|  | | 3404 | Abatacept(Orencia®)forInjectionforIntravenousUseMA08.028l | Pharmacy (08) | MA08.028l | MA08.028 | d36e1958-1fce-4396-ae80-6ec25e1fbf8c | Abatacept (Orencia®) for Injection for Intravenous Use | Abatacept (Orencia®) for Injection for Intravenous Use | {"3405": {"Id":3405,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Code Numbers and Narratives","MPPolicyAttachmentInternalSourceId":10910,"PolicyAttachmentPageName":"f2162721-ff72-4718-aacd-3969842f7801"},} |
| | | 3067 | AblationofLungTumorsMA11.052f | Surgery (11) | MA11.052f | MA11.052 | 2839fd17-915b-4224-8725-c53c735fcf58 | Ablation of Lung Tumors | Ablation of Lung Tumors | |
| | | 2874 | AbortionMA11.010d | Surgery (11) | MA11.010d | MA11.010 | 055ea54d-c495-4ea4-a6e5-eecaa2972d0c | Abortion | Abortion | |
| | | 2702 | AcupunctureMA12.004e | Miscellaneous (12) | MA12.004e | MA12.004 | 1a445df6-53d8-43de-a5bd-b3860e087663 | Acupuncture | Acupuncture | {"2703": {"Id":2703,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Acupuncture","MPPolicyAttachmentInternalSourceId":10301,"PolicyAttachmentPageName":"133a73b3-bb67-418a-87ab-74f883a81d93"},} |
| | | 3277 | AcuteCareFacilityInpatientTransfersMA12.003b | Miscellaneous (12) | MA12.003b | MA12.003 | 629094f3-d83c-4bf5-8e0a-306bfadfaec6 | Acute Care Facility Inpatient Transfers | Acute Care Facility Inpatient Transfers | |
| | | 2023 | ADAMTS13,recombinant-krhn(Adzynma)MA08.171 | Pharmacy (08) | MA08.171 | MA08.171 | 59222766-28a2-4433-a09a-3f71f8f343a6 | ADAMTS13, recombinant-krhn (Adzynma) | ADAMTS13, recombinant-krhn (Adzynma) | |
| | | 3202 | Ado-TrastuzumabEmtansine(Kadcyla®)MA08.066i | Pharmacy (08) | MA08.066i | MA08.066 | da5121d9-1b96-4d28-916c-dce319b2c2bb | Ado-Trastuzumab Emtansine (Kadcyla®) | Ado-Trastuzumab Emtansine (Kadcyla®) | |
| | | 2792 | Agalsidasebeta(Fabrazyme)andpegunigalsidasealfa-iwxj(Elfabrio)MA08.033d | Pharmacy (08) | MA08.033d | MA08.033 | 8b3f3418-a799-413e-9cfb-772bcfeb39a5 | Agalsidase beta (Fabrazyme) and pegunigalsidase alfa-iwxj (Elfabrio) | Agalsidase beta (Fabrazyme) and pegunigalsidase alfa-iwxj (Elfabrio) | |
| | | 2220 | AirAmbulanceServicesMA12.007b | Miscellaneous (12) | MA12.007b | MA12.007 | 47a5d03d-f43b-4b15-94ed-4bf842be7b40 | Air Ambulance Services | Air Ambulance Services | |
| | | 3286 | Alemtuzumab(Lemtrada®)MA08.015e | Pharmacy (08) | MA08.015e | MA08.015 | 2c80f436-9257-415c-8490-9a73a3c13b2f | Alemtuzumab (Lemtrada®) | Alemtuzumab (Lemtrada®) | |
| | | 2923 | Alglucosidasealfa(e.g.,Lumizyme®),Avalglucosidasealfa-ngpt(Nexviazyme®),Cipaglucosidasealfa-atga(Pombiliti™)MA08.036g | Pharmacy (08) | MA08.036g | MA08.036 | 5f9531c9-2035-4bc7-b5e0-6b5a87a588e5 | Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® ), Cipaglucosidase alfa-atga (Pombiliti™ ) | Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® ), Cipaglucosidase alfa-atga (Pombiliti™ ) | |
| | | 2885 | AllergyImmunotherapyMA07.055e | Medicine (07) | MA07.055e | MA07.055 | 60109ced-4a2c-4fc6-9f1b-ce25c3eb3442 | Allergy Immunotherapy | Allergy Immunotherapy | |
| | | 2995 | Alpha-1AntitrypsinTherapy(e.g.,Prolastin-C,AralastNP,Glassia,Zemaira)MA08.050c | Pharmacy (08) | MA08.050c | MA08.050 | 138dba6d-6f43-4e12-a0e7-d355f0f52313 | Alpha-1 Antitrypsin Therapy (e.g., Prolastin-C, Aralast NP, Glassia, Zemaira) | Alpha-1 Antitrypsin Therapy (e.g., Prolastin-C, Aralast NP, Glassia, Zemaira) | |
| | | 2904 | AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)DevicesMA07.005d | Medicine (07) | MA07.005d | MA07.005 | d3aa4fb8-db1c-4223-8bed-18ab90d54217 | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices | |
| | | 3366 | AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)MonitoringMA07.026s | Medicine (07) | MA07.026s | MA07.026 | 0e08f83a-385f-45ba-a9f2-8afc60922eb3 | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring | |
| | | 3148 | Amivantamab-vmjw(Rybrevant®)andAmivantamabandhyaluronidase-lpuj(RybrevantFaspro™)MA08.148d | Pharmacy (08) | MA08.148d | MA08.148 | 04667956-35f4-49b7-a020-af5f12eadbc8 | Amivantamab-vmjw (Rybrevant®) and Amivantamab and hyaluronidase-lpuj (Rybrevant Faspro™) | Amivantamab-vmjw (Rybrevant®) and Amivantamab and hyaluronidase-lpuj (Rybrevant Faspro™) | |
