (Adcetris®)Brentuximab Vedotin (Adcetris®)
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1601Bronchial ThermoplastySurgery (11)11.16.07b11.16.0785256AA800623D7A852585A4005899ACBronchial ThermoplastyBronchial Thermoplasty
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3071Burosumab-twza(Crysvita®)08.01.49bPharmacy (08)08.01.49b08.01.4991c0ca12-9c10-4251-95cb-0d26375505baBurosumab-twza (Crysvita®)Burosumab-twza (Crysvita®)
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3036Canakinumab(Ilaris®)08.01.51aMiscellaneous (12)08.01.51a08.01.51d28522d7-c8b8-4e7d-a7ae-28920d8964b0Canakinumab (Ilaris®)Canakinumab (Ilaris®)
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3727CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)Programs10.01.01nRehabilitation Services (10)10.01.01n10.01.0151849fc3-b6b2-4b18-9bb5-8d8b12e525c3Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) ProgramsCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
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2928CareManagementandCarePlanningServices00.01.59hAdministrative (00)00.01.59h00.01.59dab50f18-23da-4fbc-a6ec-142a67aa94e7Care Management and Care Planning ServicesCare Management and Care Planning Services
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2677Carfilzomib(Kyprolis®)08.01.05gPharmacy (08)08.01.05g08.01.0524c34fb2-6bd5-48be-a2a3-e7136af3f275Carfilzomib (Kyprolis®)Carfilzomib (Kyprolis®)
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2815CastandSplintApplicationsandAssociatedSupplies00.10.15dAdministrative (00)00.10.15d00.10.15ead5d815-c736-402d-a236-12375fa27c39Cast and Splint Applications and Associated SuppliesCast and Splint Applications and Associated Supplies
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3264CataractSurgery11.01.07eSurgery (11)11.01.07e11.01.07cf334ac5-936c-4a2f-a834-5d2bc9e152d2Cataract SurgeryCataract Surgery
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3574CatheterAblationofCardiacArrhythmias11.02.06mSurgery (11)11.02.06m11.02.06d1b5541d-1d75-4fe9-b464-5ec9d907a08cCatheter Ablation of Cardiac ArrhythmiasCatheter Ablation of Cardiac Arrhythmias
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2427Cemiplimab-rwlc (LIBTAYO®)Pharmacy (08)08.01.6608.01.6685256AA800623D7A8525857A004FE849Cemiplimab-rwlc (LIBTAYO®)Cemiplimab-rwlc (LIBTAYO®)
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3230Cerliponasealfa(Brineura®)08.01.39cPharmacy (08)08.01.39c08.01.397f0fe3cf-38d7-4067-a609-377ca7fdb1bbCerliponase alfa (Brineura®)Cerliponase alfa (Brineura®)
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2672CervicalTractionDevicesforIn-homeUse05.00.61gDME (05)05.00.61g05.00.612892d91c-09af-4047-9d95-193f41591437Cervical Traction Devices for In-home UseCervical Traction Devices for In-home Use
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3551Cetuximab(Erbitux®)08.00.67mPharmacy (08)08.00.67m08.00.6797676303-7d9b-4fac-b144-cbb4ef0f89d2Cetuximab (Erbitux®)Cetuximab (Erbitux®)
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3567ChemicalPeels11.08.08gSurgery (11)11.08.08g11.08.08a47d58ff-608b-44de-aa95-33eacd21c307Chemical PeelsChemical Peels
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3702ChimericAntigenReceptor(CAR)Therapy08.01.43iPharmacy (08)08.01.43i08.01.43251b32c7-c105-4d44-8528-af7641debe12Chimeric Antigen Receptor (CAR) TherapyChimeric Antigen Receptor (CAR) Therapy
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3311ChiropracticSpinalandExtraspinalManipulationTherapy10.02.02jRehabilitation Services (10)10.02.02j10.02.0279223218-5ff1-491f-aae1-eb232d8fa401Chiropractic Spinal and Extraspinal Manipulation TherapyChiropractic Spinal and Extraspinal Manipulation Therapy
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3773CoagulationFactors08.00.92adPharmacy (08)08.00.92ad08.00.921c1ff6fe-09b9-436b-bf31-352aed9cc2d9Coagulation Factors Coagulation Factors
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3686Cobalamin(VitaminB12),FolicAcid,andHomocysteineTesting06.02.54bPathology and Laboratory (06)06.02.54b06.02.543246e94a-2e1d-4c63-9093-c8bd45f9663fCobalamin (Vitamin B12), Folic Acid, and Homocysteine TestingCobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
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3164CochlearImplant11.01.02pSurgery (11)11.01.02p11.01.02e4d1c502-60ae-4c63-8021-a778a10a3c5dCochlear ImplantCochlear Implant
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3401ColorectalCancerScreening11.03.12tSurgery (11)11.03.12t11.03.1225a66d22-ffc8-4c6d-b207-353c23c84b2eColorectal Cancer ScreeningColorectal Cancer Screening
B55889244594F1F085258574005DA579.aspx
  
