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c78d0ed5-4c6d-433d-9d8b-657b147bdc85.aspx
  
145Abatacept(Orencia®)forInjectionforIntravenousUseMA08.028iPharmacy (08)MA08.028iMA08.028c78d0ed5-4c6d-433d-9d8b-657b147bdc85Abatacept (Orencia®) for Injection for Intravenous UseAbatacept (Orencia®) for Injection for Intravenous Use
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1198AbortionMA11.010dSurgery (11)MA11.010dMA11.010cc1a6539-080b-46db-b903-d4804467b8faAbortionAbortion
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794AcupunctureMA12.004cMiscellaneous (12)MA12.004cMA12.0045f7e1494-96da-48b4-93ce-192427fc02d6AcupunctureAcupuncture
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969AcuteCareFacilityInpatientTransfersMA12.003bMiscellaneous (12)MA12.003bMA12.00340a201d5-c72e-4858-8d07-5423c65af08dAcute Care Facility Inpatient TransfersAcute Care Facility Inpatient Transfers
95b7c282-9261-42ad-8df3-2ab8f462523c.aspx
  
1255ADAMTS13,recombinant-krhn(Adzynma)MA08.171Pharmacy (08)MA08.171MA08.17195b7c282-9261-42ad-8df3-2ab8f462523cADAMTS13, recombinant-krhn (Adzynma)ADAMTS13, recombinant-krhn (Adzynma)
c16fa0c8-7e0b-41bf-b18d-34c34971191f.aspx
  
856Ado-TrastuzumabEmtansine(Kadcyla®)MA08.066gPharmacy (08)MA08.066gMA08.066c16fa0c8-7e0b-41bf-b18d-34c34971191fAdo-Trastuzumab Emtansine (Kadcyla®)Ado-Trastuzumab Emtansine (Kadcyla®)
{"857": {"Id":857,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":8440,"PolicyAttachmentPageName":"62ca80d5-8705-423a-8dd1-972f9aa029b6"},}
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445Agalsidasebeta(Fabrazyme®)MA08.033cPharmacy (08)MA08.033cMA08.033cebae34d-a86a-4fd1-8dcf-98a57f509ee7Agalsidase beta (Fabrazyme®)Agalsidase beta (Fabrazyme®)
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1148AirAmbulanceServicesMA12.007bMiscellaneous (12)MA12.007bMA12.00766c3e611-3717-4969-b891-61d21233a143Air Ambulance ServicesAir Ambulance Services
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977Alemtuzumab(Lemtrada®)MA08.015dPharmacy (08)MA08.015dMA08.015cd081d46-88c8-49fc-9358-495cc20afd4aAlemtuzumab (Lemtrada®)Alemtuzumab (Lemtrada®)
ae9a96dd-7fcc-42dd-8131-748117e301e2.aspx
  
993Alglucosidasealfa(e.g.,Lumizyme®),Avalglucosidasealfa-ngpt(Nexviazyme®),Cipaglucosidasealfa-atga(Pombiliti™)MA08.036gPharmacy (08)MA08.036gMA08.036ae9a96dd-7fcc-42dd-8131-748117e301e2Alglucosidase 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™ )
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1024AllergyImmunotherapyMA07.055dMedicine (07)MA07.055dMA07.0557c1d9cf9-dd9c-4e19-924e-ad01a9b72bdaAllergy ImmunotherapyAllergy Immunotherapy
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1011Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C,AralastNP,Glassia,Zemaira)MA08.050bPharmacy (08)MA08.050bMA08.05093d63acf-a8cc-41bc-a2c5-18238795ccfbAlpha 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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1205AlwaysBundledProcedureCodesMA00.026uAdministrative (00)MA00.026uMA00.026fb0415f4-080c-4653-a23c-1a905adb9d8cAlways Bundled Procedure CodesAlways Bundled Procedure Codes
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829AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)DevicesMA07.005cMedicine (07)MA07.005cMA07.0050965b016-d0af-46b4-8b97-9e4f7af19146Ambulatory 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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873AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)MonitoringMA07.026pMedicine (07)MA07.026pMA07.02674d09c5f-1f0d-4d2b-b995-f8fc6198197aAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
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1081Amivantamab-vmjw(Rybrevant®)MA08.148aPharmacy (08)MA08.148aMA08.14882bf3454-ff11-494a-82fc-4a277c9e2c6cAmivantamab-vmjw (Rybrevant®)Amivantamab-vmjw (Rybrevant®)
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1123AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagementMA01.008bAnesthesia (01)MA01.008bMA01.0089ff8c92f-88b3-41bb-9512-a104871610a8Anesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint ManagementAnesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management
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1137Anifrolumab-fnia(Saphnelo®)MA08.140cPharmacy (08)MA08.140cMA08.140ffb29139-c6b9-4389-9ceb-5670bc56e674Anifrolumab-fnia (Saphnelo®)Anifrolumab-fnia (Saphnelo®)
3279c85b-4f6c-4134-87cb-1c314c3f60c0.aspx
  