| | | 2767 | AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagementMA01.008d | Anesthesia (01) | MA01.008d | MA01.008 | c75c2565-c4e2-4265-af85-c55cfde08fa5 | Anesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management | Anesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management | {"2768": {"Id":2768,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":10364,"PolicyAttachmentPageName":"e585cc8c-44be-408a-9b36-9dadace2ca09"},} |
| | | 3008 | Anifrolumab-fnia(Saphnelo®)MA08.140c | Pharmacy (08) | MA08.140c | MA08.140 | dcc9a712-ded7-46bf-8809-07dabdd5609d | Anifrolumab-fnia (Saphnelo®) | Anifrolumab-fnia (Saphnelo®) | |
| | | 3344 | Ankle-Foot/Knee-Ankle-FootOrthosisMA05.010m | DME (05) | MA05.010m | MA05.010 | 41a30c27-e0fe-4bd3-ae89-54a68eb5202b | Ankle-Foot/Knee-Ankle-Foot Orthosis | Ankle-Foot/Knee-Ankle-Foot Orthosis | {"3345": {"Id":3345,"MPAttachmentLetter":"A","Title":"HCPCS CODES FOR ANKLE-FOOT/ KNEE-ANKLE FOOT ORTHOSIS","MPPolicyAttachmentInternalSourceId":10939,"PolicyAttachmentPageName":"1e0b9747-29b9-4f76-9135-ec261f44a26c"},} |
| | | 2809 | ApheresisTherapyMA06.001g | Pathology and Laboratory (06) | MA06.001g | MA06.001 | d15b4765-6ba7-4f57-9329-bde1fee15de9 | Apheresis Therapy | Apheresis Therapy | |
| | | 2529 | Apos®biomechanicalshoesystemMA05.070 | DME (05) | MA05.070 | MA05.070 | 751ca53f-d348-42c6-b5fd-c66543cefceb | Apos® biomechanical shoe system | Apos® biomechanical shoe system | |
| | | 2772 | ApplicationandRemovalofTattoosMA11.072 | Surgery (11) | MA11.072 | MA11.072 | f88dd41a-d5ac-440d-81ff-1a525c137fab | Application and Removal of Tattoos | Application and Removal of Tattoos | |
| | | 3244 | AqueousShunts,MinimallyInvasiveGlaucomaSurgeries(includingMicrostents),Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucomaMA11.105l | Surgery (11) | MA11.105l | MA11.105 | 24e92ccb-220d-4c7b-91ba-affa559ffe36 | Aqueous Shunts, Minimally Invasive Glaucoma Surgeries (including Microstents), Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | Aqueous Shunts, Minimally Invasive Glaucoma Surgeries (including Microstents), Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma | {"3245": {"Id":3245,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":10551,"PolicyAttachmentPageName":"5a05d46c-4873-4d26-9fb9-c8874bfc24ca"},} |
| | | 3010 | AsparaginaseErwiniaChrysanthemi(recombinant)-rywn(Rylaze®)MA08.085k | Pharmacy (08) | MA08.085k | MA08.085 | 5add7c67-eeab-4281-83cd-5a2df2157bf8 | Asparaginase Erwinia Chrysanthemi (recombinant)-rywn (Rylaze®) | Asparaginase Erwinia Chrysanthemi (recombinant)-rywn (Rylaze®) | |
| | | 3270 | Atezolizumab(Tecentriq®)andAtezolizumabwithHyaluronidase-tqjs(TecentriqHybreza™)MA08.127g | Pharmacy (08) | MA08.127g | MA08.127 | d433bae1-4ddf-4785-a89b-2f0b4c154a12 | Atezolizumab (Tecentriq®) and Atezolizumab with Hyaluronidase-tqjs (Tecentriq Hybreza™) | Atezolizumab (Tecentriq®) and Atezolizumab with Hyaluronidase-tqjs (Tecentriq Hybreza™) | {"3271": {"Id":3271,"MPAttachmentLetter":"A","Title":"Atezolizumab (Tecentriq®) and Atezolizumab with Hyaluronidase-tqjs (Tecentriq Hybreza™)","MPPolicyAttachmentInternalSourceId":10705,"PolicyAttachmentPageName":"5cc9c415-8033-4936-b56f-6aa71ab8f7f8"},} |
| | | 3028 | AuricularProsthesesMA05.068 | DME (05) | MA05.068 | MA05.068 | 46599454-faec-42fc-a0f8-72e9a16691ea | Auricular Prostheses | Auricular Prostheses | |
| | | 3358 | AutomaticExternalCardioverterDefibrillators(WearableandNonwearable)MA05.005h | DME (05) | MA05.005h | MA05.005 | acbe0c17-ceab-4dde-a317-78de9449a832 | Automatic External Cardioverter Defibrillators (Wearable and Nonwearable) | Automatic External Cardioverter Defibrillators (Wearable and Nonwearable) | {"3359": {"Id":3359,"MPAttachmentLetter":"A","Title":"ICD-10 codes used to represent the Wearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":11022,"PolicyAttachmentPageName":"6a093b2b-1f26-4652-9f29-8196216c535b"},"3360": {"Id":3360,"MPAttachmentLetter":"B","Title":"ICD-10 codes used to represent the Nonwearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":11023,"PolicyAttachmentPageName":"d9a9b181-d2b7-4128-a693-9abc6020c14e"},} |