1917Complementary and Integrative Health ServicesMiscellaneous (12)12.00.03g12.00.03B55889244594F1F085258574005DA579Complementary and Integrative Health ServicesComplementary and Integrative Health Services
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3371CompleteDecongestiveTherapy(CDT)07.06.01bMedicine (07)07.06.01b07.06.01335f806f-5741-4098-9952-55b12dc1e476Complete Decongestive Therapy (CDT)Complete Decongestive Therapy (CDT)
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3239CompositeTissueAllotransplantationoftheHand(s)andFace11.14.30Surgery (11)11.14.3011.14.30c4cb29d5-a6d2-451f-9cb0-66bc9d495580Composite Tissue Allotransplantation of the Hand(s) and FaceComposite Tissue Allotransplantation of the Hand(s) and Face
d7412bfb-d233-41cb-abab-b9e378c4702b.aspx
  
3237CompressionGarments05.00.37fDME (05)05.00.37f05.00.37d7412bfb-d233-41cb-abab-b9e378c4702bCompression GarmentsCompression Garments
742c5690-7789-4c49-a3c4-f7fd8d3f4b9b.aspx
  
3575Computer-AidedDetection(CAD)SystemforUsewithChestRadiographs09.00.42cRadiology (09)09.00.42c09.00.42742c5690-7789-4c49-a3c4-f7fd8d3f4b9bComputer-Aided Detection (CAD) System for Use with Chest RadiographsComputer-Aided Detection (CAD) System for Use with Chest Radiographs
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3241Computer-assistedMusculoskeletalSurgicalNavigationalOrthopedicProcedure11.14.17eSurgery (11)11.14.17e11.14.17cea741ca-e1f5-411d-8d34-6af7ac2699a5Computer-assisted Musculoskeletal Surgical Navigational Orthopedic ProcedureComputer-assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
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1986Consultation ServicesAdministrative (00)00.01.6900.01.69F3BA7DB0E980312B8525854B005EE64CConsultation ServicesConsultation Services
85260157-6027-4369-af1d-61b4a40dc379.aspx
  
3633ContactLensesfortheTreatmentofPersistent(Corneal)EpithelialDefects07.13.11kMedicine (07)07.13.11k07.13.1185260157-6027-4369-af1d-61b4a40dc379Contact Lenses for the Treatment of Persistent (Corneal) Epithelial DefectsContact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
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3132ContrastAgentsUsedinConjunctionwithEchocardiography09.00.11eRadiology (09)09.00.11e09.00.116559b183-cc4e-4272-9c94-1515a87d738aContrast Agents Used in Conjunction with EchocardiographyContrast Agents Used in Conjunction with Echocardiography
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2683CornealPachymetryUsingUltrasound07.13.07kMedicine (07)07.13.07k07.13.07eeb622d6-06b3-4b65-b45b-8e30a72cc6fbCorneal Pachymetry Using UltrasoundCorneal Pachymetry Using Ultrasound
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3370CosmeticProcedures12.01.03aMiscellaneous (12)12.01.03a12.01.033fbb0f4b-f2c3-4e5e-8f16-ed646b2faaafCosmetic ProceduresCosmetic Procedures
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3704CoverageofAnticancerPrescriptionOralandInjectableDrugsandBiologicsandSupportiveAgents08.01.08fPharmacy (08)08.01.08f08.01.08eb3d24f8-ff5c-4a3d-96f1-72d2accdd283Coverage 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
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2645CranialElectrotherapyStimulation05.00.80ADME (05)05.00.80A05.00.80237abae4-3c2e-4ac9-bd1b-670132546eb6Cranial Electrotherapy StimulationCranial Electrotherapy Stimulation
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3034CranialRemoldingOrthoses(Helmets)05.00.25iDME (05)05.00.25i05.00.254c0f9461-3615-42b9-8172-7d831e57933aCranial Remolding Orthoses (Helmets)Cranial Remolding Orthoses (Helmets)
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1811Criteria for Reimbursement of Emergency Room ServicesAdministrative (00)00.10.03j00.10.0385256AA800623D7A852584710058EC0ECriteria for Reimbursement of Emergency Room ServicesCriteria for Reimbursement of Emergency Room Services
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3217crizanlizumab-tmca(Adakveo®)08.00.04Pharmacy (08)08.00.0408.00.0453d97f91-f6e4-42d5-b65b-9b2b85479a07crizanlizumab-tmca (Adakveo®)crizanlizumab-tmca (Adakveo®)
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3245CryosurgicalAblationoftheProstateGland11.11.03dSurgery (11)11.11.03d11.11.03f8864ad8-763e-4de5-b347-c1e53faf3f62Cryosurgical Ablation of the Prostate GlandCryosurgical Ablation of the Prostate Gland
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3331Daratumumab(Darzalex®),Daratumumab,andHyaluronidase-fihj(DarzalexFaspro®)08.01.29iPharmacy (08)08.01.29i08.01.29caddc052-448d-47ed-ab6a-9038bbc469d3Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®)Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®)
d93acb77-0d6c-4707-bd4a-443705511a77.aspx
  