928Ankle-Foot/Knee-Ankle-FootOrthosesMA05.010jDME (05)MA05.010jMA05.0103279c85b-4f6c-4134-87cb-1c314c3f60c0Ankle-Foot/Knee-Ankle-Foot OrthosesAnkle-Foot/Knee-Ankle-Foot Orthoses
{"929": {"Id":929,"MPAttachmentLetter":"A","Title":"HCPCS CODES FOR ANKLE-FOOT/ KNEE-ANKLE FOOT ORTHOSIS","MPPolicyAttachmentInternalSourceId":8451,"PolicyAttachmentPageName":"9fca7e50-d4e4-4ead-a708-5f649d046039"},}
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165ApheresisTherapyMA06.001ePathology and Laboratory (06)MA06.001eMA06.00183351e2c-0a5c-49e3-bca7-f333d1078e85Apheresis TherapyApheresis Therapy
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618Apos®biomechanicalshoesystemMA05.070DME (05)MA05.070MA05.07047c99712-e793-41e9-896f-5bb670f548c6Apos® biomechanical shoe systemApos® biomechanical shoe system
c3542857-3c91-4a43-90c5-1f396b6d349e.aspx
  
798ApplicationandRemovalofTattoosMA11.072Surgery (11)MA11.072MA11.072c3542857-3c91-4a43-90c5-1f396b6d349eApplication and Removal of TattoosApplication and Removal of Tattoos
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1089AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucomaMA11.105jSurgery (11)MA11.105jMA11.105e09477ca-37b6-4df8-949c-3203118199dbAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
{"1090": {"Id":1090,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":8592,"PolicyAttachmentPageName":"c47da178-16d6-48ea-a433-139702744bf4"},}
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515ArtificialIntervertebralLumbarDiscInsertionMA11.114bSurgery (11)MA11.114bMA11.1145fa4dad7-a936-4c6f-b09e-1871181da1f7Artificial Intervertebral Lumbar Disc InsertionArtificial Intervertebral Lumbar Disc Insertion
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90AsparaginaseErwiniaChrysanthemi(Erwinaze®),asparaginaseerwiniachrysanthemi(recombinant)-rywn(Rylaze®)MA08.085gPharmacy (08)MA08.085gMA08.085bbb2ec04-6a36-462b-b4e8-4bf1b585ef3aAsparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze®) Asparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze®)
470a7101-b73c-4c56-a95d-c6d00feed802.aspx
  