| | | 2778 | AutonomicNervousSystemTestingMA07.027h | Medicine (07) | MA07.027h | MA07.027 | 0f73ec54-34df-4775-8004-f504243dcd4d | Autonomic Nervous System Testing | Autonomic Nervous System Testing | |
| | | 2559 | Avelumab(Bavencio®)MA08.122e | Pharmacy (08) | MA08.122e | MA08.122 | e4e11021-9754-41c3-b13b-c0615d61c1b1 | Avelumab (Bavencio®) | Avelumab (Bavencio®) | |
| | | 2888 | Axatilimab-csfr(Niktimvo™)forIntravenousUseMA08.180 | Pharmacy (08) | MA08.180 | MA08.180 | 42c3381d-b012-4b4e-b298-af81886f1a17 | Axatilimab-csfr (Niktimvo™) for Intravenous Use | Axatilimab-csfr (Niktimvo™) for Intravenous Use | |
| | | 1876 | BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitisorRecurrentAcuteRhinosinusitisMA11.100f | Surgery (11) | MA11.100f | MA11.100 | 3e2a9d42-9ad7-4d16-98dc-56557bded97c | Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis or Recurrent Acute Rhinosinusitis | Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis or Recurrent Acute Rhinosinusitis | |
| | | 3155 | Belantamabmafodotin-blmf(Blenrep)MA08.192a | Pharmacy (08) | MA08.192a | MA08.192 | 83a0b2ce-c2f1-49d3-810c-e97683af31b8 | Belantamab mafodotin-blmf (Blenrep) | Belantamab mafodotin-blmf (Blenrep) | |
| | | 3220 | Belimumab(Benlysta®)forIntravenousUseMA08.057d | Pharmacy (08) | MA08.057d | MA08.057 | 9bf3124b-96b9-4909-bc75-f7083a281683 | Belimumab (Benlysta®) for Intravenous Use | Belimumab (Benlysta®) for Intravenous Use | |
| | | 2958 | Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUseMA08.072p | Pharmacy (08) | MA08.072p | MA08.072 | 93d1c3a1-5222-4336-b8f7-95217b0d3de8 | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use | {"2959": {"Id":2959,"MPAttachmentLetter":"A","Title":"ICD 10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":10204,"PolicyAttachmentPageName":"84776353-d470-4d87-bbef-e3f15bd63aec"},} |
| | | 3184 | BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampusMA00.037o | Administrative (00) | MA00.037o | MA00.037 | 2aafbdb6-eff9-4ba2-b787-589ab3a367b2 | 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 | {"3185": {"Id":3185,"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 - CPT/HCPCS Codes","MPPolicyAttachmentInternalSourceId":10684,"PolicyAttachmentPageName":"133427a8-488f-446a-9fce-de588a5f7032"},} |
| | | 3297 | BioengineeredSkinSubstitutesMA11.015ah | Surgery (11) | MA11.015ah | MA11.015 | ce392f0f-f219-4954-be27-4fc63ac89c00 | Bioengineered Skin Substitutes | Bioengineered Skin Substitutes | {"3298": {"Id":3298,"MPAttachmentLetter":"A","Title":"Skin substitutes and their approved indications.","MPPolicyAttachmentInternalSourceId":10498,"PolicyAttachmentPageName":"8b08127d-c6ce-44ba-bba1-73ea2befac20"},} |
| | | 2875 | BiofeedbackTherapyMA07.010c | Medicine (07) | MA07.010c | MA07.010 | 96da06ed-00d9-4801-a10f-eca056e4efaa | Biofeedback Therapy | Biofeedback Therapy | |
| | | 3279 | BioimpedancefortheDetectionofLymphedemaMA07.052a | Medicine (07) | MA07.052a | MA07.052 | 7442f8d6-2bef-4c1c-8c27-80b3960334b3 | Bioimpedance for the Detection of Lymphedema | Bioimpedance for the Detection of Lymphedema | |
| | | 2419 | Blinatumomab(Blincyto®)MA08.058h | Pharmacy (08) | MA08.058h | MA08.058 | 8ca320a0-0572-4581-a68e-393fca7d4241 | Blinatumomab (Blincyto®) | Blinatumomab (Blincyto®) | |
| | | 3030 | Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAidsMA11.049h | Surgery (11) | MA11.049h | MA11.049 | 79a3fc93-1e11-4cb8-9bcc-cea04391d92a | Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids | Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids | |
| | | 3120 | BotulinumToxinAgentsMA08.017n | Pharmacy (08) | MA08.017n | MA08.017 | ad8008ad-02fe-4e6f-a773-b0febab233ea | Botulinum Toxin Agents | Botulinum Toxin Agents | {"3121": {"Id":3121,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":10527,"PolicyAttachmentPageName":"49fbfbcf-4211-4ae6-83e2-c2d6baff1786"},} |