3395DayRehabilitation10.00.02cRehabilitation Services (10)10.00.02c10.00.02d93acb77-0d6c-4707-bd4a-443705511a77Day RehabilitationDay Rehabilitation
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3661DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNails11.08.17kSurgery (11)11.08.17k11.08.1762e02374-fa4f-44d0-92b6-3997cb88b0f8Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe NailsDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
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2661DeepBrainStimulation(DBS)11.15.20pSurgery (11)11.15.20p11.15.207ab9c75e-ec48-47b0-9461-0cfae8b2cce8Deep Brain Stimulation (DBS)Deep Brain Stimulation (DBS)
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3601DenervationoftheSpinalNervesforChronicPain(AmerihealthAdministrators)11.15.09pSurgery (11)11.15.09p11.15.092937c99d-edd9-499f-905d-201efac4beb6Denervation of the Spinal Nerves for Chronic Pain (Amerihealth Administrators)Denervation of the Spinal Nerves for Chronic Pain (Amerihealth Administrators)
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3227Denosumab(Prolia®,Xgeva®),Romosozumab-aqqg(Evenity®)08.00.94oPharmacy (08)08.00.94o08.00.944f5f5b87-4b5c-46af-874f-cc8c1c7548e9Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)
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2991DiagnosticRadiologyServicesIncludedinCapitation00.03.02abAdministrative (00)00.03.02ab00.03.02e4575742-3afd-4e86-a0f5-24ebba7753f9Diagnostic Radiology Services Included in CapitationDiagnostic Radiology Services Included in Capitation
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2947DirectAccesstoObstetrics/Gynecology(OB/GYN)Services00.09.01hAdministrative (00)00.09.01h00.09.01b1ef5086-c4c5-4583-836b-b89027c587a7Direct Access to Obstetrics/Gynecology (OB/GYN) ServicesDirect Access to Obstetrics/Gynecology (OB/GYN) Services
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3252Dofetilide(Tikosyn®)UseintheInpatientSetting08.00.49ePharmacy (08)08.00.49e08.00.4946492617-4cbd-442b-a4e2-b29e7eee784dDofetilide (Tikosyn®) Use in the Inpatient SettingDofetilide (Tikosyn®) Use in the Inpatient Setting
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3681Dostarlimab-gxly(Jemperli)08.01.79aPharmacy (08)08.01.79a08.01.79b9f8561c-b0a8-49da-ae0e-857a937afba5Dostarlimab-gxly (Jemperli)Dostarlimab-gxly (Jemperli)
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3759Drug-ElutingBeadsandBlandEmbolizationfortheTreatmentofHepaticMalignancies07.05.07dMedicine (07)07.05.07d07.05.07fb9e6254-693c-42df-87b8-bcbf4c64768cDrug-Eluting Beads and Bland Embolization for the Treatment of Hepatic MalignanciesDrug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
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3530DrugsUsedfortheMaintenanceTreatmentofOpioidorAlcoholUseDisorder(e.g.,NaltrexoneImplants,ProbuphineImplant,SublocadeInjection,VivitrolInjection)08.01.37aPharmacy (08)08.01.37a08.01.37c3ef2931-7c17-4361-ba9e-1ac5e7573f42Drugs 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)
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3716DurableMedicalEquipment(DME)andConsumableMedicalSupplies05.00.21yDME (05)05.00.21y05.00.21c991792a-ba91-4b64-b926-a451924314a9Durable Medical Equipment (DME) and Consumable Medical SuppliesDurable Medical Equipment (DME) and Consumable Medical Supplies
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3020DurableMedicalEquipment(DME)NotSubjecttoaRentaltoPurchaseMaximum05.00.48kDME (05)05.00.48k05.00.48bf7c7de8-7799-4645-adb6-e4be539f9bddDurable Medical Equipment (DME) Not Subject to a Rental to Purchase MaximumDurable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
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