174Atezolizumab(Tecentriq®)MA08.127cPharmacy (08)MA08.127cMA08.127470a7101-b73c-4c56-a95d-c6d00feed802Atezolizumab (Tecentriq®)Atezolizumab (Tecentriq®)
{"175": {"Id":175,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":7935,"PolicyAttachmentPageName":"2a674725-e065-4aeb-ac7d-90d71ca86c29"},}
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1078AuricularProsthesesMA05.068DME (05)MA05.068MA05.0681196f21f-3450-490c-852b-febc54f66776Auricular ProsthesesAuricular Prostheses
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176AutomaticExternalCardioverterDefibrillators(WearableandNonwearable)MA05.005gDME (05)MA05.005gMA05.005fd4b92c2-e09e-49c1-aade-91437bc8c2efAutomatic External Cardioverter Defibrillators (Wearable and Nonwearable)Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
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970AutonomicNervousSystemTestingMA07.027fMedicine (07)MA07.027fMA07.027395653c6-5556-4b09-8bb6-9f5cbb54d2ddAutonomic Nervous System TestingAutonomic Nervous System Testing
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739Avelumab(Bavencio®)MA08.122cPharmacy (08)MA08.122cMA08.12265770840-7606-4b9c-9fc4-1a8d5cdf6a68Avelumab (Bavencio®)Avelumab (Bavencio®)
{"740": {"Id":740,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":8158,"PolicyAttachmentPageName":"0ce161e8-c92b-462c-933c-0a3ed2885ae9"},}
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453BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitisMA11.100eSurgery (11)MA11.100eMA11.1004ec6f182-b318-469b-b306-43eb105418a4Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic RhinosinusitisBalloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
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1069Belimumab(Benlysta®)forIntravenousUseMA08.057dPharmacy (08)MA08.057dMA08.057ea8f920a-fc0b-497b-ad5e-a25e4944e36fBelimumab (Benlysta®) for Intravenous UseBelimumab (Benlysta®) for Intravenous Use
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435Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUseMA08.072mPharmacy (08)MA08.072mMA08.0720cef7ca4-a77e-4393-ae91-438493192dbeBevacizumab (Avastin®) and Related Biosimilars For Oncologic UseBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
{"436": {"Id":436,"MPAttachmentLetter":"B","Title":"ICD 10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":8155,"PolicyAttachmentPageName":"fdf5c494-26dc-4cd0-b7ad-c7d899f1080d"},"437": {"Id":437,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements","MPPolicyAttachmentInternalSourceId":8156,"PolicyAttachmentPageName":"f2633c9a-36db-450b-b34b-725a855121ce"},}
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35BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampusMA00.037lAdministrative (00)MA00.037lMA00.037a943aaee-c928-4c2c-beee-17218edad0c2Billing 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
{"36": {"Id":36,"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":7873,"PolicyAttachmentPageName":"a514181b-b263-4d9c-88cf-7d960f6de980"},}
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1133BiofeedbackTherapyMA07.010cMedicine (07)MA07.010cMA07.0109092ab12-85f9-4db7-af18-4a5b65ba07f0Biofeedback TherapyBiofeedback Therapy
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1292BioimpedancefortheDetectionofLymphedemaMA07.052Medicine (07)MA07.052MA07.0527afcb7bb-2baf-4668-9a41-2b522051ffecBioimpedance for the Detection of LymphedemaBioimpedance for the Detection of Lymphedema
cec9b72e-baaf-485a-bae9-786ae6020695.aspx
  
331Blepharoplasty,RepairofBlepharoptosis,RepairofBrowPtosis,andCanthoplasty/CanthopexyMA11.047dSurgery (11)MA11.047dMA11.047cec9b72e-baaf-485a-bae9-786ae6020695Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/CanthopexyBlepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
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454Blinatumomab(Blincyto®)MA08.058fPharmacy (08)MA08.058fMA08.058a4c5d6e6-affe-4ced-8308-084c9c9be6b4Blinatumomab (Blincyto®) Blinatumomab (Blincyto®)
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989Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAidsMA11.049gSurgery (11)MA11.049gMA11.0492098fab0-09bc-4325-aba2-2b77632a83b2Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing AidsBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
caa652b3-02e8-4521-bb10-d3acd06f60d9.aspx
  
1052BotulinumToxinAgentsMA08.017kPharmacy (08)MA08.017kMA08.017caa652b3-02e8-4521-bb10-d3acd06f60d9Botulinum Toxin AgentsBotulinum Toxin Agents
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728BrentuximabVedotin(Adcetris®)MA08.068iPharmacy (08)MA08.068iMA08.0686b7ada7d-6cf4-4a75-b3ca-73aa5c8dc08eBrentuximab Vedotin (Adcetris®)Brentuximab Vedotin (Adcetris®)
{"729": {"Id":729,"MPAttachmentLetter":"A","Title":"ICD 10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":7785,"PolicyAttachmentPageName":"b95f3feb-558a-4cbb-996f-e24227c06f0f"},}
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1067BronchialValvesMA11.020Surgery (11)MA11.020MA11.02062a855de-c1ea-4d37-9b01-a8d408546250Bronchial ValvesBronchial Valves
cd48927f-ea18-4d21-a20f-fc64084e9fb2.aspx
  