| | | 2424 | BrentuximabVedotin(Adcetris®)MA08.068l | Pharmacy (08) | MA08.068l | MA08.068 | 08f7cd0d-e498-432e-a343-9dcd830131be | Brentuximab Vedotin (Adcetris®) | Brentuximab Vedotin (Adcetris®) | |
| | | 3191 | BronchialValvesMA11.020 | Surgery (11) | MA11.020 | MA11.020 | 8d8976a0-9da5-47ae-b253-76c001ae771d | Bronchial Valves | Bronchial Valves | |
| | | 3157 | BundledProcedureCodesMA00.026ab | Administrative (00) | MA00.026ab | MA00.026 | 14523d03-bffd-48b1-8e96-e42da146041c | Bundled Procedure Codes | Bundled Procedure Codes | {"3158": {"Id":3158,"MPAttachmentLetter":"D","Title":"Procedures and Services Not Eligible for Separate Reimbursement When Reported With Another Specific Procedure or Service","MPPolicyAttachmentInternalSourceId":10795,"PolicyAttachmentPageName":"7b5783df-6a8e-441f-a10a-6aa5a0ad6f9a"},"3159": {"Id":3159,"MPAttachmentLetter":"C","Title":"Procedures and Services Not Eligible for Reimbursement","MPPolicyAttachmentInternalSourceId":10796,"PolicyAttachmentPageName":"20e311ad-23a0-4ddc-845a-ff2646bf3fac"},"3160": {"Id":3160,"MPAttachmentLetter":"A","Title":"Always Bundled Procedures and Services (Status B); Bundled Procedures and Services (Status T)","MPPolicyAttachmentInternalSourceId":10797,"PolicyAttachmentPageName":"d409cf0d-1662-4bd4-bae3-534c561a7b59"},"3161": {"Id":3161,"MPAttachmentLetter":"B","Title":"Procedures and Services Not Eligible for Separate Reimbursement","MPPolicyAttachmentInternalSourceId":10798,"PolicyAttachmentPageName":"e3c60fd6-245b-46b8-9222-fc36cb533900"},} |
| | | 3212 | Burosumab-twza(Crysvita®)MA08.099b | Pharmacy (08) | MA08.099b | MA08.099 | a261a052-5961-445d-a595-5248424ff1a5 | Burosumab-twza (Crysvita®) | Burosumab-twza (Crysvita®) | |
| | | 2028 | Canakinumab(Ilaris®)MA08.101c | Pharmacy (08) | MA08.101c | MA08.101 | 640e1009-3d23-4291-9c2f-b37a382ab426 | Canakinumab (Ilaris®) | Canakinumab (Ilaris®) | {"2029": {"Id":2029,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":9690,"PolicyAttachmentPageName":"53353162-3261-4d61-a7fb-7e68dac80857"},} |
| | | 2774 | CanesandCrutchesMA05.052c | DME (05) | MA05.052c | MA05.052 | 962922a4-aef5-4689-9b1b-85ee11a271a2 | Canes and Crutches | Canes and Crutches | |
| | | 2886 | CapsuleEndoscopyMA07.022f | Medicine (07) | MA07.022f | MA07.022 | dd600a4d-bbb5-4700-93b3-8514af6588df | Capsule Endoscopy | Capsule Endoscopy | |
| | | 2854 | CardiacContractilityModulationMA05.038 | DME (05) | MA05.038 | MA05.038 | f6dc6319-3385-4d84-b540-8de9cbd22e64 | Cardiac Contractility Modulation | Cardiac Contractility Modulation | |
| | | 3367 | CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)ProgramsMA10.002h | Rehabilitation Services (10) | MA10.002h | MA10.002 | 768bc701-be28-4789-8cc2-c67f12ee0ea8 | Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs | Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs | {"3368": {"Id":3368,"MPAttachmentLetter":"A","Title":"Medically Necessary ICD-10 Codes","MPPolicyAttachmentInternalSourceId":10949,"PolicyAttachmentPageName":"f7effe71-11bf-4fbc-91a8-9c141c79a625"},} |
| | | 3300 | CareManagementandCarePlanningServicesMA00.006p | Administrative (00) | MA00.006p | MA00.006 | b432df98-8e31-4db0-a39e-f35c170d13a2 | Care Management and Care Planning Services | Care Management and Care Planning Services | |
| | | 2471 | Carfilzomib(Kyprolis®)MA08.062k | Pharmacy (08) | MA08.062k | MA08.062 | 2cc54b39-ae64-4294-a882-94ec127233cc | Carfilzomib (Kyprolis®) | Carfilzomib (Kyprolis®) | |
| | | 3124 | CastandSplintApplicationsandAssociatedSuppliesMA00.012d | Administrative (00) | MA00.012d | MA00.012 | 6f269645-e9cc-4e62-8b4e-616ddead622d | Cast and Splint Applications and Associated Supplies | Cast and Splint Applications and Associated Supplies | {"3125": {"Id":3125,"MPAttachmentLetter":"A","Title":"Procedures Related to Cast and Splint Applications and Associated Supplies","MPPolicyAttachmentInternalSourceId":10710,"PolicyAttachmentPageName":"94ae0fa6-112c-454a-a4b7-2d5cafa003c7"},} |
