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e4b8905e-d5a9-49d0-879a-effe587eb144.aspx
  
2393Abatacept(Orencia®)forInjectionforIntravenousUseMA08.028kPharmacy (08)MA08.028kMA08.028e4b8905e-d5a9-49d0-879a-effe587eb144Abatacept (Orencia®) for Injection for Intravenous UseAbatacept (Orencia®) for Injection for Intravenous Use
{"2394": {"Id":2394,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":9996,"PolicyAttachmentPageName":"28fc674d-cfc0-4970-adc3-e399ce0df136"},}
6d2ef7be-9985-4fd4-8754-ab74c8895333.aspx
  
2634AblationofLungTumorsMA11.052fSurgery (11)MA11.052fMA11.0526d2ef7be-9985-4fd4-8754-ab74c8895333Ablation of Lung TumorsAblation of Lung Tumors
055ea54d-c495-4ea4-a6e5-eecaa2972d0c.aspx
  
2874AbortionMA11.010dSurgery (11)MA11.010dMA11.010055ea54d-c495-4ea4-a6e5-eecaa2972d0cAbortionAbortion
1a445df6-53d8-43de-a5bd-b3860e087663.aspx
  
2702AcupunctureMA12.004eMiscellaneous (12)MA12.004eMA12.0041a445df6-53d8-43de-a5bd-b3860e087663AcupunctureAcupuncture
{"2703": {"Id":2703,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Acupuncture","MPPolicyAttachmentInternalSourceId":10301,"PolicyAttachmentPageName":"133a73b3-bb67-418a-87ab-74f883a81d93"},}
ebc64a67-4cc0-40c4-a357-b8f3d41752f1.aspx
  
2300AcuteCareFacilityInpatientTransfersMA12.003bMiscellaneous (12)MA12.003bMA12.003ebc64a67-4cc0-40c4-a357-b8f3d41752f1Acute Care Facility Inpatient TransfersAcute Care Facility Inpatient Transfers
59222766-28a2-4433-a09a-3f71f8f343a6.aspx
  
2023ADAMTS13,recombinant-krhn(Adzynma)MA08.171Pharmacy (08)MA08.171MA08.17159222766-28a2-4433-a09a-3f71f8f343a6ADAMTS13, recombinant-krhn (Adzynma)ADAMTS13, recombinant-krhn (Adzynma)
909b2424-58a5-4d5c-9d19-681ebb42575e.aspx
  
2460Ado-TrastuzumabEmtansine(Kadcyla®)MA08.066hPharmacy (08)MA08.066hMA08.066909b2424-58a5-4d5c-9d19-681ebb42575eAdo-Trastuzumab Emtansine (Kadcyla®)Ado-Trastuzumab Emtansine (Kadcyla®)
8b3f3418-a799-413e-9cfb-772bcfeb39a5.aspx
  
2792Agalsidasebeta(Fabrazyme)andpegunigalsidasealfa-iwxj(Elfabrio)MA08.033dPharmacy (08)MA08.033dMA08.0338b3f3418-a799-413e-9cfb-772bcfeb39a5Agalsidase beta (Fabrazyme) and pegunigalsidase alfa-iwxj (Elfabrio)Agalsidase beta (Fabrazyme) and pegunigalsidase alfa-iwxj (Elfabrio)
47a5d03d-f43b-4b15-94ed-4bf842be7b40.aspx
  
2220AirAmbulanceServicesMA12.007bMiscellaneous (12)MA12.007bMA12.00747a5d03d-f43b-4b15-94ed-4bf842be7b40Air Ambulance ServicesAir Ambulance Services
94d8d668-7fe5-44de-9f66-f8e2429bff8c.aspx
  
2338Alemtuzumab(Lemtrada®)MA08.015ePharmacy (08)MA08.015eMA08.01594d8d668-7fe5-44de-9f66-f8e2429bff8cAlemtuzumab (Lemtrada®)Alemtuzumab (Lemtrada®)
5f9531c9-2035-4bc7-b5e0-6b5a87a588e5.aspx
  
2923Alglucosidasealfa(e.g.,Lumizyme®),Avalglucosidasealfa-ngpt(Nexviazyme®),Cipaglucosidasealfa-atga(Pombiliti™)MA08.036gPharmacy (08)MA08.036gMA08.0365f9531c9-2035-4bc7-b5e0-6b5a87a588e5Alglucosidase 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™ )
60109ced-4a2c-4fc6-9f1b-ce25c3eb3442.aspx
  