1025Burosumab-twza(Crysvita®)MA08.099bPharmacy (08)MA08.099bMA08.099cd48927f-ea18-4d21-a20f-fc64084e9fb2Burosumab-twza (Crysvita®)Burosumab-twza (Crysvita®)
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67Canakinumab(Ilaris®)MA08.101bPharmacy (08)MA08.101bMA08.10165d5da76-4026-4359-8b9f-bb8e36f6d124Canakinumab (Ilaris®)Canakinumab (Ilaris®)
90be0df6-4917-4222-a90b-99f6461b61f8.aspx
  
769CanesandCrutchesMA05.052bDME (05)MA05.052bMA05.05290be0df6-4917-4222-a90b-99f6461b61f8Canes and CrutchesCanes and Crutches
dabf0152-819f-40c4-8150-035de6fa9461.aspx
  
788CapsuleEndoscopyMA07.022eMedicine (07)MA07.022eMA07.022dabf0152-819f-40c4-8150-035de6fa9461Capsule EndoscopyCapsule Endoscopy
955aca1a-8275-47f3-9a8f-0f6d2682d8eb.aspx
  
851CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)ProgramsMA10.002fRehabilitation Services (10)MA10.002fMA10.002955aca1a-8275-47f3-9a8f-0f6d2682d8ebCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) ProgramsCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
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758CareManagementandCarePlanningServicesMA00.006nAdministrative (00)MA00.006nMA00.00601b0b8c2-eef7-4039-99cd-dae23b2c63e8Care Management and Care Planning ServicesCare Management and Care Planning Services
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637Carfilzomib(Kyprolis)MA08.062hPharmacy (08)MA08.062hMA08.062e398b664-20bc-4529-b33b-7b500da57db8Carfilzomib (Kyprolis)Carfilzomib (Kyprolis)
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39CastandSplintApplicationsandAssociatedSuppliesMA00.012cAdministrative (00)MA00.012cMA00.012bda6ce16-012b-4729-b2f6-1fc760164679Cast and Splint Applications and Associated SuppliesCast and Splint Applications and Associated Supplies
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1138CataractSurgeryMA11.054eSurgery (11)MA11.054eMA11.0546d9edd1a-96ab-4fe5-b196-e98b567febd4Cataract SurgeryCataract Surgery
{"1139": {"Id":1139,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":8500,"PolicyAttachmentPageName":"2c59af64-e765-49f6-a784-b795ea526113"},}
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334CatheterAblationofCardiacArrhythmiasMA11.060gSurgery (11)MA11.060gMA11.060ff571ab5-803e-4115-98d9-d2bedd280117Catheter Ablation of Cardiac ArrhythmiasCatheter Ablation of Cardiac Arrhythmias
6ea90eb0-52f4-4d24-a70d-9dac5c7c22de.aspx
  
181Cemiplimab-rwlc(Libtayo®)MA08.124cPharmacy (08)MA08.124cMA08.1246ea90eb0-52f4-4d24-a70d-9dac5c7c22deCemiplimab-rwlc (Libtayo®)Cemiplimab-rwlc (Libtayo®)
b45f74bc-8810-436d-bb2c-24e6eadc8335.aspx
  