| | | 3036 | CataractSurgeryMA11.054e | Surgery (11) | MA11.054e | MA11.054 | 90dc7037-caf3-4ee2-b09c-234293373a47 | Cataract Surgery | Cataract Surgery | {"3037": {"Id":3037,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":10687,"PolicyAttachmentPageName":"ac088438-3feb-4833-86df-82c7dbcc646b"},} |
| | | 3376 | CatheterAblationofCardiacArrhythmiasMA11.060i | Surgery (11) | MA11.060i | MA11.060 | 005f3f23-b17b-4144-a1d9-b4116d087470 | Catheter Ablation of Cardiac Arrhythmias | Catheter Ablation of Cardiac Arrhythmias | |
| | | 2577 | Cemiplimab-rwlc(Libtayo®)MA08.124e | Pharmacy (08) | MA08.124e | MA08.124 | 193f5d5b-8093-4d08-804c-65da60b3134f | Cemiplimab-rwlc (Libtayo®) | Cemiplimab-rwlc (Libtayo®) | |
| | | 3186 | Cerliponasealfa(Brineura®)MA08.089d | Pharmacy (08) | MA08.089d | MA08.089 | 471915df-cea3-4d3b-9fa0-618c634e2a9d | Cerliponase alfa (Brineura®) | Cerliponase alfa (Brineura®) | {"3187": {"Id":3187,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements for Cerliponase alfa (Brineura®)","MPPolicyAttachmentInternalSourceId":10715,"PolicyAttachmentPageName":"884cf4b9-19a6-4d27-8c0d-0ac5ec2c7373"},} |
| | | 2530 | CervicalTractionDevicesforIn-homeUseMA05.009b | DME (05) | MA05.009b | MA05.009 | 4f290435-4662-446d-bbe8-26fa84229cc0 | Cervical Traction Devices for In-home Use | Cervical Traction Devices for In-home Use | |
| | | 3391 | Cetuximab(Erbitux®)MA08.031h | Pharmacy (08) | MA08.031h | MA08.031 | 6e46d9fe-1c35-4d93-8756-912ed4435d4a | Cetuximab (Erbitux®) | Cetuximab (Erbitux®) | {"3392": {"Id":3392,"MPAttachmentLetter":"B","Title":"ICD-10 Codes for Cetuximab (Erbitux®)","MPPolicyAttachmentInternalSourceId":10962,"PolicyAttachmentPageName":"76ed4b02-764d-48dc-83cf-18353c05922b"},"3393": {"Id":3393,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":10963,"PolicyAttachmentPageName":"d1b26b02-b7fb-45a0-a186-b37260c2b58b"},} |
| | | 2779 | ChemicalPeelsMA11.103c | Surgery (11) | MA11.103c | MA11.103 | d427612e-03ff-41cb-998f-d783a2860923 | Chemical Peels | Chemical Peels | |
| | | 2746 | ChimericAntigenReceptor(CART)Therapy:YescartaTecartus,Breyanzi,KymriahandAucatzylMA08.093q | Pharmacy (08) | MA08.093q | MA08.093 | ed98942f-28e7-4647-896a-66a6f8dd7962 | Chimeric Antigen Receptor (CART) Therapy: Yescarta Tecartus, Breyanzi, Kymriah and Aucatzyl | Chimeric Antigen Receptor (CART) Therapy: Yescarta Tecartus, Breyanzi, Kymriah and Aucatzyl | |
| | | 2747 | ChimericAntigenReceptorT-cell(CAR-T)Therapy:Carvykti®andAbecma®MA08.190 | Pharmacy (08) | MA08.190 | MA08.190 | 051cfa01-4c48-4aaf-9372-77bcc638a5e7 | Chimeric Antigen Receptor T-cell (CAR-T) Therapy: Carvykti® and Abecma® | Chimeric Antigen Receptor T-cell (CAR-T) Therapy: Carvykti® and Abecma® | |
| | | 3336 | ChiropracticServicesMA10.004i | Rehabilitation Services (10) | MA10.004i | MA10.004 | de6d7618-a4f0-4a6d-9b85-84202c07165d | Chiropractic Services | Chiropractic Services | |
| | | 2642 | CoagulationFactorsMA08.004z | Pharmacy (08) | MA08.004z | MA08.004 | 4abbc724-be9c-450f-a8f6-5fbe74484033 | Coagulation Factors | Coagulation Factors | |
| | | 2487 | Cobalamin(VitaminB12),FolicAcid,andHomocysteineTestingMA06.032a | Pathology and Laboratory (06) | MA06.032a | MA06.032 | 47d731d2-4723-459c-a2dd-59763d549daa | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing | {"2488": {"Id":2488,"MPAttachmentLetter":"A","Title":"ICD 10 CODES FOR MEDICALLY NECESSARY COBALAMIN (VITAMIN B12), FOLIC ACID, AND/OR HOMOCYSTEINE TESTING (CPT CODES 82607, 82746, AND 83090)","MPPolicyAttachmentInternalSourceId":10194,"PolicyAttachmentPageName":"c5274e8d-3cf4-461e-8f66-b2f2faf173fd"},} |
| | | 3040 | CochlearImplantationMA11.039e | Surgery (11) | MA11.039e | MA11.039 | 3d3af748-24d4-400b-a350-953d56152174 | Cochlear Implantation | Cochlear Implantation | |
| | | 3195 | Collagenaseclostridiumhistolyticum(Xiaflex®),collagenaseclostridiumhistolyticum-aaes(Qwo®)MA08.128 | Pharmacy (08) | MA08.128 | MA08.128 | b0f30529-a44b-44ae-b6bf-6d0f5abaf1b9 | Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo®) | Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo®) | |