2885AllergyImmunotherapyMA07.055eMedicine (07)MA07.055eMA07.05560109ced-4a2c-4fc6-9f1b-ce25c3eb3442Allergy ImmunotherapyAllergy Immunotherapy
138dba6d-6f43-4e12-a0e7-d355f0f52313.aspx
  
2995Alpha-1AntitrypsinTherapy(e.g.,Prolastin-C,AralastNP,Glassia,Zemaira)MA08.050cPharmacy (08)MA08.050cMA08.050138dba6d-6f43-4e12-a0e7-d355f0f52313Alpha-1 Antitrypsin Therapy (e.g., Prolastin-C, Aralast NP, Glassia, Zemaira)Alpha-1 Antitrypsin Therapy (e.g., Prolastin-C, Aralast NP, Glassia, Zemaira)
d3aa4fb8-db1c-4223-8bed-18ab90d54217.aspx
  
2904AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)DevicesMA07.005dMedicine (07)MA07.005dMA07.005d3aa4fb8-db1c-4223-8bed-18ab90d54217Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) DevicesAmbulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
6cf66ad2-c2c7-43cf-b5c4-c9456152c32f.aspx
  
1996AmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)MonitoringMA07.026rMedicine (07)MA07.026rMA07.0266cf66ad2-c2c7-43cf-b5c4-c9456152c32fAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) MonitoringAmbulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
de64b3a7-335d-457b-9781-86bcaeb3a855.aspx
  
2972Amivantamab-vmjw(Rybrevant®)andAmivantamabandhyaluronidase-lpuj(RybrevantFaspro™)MA08.148cPharmacy (08)MA08.148cMA08.148de64b3a7-335d-457b-9781-86bcaeb3a855Amivantamab-vmjw (Rybrevant®) and Amivantamab and hyaluronidase-lpuj (Rybrevant Faspro™)Amivantamab-vmjw (Rybrevant®) and Amivantamab and hyaluronidase-lpuj (Rybrevant Faspro™)
c75c2565-c4e2-4265-af85-c55cfde08fa5.aspx
  
2767AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagementMA01.008dAnesthesia (01)MA01.008dMA01.008c75c2565-c4e2-4265-af85-c55cfde08fa5Anesthesia 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
{"2768": {"Id":2768,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":10364,"PolicyAttachmentPageName":"e585cc8c-44be-408a-9b36-9dadace2ca09"},}
dcc9a712-ded7-46bf-8809-07dabdd5609d.aspx
  
3008Anifrolumab-fnia(Saphnelo®)MA08.140cPharmacy (08)MA08.140cMA08.140dcc9a712-ded7-46bf-8809-07dabdd5609dAnifrolumab-fnia (Saphnelo®)Anifrolumab-fnia (Saphnelo®)
1e2ee097-25d1-4944-b35d-f84b42e73e55.aspx
  
1969Ankle-Foot/Knee-Ankle-FootOrthosesMA05.010kDME (05)MA05.010kMA05.0101e2ee097-25d1-4944-b35d-f84b42e73e55Ankle-Foot/Knee-Ankle-Foot OrthosesAnkle-Foot/Knee-Ankle-Foot Orthoses
{"1970": {"Id":1970,"MPAttachmentLetter":"A","Title":"HCPCS CODES FOR ANKLE-FOOT/ KNEE-ANKLE FOOT ORTHOSIS","MPPolicyAttachmentInternalSourceId":9618,"PolicyAttachmentPageName":"b2e48c48-1812-43b5-9db2-ae57f94f8733"},}
3f32d131-30f7-467b-83bd-e9093d3e0682.aspx
  
2425ApheresisTherapyMA06.001fPathology and Laboratory (06)MA06.001fMA06.0013f32d131-30f7-467b-83bd-e9093d3e0682Apheresis TherapyApheresis Therapy
751ca53f-d348-42c6-b5fd-c66543cefceb.aspx
  
2529Apos®biomechanicalshoesystemMA05.070DME (05)MA05.070MA05.070751ca53f-d348-42c6-b5fd-c66543cefcebApos® biomechanical shoe systemApos® biomechanical shoe system
f88dd41a-d5ac-440d-81ff-1a525c137fab.aspx
  
2772ApplicationandRemovalofTattoosMA11.072Surgery (11)MA11.072MA11.072f88dd41a-d5ac-440d-81ff-1a525c137fabApplication and Removal of TattoosApplication and Removal of Tattoos
cd4ab4d2-610b-460e-98c3-4e742725cdb5.aspx
  
