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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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912AbortionMA11.010cSurgery (11)MA11.010cMA11.010fee8f850-ab5b-4f1d-8146-3a5cc824e97aAbortionAbortion
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794AcupunctureMA12.004cMiscellaneous (12)MA12.004cMA12.0045f7e1494-96da-48b4-93ce-192427fc02d6AcupunctureAcupuncture
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311AcuteCareFacilityInpatientTransfersMA12.003bMiscellaneous (12)MA12.003bMA12.003e76d4120-744a-4452-9c0d-61fe9ceee8c7Acute Care Facility Inpatient TransfersAcute Care Facility Inpatient Transfers
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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512AirAmbulanceServicesMA12.007bMiscellaneous (12)MA12.007bMA12.0079d88ca51-1ca6-4e1d-b836-d8e28f0ff6cbAir Ambulance ServicesAir Ambulance Services
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511Alemtuzumab(Lemtrada®)MA08.015dPharmacy (08)MA08.015dMA08.015fdb6e4d5-90e3-4bc6-9fc8-111e22586e8bAlemtuzumab (Lemtrada®)Alemtuzumab (Lemtrada®)
68a63c87-8ed0-4058-a107-2a6c84071eb8.aspx
  
156Alglucosidasealfa(e.g.,Lumizyme®),Avalglucosidasealfa-ngpt(Nexviazyme®)MA08.036fPharmacy (08)MA08.036fMA08.03668a63c87-8ed0-4058-a107-2a6c84071eb8Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme®)Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme®)
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573AllergyImmunotherapyMA07.055dMedicine (07)MA07.055dMA07.05554eab645-f9e3-42bb-ab87-55ba1c52afb9Allergy ImmunotherapyAllergy Immunotherapy
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513Alpha1-AntitrypsinTherapy(e.g.,Prolastin-C,AralastNP,Glassia,Zemaira)MA08.050bPharmacy (08)MA08.050bMA08.050ee2c19b1-8c7e-4af7-8b0a-80b73be66b5aAlpha 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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754AlwaysBundledProcedureCodesMA00.026tAdministrative (00)MA00.026tMA00.0263b0f3d04-cee3-4474-9db7-0476f9b2190cAlways 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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641AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)MonitoringMA07.026oMedicine (07)MA07.026oMA07.026efb64610-bc93-457a-b1a4-1580680acf72Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
1c666867-fd26-420a-8f5c-39413ac4a535.aspx
  
631Amivantamab-vmjw(Rybrevant™)MA08.148Pharmacy (08)MA08.148MA08.1481c666867-fd26-420a-8f5c-39413ac4a535Amivantamab-vmjw (Rybrevant™)Amivantamab-vmjw (Rybrevant™)
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574AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagementMA01.008bAnesthesia (01)MA01.008bMA01.008126d9e1f-15e5-4b43-829c-43d0edecdcabAnesthesia 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
c1622980-dfd1-47b1-8025-4ab0c3d67a28.aspx
  
575Anifrolumab-fnia(Saphnelo®)MA08.140bPharmacy (08)MA08.140bMA08.140c1622980-dfd1-47b1-8025-4ab0c3d67a28Anifrolumab-fnia (Saphnelo®)Anifrolumab-fnia (Saphnelo®)
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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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89AnorectalManometry,Electromyography(EMG)ofAnorectalorUrethralSphincters;BiofeedbackTrainingforPerinealMusclesandAnorectalorUrethralSphinctersMA07.018cMedicine (07)MA07.018cMA07.01857b0addb-6748-4c73-8e2e-235276cf80a1Anorectal Manometry, Electromyography (EMG) of Anorectal or Urethral Sphincters; Biofeedback Training for Perineal Muscles and Anorectal or Urethral SphinctersAnorectal Manometry, Electromyography (EMG) of Anorectal or Urethral Sphincters; Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters
83351e2c-0a5c-49e3-bca7-f333d1078e85.aspx
  
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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61AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucomaMA11.105jSurgery (11)MA11.105jMA11.105a148b47d-dd60-4389-b5b6-b2cda8163d9eAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
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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®)
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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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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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179AutonomicNervousSystemTestingMA07.027fMedicine (07)MA07.027fMA07.027aa01a994-7653-459a-8aad-e9c0ba944af2Autonomic 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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96Belimumab(Benlysta®)forIntravenousUseMA08.057dPharmacy (08)MA08.057dMA08.057550056d1-78e8-4577-b9ba-621658d7bcb3Belimumab (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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180BiofeedbackTherapyMA07.010aMedicine (07)MA07.010aMA07.0100e0434e4-305e-4a53-84d7-8b0afce67c9eBiofeedback TherapyBiofeedback Therapy
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330BioimpedancefortheDetectionofLymphedemaMA07.052Medicine (07)MA07.052MA07.052c28db511-82c1-442c-a666-4b1d4d7fd95cBioimpedance 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
{"332": {"Id":332,"MPAttachmentLetter":"A","Title":"ICD-10 Coding","MPPolicyAttachmentInternalSourceId":7944,"PolicyAttachmentPageName":"8e4d325e-184b-4d8e-b3a9-f6949a3156f7"},}
a4c5d6e6-affe-4ced-8308-084c9c9be6b4.aspx
  