| | | 2782 | CommodeChairsMA05.036c | DME (05) | MA05.036c | MA05.036 | 9ca7eb73-e72f-4330-ad21-8b3e938e736a | Commode Chairs | Commode Chairs | |
| | | 1065 | ComplementaryandIntegrativeHealthServicesMA12.001e | Miscellaneous (12) | MA12.001e | MA12.001 | 2b9ece34-5173-46a4-821e-fa55c65cd42a | Complementary and Integrative Health Services | Complementary and Integrative Health Services | |
| | | 3099 | CompositeTissueAllotransplantationoftheHand(s)andFaceMA11.112 | Surgery (11) | MA11.112 | MA11.112 | 5516d269-adbe-4de6-b70c-14a8ca486219 | Composite Tissue Allotransplantation of the Hand(s) and Face | Composite Tissue Allotransplantation of the Hand(s) and Face | |
| | | 3104 | CompressionGarmentsMA05.045g | DME (05) | MA05.045g | MA05.045 | 597b3f10-2706-4d49-93c4-152fad0d9196 | Compression Garments | Compression Garments | |
| | | 3211 | Computer-AidedDetection(CAD)SystemforUsewithChestRadiographsMA09.014b | Radiology (09) | MA09.014b | MA09.014 | 90bac643-6c11-450b-94b7-99cec261e324 | Computer-Aided Detection (CAD) System for Use with Chest Radiographs | Computer-Aided Detection (CAD) System for Use with Chest Radiographs | |
| | | 2765 | Computer-AssistedMusculoskeletalSurgicalNavigationalOrthopedicProcedureMA11.088c | Surgery (11) | MA11.088c | MA11.088 | 6afaf555-2468-484e-8413-2dff01ca6a41 | Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure | Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure | |
| | | 3287 | ContinuousGlucoseMonitorsandHomeBloodGlucoseMonitorsandSuppliesMA00.002t | Administrative (00) | MA00.002t | MA00.002 | 850f70d7-d561-4d61-815d-fa1e4685aedb | Continuous Glucose Monitors and Home Blood Glucose Monitors and Supplies | Continuous Glucose Monitors and Home Blood Glucose Monitors and Supplies | {"3288": {"Id":3288,"MPAttachmentLetter":"B","Title":"Implantable Continuous Glucose Monitors (I-CGM)","MPPolicyAttachmentInternalSourceId":10757,"PolicyAttachmentPageName":"11bb81c4-1a20-41a7-ab27-93af1e902436"},"3289": {"Id":3289,"MPAttachmentLetter":"A","Title":"ICD10: Long-Term Interstitial CGMS (Non-Implantable)","MPPolicyAttachmentInternalSourceId":10758,"PolicyAttachmentPageName":"ac3f8199-9983-4c5b-ace5-3c7389a49c7c"},} |
| | | 1780 | ContrastAgentsUsedinConjunctionwithEchocardiographyMA09.004c | Radiology (09) | MA09.004c | MA09.004 | 842dcaa2-0a33-4711-a694-34e27677d4f9 | Contrast Agents Used in Conjunction with Echocardiography | Contrast Agents Used in Conjunction with Echocardiography | |
| | | 3280 | CornealPachymetryUsingUltrasoundMA07.046h | Medicine (07) | MA07.046h | MA07.046 | 61218214-5a3f-4bd4-b3ee-c11fd48008a4 | Corneal Pachymetry Using Ultrasound | Corneal Pachymetry Using Ultrasound | {"3281": {"Id":3281,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes Eligible to be Reported for Corneal Pachymetry Using Ultrasound","MPPolicyAttachmentInternalSourceId":10772,"PolicyAttachmentPageName":"25877884-29d1-42af-b49a-c4a2a3221444"},} |
| | | 3054 | Cosibelimab-ipdl(Unloxcyt™)MA08.184a | Pharmacy (08) | MA08.184a | MA08.184 | cd3b0151-80e6-4696-9099-af9f7bfd68bd | Cosibelimab-ipdl (Unloxcyt™) | Cosibelimab-ipdl (Unloxcyt™) | |
| | | 3107 | CosmeticProceduresMA12.009a | Miscellaneous (12) | MA12.009a | MA12.009 | 1f261ac5-33b1-4933-8d58-8276f6f46ba0 | Cosmetic Procedures | Cosmetic Procedures | |
| | | 1506 | CoverageofMedicalDevicesMA05.040b | DME (05) | MA05.040b | MA05.040 | 6c112be2-1a7e-41f5-904b-82a4223bec8b | Coverage of Medical Devices | Coverage of Medical Devices | |
| | | 3332 | CranialElectrotherapyStimulationMA05.066d | DME (05) | MA05.066d | MA05.066 | 326b3aba-e86d-49b8-9a44-641c5d22ddb9 | Cranial Electrotherapy Stimulation | Cranial Electrotherapy Stimulation | |
| | | 3106 | Crizanlizumab-tmca(Adakveo®) MA08.109c | Pharmacy (08) | MA08.109c | MA08.109 | dc63acf0-fa5a-42b6-8ef1-0658999a340b | Crizanlizumab-tmca (Adakveo®) | Crizanlizumab-tmca (Adakveo®) | |
| | | 2009 | Crovalimab-akkz(PiaSky)MA08.178 | Pharmacy (08) | MA08.178 | MA08.178 | 167a066b-85de-4200-8a02-d49b264809f1 | Crovalimab-akkz (PiaSky) | Crovalimab-akkz (PiaSky) | |