580Cerliponasealfa(Brineura®)MA08.089cPharmacy (08)MA08.089cMA08.089b45f74bc-8810-436d-bb2c-24e6eadc8335Cerliponase alfa (Brineura®)Cerliponase alfa (Brineura®)
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182CervicalTractionDevicesforIn-homeUseMA05.009aDME (05)MA05.009aMA05.00978002a30-681b-4bd3-806f-5801a06f1502Cervical Traction Devices for In-home UseCervical Traction Devices for In-home Use
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819Cetuximab(Erbitux®)MA08.031gPharmacy (08)MA08.031gMA08.031a1c42244-6455-4cc1-8f06-d27da3998595Cetuximab (Erbitux®)Cetuximab (Erbitux®)
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183ChemicalPeelsMA11.103bSurgery (11)MA11.103bMA11.1030ba008b1-a216-4c89-b43e-259b874b6c3aChemical PeelsChemical Peels
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1199ChimericAntigenReceptor(CAR)TherapyMA08.093mPharmacy (08)MA08.093mMA08.0936cb6213d-3eac-4680-af56-f20612814462Chimeric Antigen Receptor (CAR) TherapyChimeric Antigen Receptor (CAR) Therapy
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964ChiropracticServicesMA10.004iRehabilitation Services (10)MA10.004iMA10.0041bf4f989-e8fe-478c-92dc-271df20e0080Chiropractic ServicesChiropractic Services
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732CoagulationFactorsMA08.004vPharmacy (08)MA08.004vMA08.0043859f8b4-b0b8-4620-9793-5a2ea6ac6b4bCoagulation FactorsCoagulation Factors
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1212Cobalamin(VitaminB12),FolicAcid,andHomocysteineTestingMA06.032aPathology and Laboratory (06)MA06.032aMA06.032ad839354-6971-41a0-8d01-ad241d09fb08Cobalamin (Vitamin B12), Folic Acid, and Homocysteine TestingCobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
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918CochlearImplantationMA11.039eSurgery (11)MA11.039eMA11.0394a37023a-9005-494a-b45d-e871483492b0Cochlear ImplantationCochlear Implantation
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800Collagenaseclostridiumhistolyticum(Xiaflex®),collagenaseclostridiumhistolyticum-aaes(Qwo®)MA08.128Pharmacy (08)MA08.128MA08.128fee78a0b-02d4-430c-b646-cfac446d41a4Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo®)Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo®)
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783CommodeChairsMA05.036bDME (05)MA05.036bMA05.03637a80c47-f90c-47ee-b58c-d4b25d90306dCommode ChairsCommode Chairs
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1065ComplementaryandIntegrativeHealthServicesMA12.001eMiscellaneous (12)MA12.001eMA12.0012b9ece34-5173-46a4-821e-fa55c65cd42aComplementary and Integrative Health ServicesComplementary and Integrative Health Services
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1245CompleteDecongestiveTherapy(CDT)MA07.042Medicine (07)MA07.042MA07.042432753c6-2f7e-4a74-9757-7fee1ebd8168Complete Decongestive Therapy (CDT)Complete Decongestive Therapy (CDT)
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920CompositeTissueAllotransplantationoftheHand(s)andFaceMA11.112Surgery (11)MA11.112MA11.1126c2c276e-9fa3-429e-bc58-9a5ee9545ebaComposite Tissue Allotransplantation of the Hand(s) and FaceComposite Tissue Allotransplantation of the Hand(s) and Face
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1119CompressionGarmentsMA05.045eDME (05)MA05.045eMA05.04516c95899-4a2d-4018-ae58-6808e5ab1663Compression GarmentsCompression Garments
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526Computer-AidedDetection(CAD)SystemforUsewithChestRadiographsMA09.014aRadiology (09)MA09.014aMA09.01482f2160d-33d0-469b-b1c2-239300eb08d2Computer-Aided Detection (CAD) System for Use with Chest RadiographsComputer-Aided Detection (CAD) System for Use with Chest Radiographs
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828Computer-AssistedMusculoskeletalSurgicalNavigationalOrthopedicProcedureMA11.088cSurgery (11)MA11.088cMA11.088f59aa164-15c2-44b7-bbf6-da50748c61ccComputer-Assisted Musculoskeletal Surgical Navigational Orthopedic ProcedureComputer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
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1072ConsultationServicesMA00.049bAdministrative (00)MA00.049bMA00.04981badbcb-c683-4b9d-a96f-79d468315497Consultation ServicesConsultation Services