454Blinatumomab(Blincyto®)MA08.058fPharmacy (08)MA08.058fMA08.058a4c5d6e6-affe-4ced-8308-084c9c9be6b4Blinatumomab (Blincyto®) Blinatumomab (Blincyto®)
f45e9902-48d1-471a-91c1-4cffee5ad4be.aspx
  
654Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAidsMA11.049fSurgery (11)MA11.049fMA11.049f45e9902-48d1-471a-91c1-4cffee5ad4beBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing AidsBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
4ba4a7dc-ba5c-4d83-bf20-29a1c5b7dc55.aspx
  
63BotulinumToxinAgentsMA08.017jPharmacy (08)MA08.017jMA08.0174ba4a7dc-ba5c-4d83-bf20-29a1c5b7dc55Botulinum 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"},}
a9d21997-d0a9-4339-9099-e8450bc1856b.aspx
  
65BronchialValvesMA11.020Surgery (11)MA11.020MA11.020a9d21997-d0a9-4339-9099-e8450bc1856bBronchial ValvesBronchial Valves
ab22479c-235e-4e6e-aa49-2a98e3c928db.aspx
  
66Burosumab-twza(Crysvita®)MA08.099bPharmacy (08)MA08.099bMA08.099ab22479c-235e-4e6e-aa49-2a98e3c928dbBurosumab-twza (Crysvita®)Burosumab-twza (Crysvita®)
65d5da76-4026-4359-8b9f-bb8e36f6d124.aspx
  
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
{"852": {"Id":852,"MPAttachmentLetter":"A","Title":"Medically Necessary ICD-10 Codes","MPPolicyAttachmentInternalSourceId":8306,"PolicyAttachmentPageName":"4ede227c-bda6-49e3-b3b9-29b56415b1bf"},}
01b0b8c2-eef7-4039-99cd-dae23b2c63e8.aspx
  
758CareManagementandCarePlanningServicesMA00.006nAdministrative (00)MA00.006nMA00.00601b0b8c2-eef7-4039-99cd-dae23b2c63e8Care Management and Care Planning ServicesCare Management and Care Planning Services
e398b664-20bc-4529-b33b-7b500da57db8.aspx
  
637Carfilzomib(Kyprolis)MA08.062hPharmacy (08)MA08.062hMA08.062e398b664-20bc-4529-b33b-7b500da57db8Carfilzomib (Kyprolis)Carfilzomib (Kyprolis)
bda6ce16-012b-4729-b2f6-1fc760164679.aspx
  
39CastandSplintApplicationsandAssociatedSuppliesMA00.012cAdministrative (00)MA00.012cMA00.012bda6ce16-012b-4729-b2f6-1fc760164679Cast and Splint Applications and Associated SuppliesCast and Splint Applications and Associated Supplies
{"40": {"Id":40,"MPAttachmentLetter":"A","Title":"Procedures Related to Cast and Splint Applications and Associated Supplies","MPPolicyAttachmentInternalSourceId":7876,"PolicyAttachmentPageName":"a3deedd4-346e-4c65-8ee1-a2d2b106ff2e"},}
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745CataractSurgeryMA11.054dSurgery (11)MA11.054dMA11.05468ced3f6-2d3e-46f7-992a-7d9b39df1e51Cataract SurgeryCataract Surgery
{"746": {"Id":746,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":8399,"PolicyAttachmentPageName":"1262e489-0158-4df8-b42d-d8776ee3923e"},}
ff571ab5-803e-4115-98d9-d2bedd280117.aspx
  
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®)
78002a30-681b-4bd3-806f-5801a06f1502.aspx
  