| | | 2706 | CryosurgicalAblationoftheProstateGlandMA11.022a | Surgery (11) | MA11.022a | MA11.022 | 5ae0b794-81ea-43b8-800e-25a499d06b74 | Cryosurgical Ablation of the Prostate Gland | Cryosurgical Ablation of the Prostate Gland | |
| | | 3263 | Daratumumab(Darzalex®),DaratumumabandHyaluronidase-fihj(DarzalexFaspro®)MA08.079n | Pharmacy (08) | MA08.079n | MA08.079 | a5f779ca-3075-474a-a8a9-f4322ce237f0 | Daratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®) | Daratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®) | {"3264": {"Id":3264,"MPAttachmentLetter":"A","Title":"Duration of Treatment Requirements For Daratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®)","MPPolicyAttachmentInternalSourceId":10706,"PolicyAttachmentPageName":"ed7adcbc-92f1-463c-bece-87225124b365"},} |
| | | 2443 | Datopotamabderuxtecan(Datroway®)MA08.185 | Pharmacy (08) | MA08.185 | MA08.185 | af2c5712-4282-4d3d-93f4-696bca4e9650 | Datopotamab deruxtecan (Datroway®) | Datopotamab deruxtecan (Datroway®) | |
| | | 3305 | DayRehabilitationMA10.005c | Rehabilitation Services (10) | MA10.005c | MA10.005 | 4267e37f-c91e-44b8-87cc-f3066341138e | Day Rehabilitation | Day Rehabilitation | |
| | | 2879 | DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNailsMA11.014h | Surgery (11) | MA11.014h | MA11.014 | c4598c0d-e799-43f8-ae81-7582556a6d1f | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails | {"2880": {"Id":2880,"MPAttachmentLetter":"E","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (S86.892A - Z79.01), Continued","MPPolicyAttachmentInternalSourceId":10475,"PolicyAttachmentPageName":"75c15b7f-b7af-49df-a750-4979580108b9"},"2881": {"Id":2881,"MPAttachmentLetter":"B","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E10.22 - E13.3512), Continued","MPPolicyAttachmentInternalSourceId":10476,"PolicyAttachmentPageName":"17e69e51-a46b-4cec-bd02-b097f437266a"},"2882": {"Id":2882,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (A30.0 -E10.21)","MPPolicyAttachmentInternalSourceId":10477,"PolicyAttachmentPageName":"ec64dbf2-efad-40b1-82d9-c066de3228b5"},"2883": {"Id":2883,"MPAttachmentLetter":"D","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (I87.099 - S86.891S), Continued","MPPolicyAttachmentInternalSourceId":10478,"PolicyAttachmentPageName":"61fdec43-8707-49be-afbc-c6e674eabccc"},"2884": {"Id":2884,"MPAttachmentLetter":"C","Title":"ICD-10 CM Codes Eligible to be Reported for Debridement of mycotic hypertrophic toe nails (E13.3513 - I87.093), Continued","MPPolicyAttachmentInternalSourceId":10479,"PolicyAttachmentPageName":"176862f9-66e5-4aaf-8485-693eaee4ce6b"},} |
| | | 3333 | DeepBrainStimulation(DBS)MA11.005h | Surgery (11) | MA11.005h | MA11.005 | f0d9fa1d-2c0c-4b7d-b7fd-5ae93d0981f2 | Deep Brain Stimulation (DBS) | Deep Brain Stimulation (DBS) | |
| | | 3406 | Denosumab(Prolia®,Xgeva®)andrelatedbiosimilars,andRomosozumab-aqqg(Evenity®)MA08.052r | Pharmacy (08) | MA08.052r | MA08.052 | 34eee325-b14f-41bc-adec-f86a9934120a | Denosumab (Prolia®, Xgeva®) and related biosimilars, and Romosozumab-aqqg (Evenity®) | Denosumab (Prolia®, Xgeva®) and related biosimilars, and Romosozumab-aqqg (Evenity®) | {"3407": {"Id":3407,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes","MPPolicyAttachmentInternalSourceId":10924,"PolicyAttachmentPageName":"b35acb86-ac21-4cc2-b5e5-cb320b10dbdb"},} |
| | | 3335 | DermabrasionforRhinophyma,Septoplasty,Rhinoplasty,andSeptorhinoplastyMA11.099f | Surgery (11) | MA11.099f | MA11.099 | a4085fc4-1a6e-41dc-ba25-ab634c49fc31 | Dermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and Septorhinoplasty | Dermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and Septorhinoplasty | |
| | | 2693 | DirectAccesstoObstetrics/Gynecology(OB/GYN)ServicesMA00.032h | Administrative (00) | MA00.032h | MA00.032 | 4c30fb48-2d01-4abe-81b8-817317bf3763 | Direct Access to Obstetrics/Gynecology (OB/GYN) Services | Direct Access to Obstetrics/Gynecology (OB/GYN) Services | {} |