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1201ContinuousGlucoseMonitorsandHomeBloodGlucoseMonitorsandSuppliesMA00.002nAdministrative (00)MA00.002nMA00.002c62eacf7-b9ac-4786-ae54-8ad08ae59765Continuous Glucose Monitors and Home Blood Glucose Monitors and SuppliesContinuous Glucose Monitors and Home Blood Glucose Monitors and Supplies
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43ContrastAgentsUsedinConjunctionwithEchocardiographyMA09.004cRadiology (09)MA09.004cMA09.0043f09acf7-614c-4f2a-8b31-3aeb51979ec9Contrast Agents Used in Conjunction with EchocardiographyContrast Agents Used in Conjunction with Echocardiography
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1163CornealPachymetryUsingUltrasoundMA07.046gMedicine (07)MA07.046gMA07.04634c18a0b-a842-405a-8e20-c6cadd85ed9eCorneal Pachymetry Using UltrasoundCorneal Pachymetry Using Ultrasound
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802CosmeticProceduresMA12.009aMiscellaneous (12)MA12.009aMA12.0092c6f102c-dd07-432d-8393-709313f4074fCosmetic ProceduresCosmetic Procedures
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44CoverageofMedicalDevicesMA05.040bDME (05)MA05.040bMA05.040f151966a-f669-4fce-8e49-d7196d0d9f9eCoverage of Medical DevicesCoverage of Medical Devices
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1130CranialElectrotherapyStimulationMA05.066dDME (05)MA05.066dMA05.066e50b9ce8-e5d2-4d1b-8d9d-90ad574baf5dCranial Electrotherapy StimulationCranial Electrotherapy Stimulation
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59CriteriaforReimbursementofEmergencyRoomServicesMA00.044cAdministrative (00)MA00.044cMA00.0444acb8b84-82bc-4376-ab34-107802217c38Criteria for Reimbursement of Emergency Room ServicesCriteria for Reimbursement of Emergency Room Services
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1095crizanlizumab-tmca(Adakveo®) MA08.109bPharmacy (08)MA08.109bMA08.109ab27d4c8-099c-4c4c-80d4-c47744de1a1fcrizanlizumab-tmca (Adakveo®) crizanlizumab-tmca (Adakveo®)
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1237CryosurgicalAblationoftheProstateGlandMA11.022aSurgery (11)MA11.022aMA11.022770940e9-38a5-45bf-b7fb-0210a5cbab36Cryosurgical Ablation of the Prostate GlandCryosurgical Ablation of the Prostate Gland
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1276Daratumumab(Darzalex®),DaratumumabandHyaluronidase-fihj(DarzalexFaspro®)MA08.079lPharmacy (08)MA08.079lMA08.079c59bbcae-3c42-4cb4-9f47-846763ab2714Daratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®)Daratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®)
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108DayRehabilitationMA10.005bRehabilitation Services (10)MA10.005bMA10.0055e5c8ce3-3dcb-444d-b62e-fbcdb2662295Day RehabilitationDay Rehabilitation
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1017DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNailsMA11.014gSurgery (11)MA11.014gMA11.01425099058-e04b-498b-8894-0c8703c311acDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe NailsDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
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1030DeepBrainStimulation(DBS)MA11.005hSurgery (11)MA11.005hMA11.0059d327dba-7bcb-4d59-8996-78341f24833fDeep Brain Stimulation (DBS)Deep Brain Stimulation (DBS)
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737Denosumab(Prolia®,Xgeva®),Romosozumab-aqqg(Evenity®)MA08.052lPharmacy (08)MA08.052lMA08.052b358a612-f04d-4a19-99a7-ec3c067e5a8cDenosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)
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1016DermabrasionforRhinophyma,Septoplasty,Rhinoplasty,andSeptorhinoplastyMA11.099dSurgery (11)MA11.099dMA11.0993c5ac79a-6f80-4d16-a9f3-c17ec4eb6b75Dermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and SeptorhinoplastyDermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and Septorhinoplasty
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471DirectAccesstoObstetrics/Gynecology(OB/GYN)ServicesMA00.032fAdministrative (00)MA00.032fMA00.03274bdf09b-06a0-450c-9fc7-1faf0d609876Direct Access to Obstetrics/Gynecology (OB/GYN) ServicesDirect Access to Obstetrics/Gynecology (OB/GYN) Services