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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499ChimericAntigenReceptor(CAR)TherapyMA08.093lPharmacy (08)MA08.093lMA08.093c76897ca-dcf7-41b0-917a-bc7e63ee5d84Chimeric Antigen Receptor (CAR) TherapyChimeric Antigen Receptor (CAR) Therapy
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184ChiropracticServicesMA10.004iRehabilitation Services (10)MA10.004iMA10.00460dce7e2-3607-4356-85f2-7eb458c901b7Chiropractic ServicesChiropractic Services
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732CoagulationFactorsMA08.004vPharmacy (08)MA08.004vMA08.0043859f8b4-b0b8-4620-9793-5a2ea6ac6b4bCoagulation FactorsCoagulation Factors
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335Cobalamin(VitaminB12),FolicAcid,andHomocysteineTestingMA06.032aPathology and Laboratory (06)MA06.032aMA06.03224b1835c-ed55-4a29-9490-600d7cc53310Cobalamin (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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949ComplementaryandIntegrativeHealthServicesMA12.001eMiscellaneous (12)MA12.001eMA12.0014368201d-ccf2-414a-a7a2-021187ef411aComplementary and Integrative Health ServicesComplementary and Integrative Health Services
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102CompleteDecongestiveTherapy(CDT)MA07.042Medicine (07)MA07.042MA07.0421e490804-466e-40db-a72b-a3f6db45e065Complete 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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780CompressionGarmentsMA05.045dDME (05)MA05.045dMA05.045725042b4-e5a4-402f-a810-5a8f2127c031Compression 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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42ConsultationServicesMA00.049bAdministrative (00)MA00.049bMA00.049de97240b-5932-4e9c-9b09-7d6fcbfb37efConsultation ServicesConsultation Services
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876ContinuousGlucoseMonitorsandHomeBloodGlucoseMonitorsandSuppliesMA00.002mAdministrative (00)MA00.002mMA00.002eccc8d97-c457-4618-a466-674bede5f6c4Continuous 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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456CornealPachymetryUsingUltrasoundMA07.046gMedicine (07)MA07.046gMA07.0461dd4b0fe-e142-4def-953e-a74bceb38ed0Corneal 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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655CranialElectrotherapyStimulationMA05.066dDME (05)MA05.066dMA05.066e849d185-43b5-4ccb-9f8d-f59c4eb8fbf8Cranial 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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74crizanlizumab-tmca(Adakveo®) MA08.109bPharmacy (08)MA08.109bMA08.10915212491-86c7-45e0-979d-96238adf65becrizanlizumab-tmca (Adakveo®) crizanlizumab-tmca (Adakveo®)
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75CryosurgicalAblationoftheProstateGlandMA11.022aSurgery (11)MA11.022aMA11.022bfe7d105-ad8b-4ba2-ab94-0483359e1ab3Cryosurgical Ablation of the Prostate GlandCryosurgical Ablation of the Prostate Gland
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613Daratumumab(Darzalex®),DaratumumabandHyaluronidase-fihj(DarzalexFaspro®)MA08.079kPharmacy (08)MA08.079kMA08.0790d4d2266-f202-4963-bfb9-0ee8201ace8bDaratumumab (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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458DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNailsMA11.014gSurgery (11)MA11.014gMA11.014f900a15f-a176-49f6-900e-a2d2a40d77beDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe NailsDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
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705DeepBrainStimulation(DBS)MA11.005hSurgery (11)MA11.005hMA11.00544f2879a-f6ef-4e65-819b-29c7b937cdc5Deep 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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586DermabrasionforRhinophyma,Septoplasty,Rhinoplasty,andSeptorhinoplastyMA11.099dSurgery (11)MA11.099dMA11.09942937e3d-5067-44ec-9fee-b22ed4aef6c1Dermabrasion 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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954DurableMedicalEquipment(DME)MA05.044qDME (05)MA05.044qMA05.044662704dc-6ec3-4ebe-ae2d-0ec59f047e5eDurable 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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589Durvalumab(Imfinzi®)andtremelimumab-act(Imjudo®)MA08.123cPharmacy (08)MA08.123cMA08.1230ba939cb-bc27-43c0-a0c5-b19abccaa723Durvalumab (Imfinzi®) and tremelimumab-act (Imjudo®) Durvalumab (Imfinzi®) and tremelimumab-act (Imjudo®)
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591Eculizumab(Soliris®)andRelatedBiosimilars,Ravulizumab-cwvz(Ultomiris™)MA08.044hPharmacy (08)MA08.044hMA08.0440f6dabde-ef41-407b-8038-49ae923773daEculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™)Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™)
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942Efbemalenograstimalfa-vuxw(Ryzneuta®),Eflapegrastim-xnst(Rolvedon™),Pegfilgrastim(Neulasta®)andRelatedBiosimilarsMA08.082lPharmacy (08)MA08.082lMA08.0825a954dad-c9a7-4d77-a9b2-81be80a7ded2Efbemalenograstim 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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147ElectroconvulsiveTherapy(ECT)MA14.001aBehavioral Health (14)MA14.001aMA14.001c7897d4c-ba7f-4e3a-b60b-935c06b38505Electroconvulsive Therapy (ECT)Electroconvulsive Therapy (ECT)
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195Electromyography(EMG)Studies:NeedleEMG,SurfaceEMG(SEMG)MA07.050kMedicine (07)MA07.050kMA07.0509a003eeb-04a5-4534-b02f-b7d8ed40d81aElectromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
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358Emapalumab-lzsg(Gamifant®)MA08.104bPharmacy (08)MA08.104bMA08.10411be2201-4b41-44f4-99c2-4d15dbc3a216Emapalumab-lzsg (Gamifant®)Emapalumab-lzsg (Gamifant®)
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859EndometrialAblationMA11.065dSurgery (11)MA11.065dMA11.0656a093f14-2a97-4607-9b4c-cc9f560fdde4Endometrial AblationEndometrial Ablation
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