| | | 3066 | DirectEndoscopicNecrosectomy(DEN)fortheTreatmentofPancreaticNecrosisMA11.115 | Surgery (11) | MA11.115 | MA11.115 | 8afdf536-206b-49bf-a942-506fd060bf9c | Direct Endoscopic Necrosectomy (DEN) for the Treatment of Pancreatic Necrosis | Direct Endoscopic Necrosectomy (DEN) for the Treatment of Pancreatic Necrosis | |
| | | 2905 | Dofetilide(Tikosyn®)UseintheInpatientSettingMA08.021c | Pharmacy (08) | MA08.021c | MA08.021 | 266d6272-4353-40bb-b1bd-66cf0b68ea74 | Dofetilide (Tikosyn®) Use in the Inpatient Setting | Dofetilide (Tikosyn®) Use in the Inpatient Setting | |
| | | 3053 | Dostarlimab-gxly(Jemperli)MA08.136g | Pharmacy (08) | MA08.136g | MA08.136 | e37b56e0-b9e0-44c0-bc54-21420443054f | Dostarlimab-gxly (Jemperli) | Dostarlimab-gxly (Jemperli) | |
| | | 2827 | Drug-ElutingBeadsandBlandEmbolizationfortheTreatmentofHepaticMalignanciesMA07.041c | Medicine (07) | MA07.041c | MA07.041 | c29718ec-3d4d-489b-8417-cdfc26f95a25 | Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies | Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies | |
| | | 2411 | DurableMedicalEquipment(DME)MA05.044v | DME (05) | MA05.044v | MA05.044 | 9b4b85f5-5d32-41e2-9f04-5f1e429a4d2f | Durable Medical Equipment (DME) | Durable Medical Equipment (DME) | {"2412": {"Id":2412,"MPAttachmentLetter":"A2","Title":"Equipment that Meets the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":10136,"PolicyAttachmentPageName":"68df0bde-42e2-444e-8fb1-81ff57ee9747"},"2413": {"Id":2413,"MPAttachmentLetter":"B","Title":"Items that Do Not Meet the Definition of Durable Medical Equipment (DME) or Excluded from Coverage by Medicare","MPPolicyAttachmentInternalSourceId":10137,"PolicyAttachmentPageName":"cb366a4e-4e8c-4047-b6ca-1c206af4b00d"},"2414": {"Id":2414,"MPAttachmentLetter":"A1","Title":"Equipment that Meets the Definition of Durable Medical Equipment (DME)","MPPolicyAttachmentInternalSourceId":10138,"PolicyAttachmentPageName":"984d8aef-d271-475d-a8a9-63aaef94f602"},} |
| | | 1507 | DurableMedicalEquipment(DME)NotSubjecttoaRentaltoPurchaseMaximumMA05.028e | DME (05) | MA05.028e | MA05.028 | 7961a20b-70b6-4d08-a362-6da61ef8bc97 | Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum | Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum | |
| | | 3268 | Durvalumab(Imfinzi®)andTremelimumab-actl(Imjudo®)MA08.123f | Pharmacy (08) | MA08.123f | MA08.123 | 8d060d93-cd07-4eac-9ae0-70bd22ecf9bf | Durvalumab (Imfinzi®) and Tremelimumab-actl (Imjudo®) | Durvalumab (Imfinzi®) and Tremelimumab-actl (Imjudo®) | {"3269": {"Id":3269,"MPAttachmentLetter":"A","Title":"Duration of Treatment Requirements For Durvalumab (Imfinzi®)","MPPolicyAttachmentInternalSourceId":10702,"PolicyAttachmentPageName":"a29b8f27-a910-40da-b214-a8e85d237e6c"},} |
| | | 3198 | Eculizumab(Soliris®)andRelatedBiosimilars,Ravulizumab-cwvz(Ultomiris™)forintravenousadministrationMA08.044l | Pharmacy (08) | MA08.044l | MA08.044 | d09272f2-22fb-44e8-8ecc-f63d8cbf6237 | Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™) for intravenous administration | Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™) for intravenous administration | {"3199": {"Id":3199,"MPAttachmentLetter":"A","Title":"Dosing and Frequency","MPPolicyAttachmentInternalSourceId":10713,"PolicyAttachmentPageName":"3f778055-270f-4fb3-ba52-f1b645c36fc2"},} |
| | | 3149 | Efbemalenograstimalfa-vuxw(Ryzneuta®),Eflapegrastim-xnst(Rolvedon™),Pegfilgrastim(Neulasta®)andRelatedBiosimilarsMA08.082q | Pharmacy (08) | MA08.082q | MA08.082 | b5d85f20-d2ee-4122-9e23-560d06216024 | Efbemalenograstim alfa-vuxw (Ryzneuta®), Eflapegrastim-xnst (Rolvedon™), Pegfilgrastim (Neulasta®) and Related Biosimilars | Efbemalenograstim alfa-vuxw (Ryzneuta®), Eflapegrastim-xnst (Rolvedon™), Pegfilgrastim (Neulasta®) and Related Biosimilars | {"3150": {"Id":3150,"MPAttachmentLetter":"A","Title":"EXAMPLES OF DISEASE SETTINGS AND CHEMOTHERAPY REGIMENS WITH A HIGH (>20%) OR INTERMEDIATE (10-20%) RISK FOR FEBRILE NEUTROPENIA","MPPolicyAttachmentInternalSourceId":10760,"PolicyAttachmentPageName":"7ec7c781-3985-4f1c-bedd-784678ff50ea"},} |