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847Dofetilide(Tikosyn®)UseintheInpatientSettingMA08.021cPharmacy (08)MA08.021cMA08.021751d409f-6fce-4dab-82fb-40fc562dcc1aDofetilide (Tikosyn®) Use in the Inpatient SettingDofetilide (Tikosyn®) Use in the Inpatient Setting
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858Dostarlimab-gxly(Jemperli)MA08.136ePharmacy (08)MA08.136eMA08.13682beb3a6-44d4-4115-ad2a-e541d322be71Dostarlimab-gxly (Jemperli)Dostarlimab-gxly (Jemperli)
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213Drug-ElutingBeadsandBlandEmbolizationfortheTreatmentofHepaticMalignanciesPolicyMA07.041bMedicine (07)MA07.041bMA07.04162806d68-7113-4dd0-99ad-63300f2caadbDrug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies PolicyDrug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies Policy
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1045DurableMedicalEquipment(DME)MA05.044qDME (05)MA05.044qMA05.044abab7a6b-65ff-499f-8b8a-3c671a8f5cd1Durable Medical Equipment (DME)Durable Medical Equipment (DME)
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452DurableMedicalEquipment(DME)NotSubjecttoaRentaltoPurchaseMaximumMA05.028eDME (05)MA05.028eMA05.02850b2766c-5a1a-42e1-a4b6-ab406b5e5ea8Durable 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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1058Durvalumab(Imfinzi®)andTremelimumab-actl(Imjudo®)MA08.123dPharmacy (08)MA08.123dMA08.123e60e2d1d-5090-4238-8d74-da8a5ec7603fDurvalumab (Imfinzi®) and Tremelimumab-actl (Imjudo®)Durvalumab (Imfinzi®) and Tremelimumab-actl (Imjudo®)
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1083Eculizumab(Soliris®)andRelatedBiosimilars,Ravulizumab-cwvz(Ultomiris™)forintravenousadministrationMA08.044iPharmacy (08)MA08.044iMA08.044b09db9e1-3fa2-424c-bc53-43e20eeaad7fEculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™) for intravenous  administrationEculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™) for intravenous administration
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1194Efbemalenograstimalfa-vuxw(Ryzneuta®),Eflapegrastim-xnst(Rolvedon™),Pegfilgrastim(Neulasta®)andRelatedBiosimilarsMA08.082mPharmacy (08)MA08.082mMA08.0822ae1a68f-6b24-4058-a7e5-752694e1bad9Efbemalenograstim alfa-vuxw (Ryzneuta®), Eflapegrastim-xnst (Rolvedon™), Pegfilgrastim (Neulasta®) and Related BiosimilarsEfbemalenograstim alfa-vuxw (Ryzneuta®), Eflapegrastim-xnst (Rolvedon™), Pegfilgrastim (Neulasta®) and Related Biosimilars
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702Efgartigimodalfa-fcab(Vyvgart)andefgartigimodalfaandhyaluronidase-qvfc(VyvgartHytrulo)MA08.142cPharmacy (08)MA08.142cMA08.1429d401399-9ec9-40b4-a531-cd73ddaf3b29Efgartigimod alfa - fcab (Vyvgart) and efgartigimod alfa and hyaluronidase-qvfc (Vyvgart Hytrulo)Efgartigimod alfa - fcab (Vyvgart) and efgartigimod alfa and hyaluronidase-qvfc (Vyvgart Hytrulo)
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796ElectricalStimulationandElectromagneticStimulationfortheTreatmentofWoundsMA07.013dMedicine (07)MA07.013dMA07.013a55b92be-6ad0-472a-8d6a-13d0781e56e9Electrical Stimulation and Electromagnetic Stimulation for the Treatment of WoundsElectrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
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1023ElectroconvulsiveTherapy(ECT)MA14.001aBehavioral Health (14)MA14.001aMA14.001f73a7df3-34fc-47eb-8984-ac387c1eddadElectroconvulsive Therapy (ECT)Electroconvulsive Therapy (ECT)
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865Electromyography(EMG)Studies,NerveConductionStudies(NCS),andRelatedElectrodiagnosticStudiesMA07.050lMedicine (07)MA07.050lMA07.0505b2eb4f4-dae8-4896-8a84-fbbd7970c94cElectromyography (EMG) Studies, Nerve Conduction Studies (NCS), and Related Electrodiagnostic StudiesElectromyography (EMG) Studies, Nerve Conduction Studies (NCS), and Related Electrodiagnostic Studies
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994Elranatamab-bcmm(Elrexfio™)MA08.168Pharmacy (08)MA08.168MA08.16801b304c6-6552-45f6-bac9-4c42a623f121Elranatamab-bcmm (Elrexfio™)Elranatamab-bcmm (Elrexfio™)
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