2304AqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucomaMA11.105kSurgery (11)MA11.105kMA11.105cd4ab4d2-610b-460e-98c3-4e742725cdb5Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of GlaucomaAqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
{"2305": {"Id":2305,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":9965,"PolicyAttachmentPageName":"9a5560c6-9015-4af1-9c04-0ec28d455bcd"},}
5add7c67-eeab-4281-83cd-5a2df2157bf8.aspx
  
3010AsparaginaseErwiniaChrysanthemi(recombinant)-rywn(Rylaze®)MA08.085kPharmacy (08)MA08.085kMA08.0855add7c67-eeab-4281-83cd-5a2df2157bf8Asparaginase Erwinia Chrysanthemi (recombinant)-rywn (Rylaze®)Asparaginase Erwinia Chrysanthemi (recombinant)-rywn (Rylaze®)
6d0a25df-adfd-4614-a579-7f2de91b11e8.aspx
  
2214Atezolizumab(Tecentriq®)andAtezolizumabwithHyaluronidase-tqjs(TecentriqHybreza™)MA08.127fPharmacy (08)MA08.127fMA08.1276d0a25df-adfd-4614-a579-7f2de91b11e8Atezolizumab (Tecentriq®) and Atezolizumab with Hyaluronidase-tqjs (Tecentriq Hybreza™)Atezolizumab (Tecentriq®) and Atezolizumab with Hyaluronidase-tqjs (Tecentriq Hybreza™)
288d8472-381e-4945-8477-2c66588a10f4.aspx
  
2219AuricularProsthesesMA05.068DME (05)MA05.068MA05.068288d8472-381e-4945-8477-2c66588a10f4Auricular ProsthesesAuricular Prostheses
9d7f4f35-e617-49a7-9c0a-c8d6cb393649.aspx
  
1870AutomaticExternalCardioverterDefibrillators(WearableandNonwearable)MA05.005gDME (05)MA05.005gMA05.0059d7f4f35-e617-49a7-9c0a-c8d6cb393649Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
{"1871": {"Id":1871,"MPAttachmentLetter":"B","Title":"ICD-10 codes used to represent the Nonwearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":9498,"PolicyAttachmentPageName":"ce4efa64-06a1-40ef-9fa6-7d02a16910c4"},"1872": {"Id":1872,"MPAttachmentLetter":"A","Title":"ICD-10 codes used to represent the Wearable Automatic External Defibrillator (AED):","MPPolicyAttachmentInternalSourceId":9499,"PolicyAttachmentPageName":"bd5a7389-9fa3-4954-afab-0e3800e43cd4"},}
0f73ec54-34df-4775-8004-f504243dcd4d.aspx
  
2778AutonomicNervousSystemTestingMA07.027hMedicine (07)MA07.027hMA07.0270f73ec54-34df-4775-8004-f504243dcd4dAutonomic Nervous System TestingAutonomic Nervous System Testing
e4e11021-9754-41c3-b13b-c0615d61c1b1.aspx
  
2559Avelumab(Bavencio®)MA08.122ePharmacy (08)MA08.122eMA08.122e4e11021-9754-41c3-b13b-c0615d61c1b1Avelumab (Bavencio®)Avelumab (Bavencio®)
42c3381d-b012-4b4e-b298-af81886f1a17.aspx
  
2888Axatilimab-csfr(Niktimvo™)forIntravenousUseMA08.180Pharmacy (08)MA08.180MA08.18042c3381d-b012-4b4e-b298-af81886f1a17Axatilimab-csfr (Niktimvo™) for Intravenous UseAxatilimab-csfr (Niktimvo™) for Intravenous Use
3e2a9d42-9ad7-4d16-98dc-56557bded97c.aspx
  
1876BalloonCatheterDilationofSinusOstiaforTreatmentofChronicRhinosinusitisorRecurrentAcuteRhinosinusitisMA11.100fSurgery (11)MA11.100fMA11.1003e2a9d42-9ad7-4d16-98dc-56557bded97cBalloon 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
97627e22-5773-408a-be03-ac3ebf3a014d.aspx
  
2983Belantamabmafodotin-blmf(Blenrep)MA08.192Pharmacy (08)MA08.192MA08.19297627e22-5773-408a-be03-ac3ebf3a014dBelantamab mafodotin-blmf (Blenrep)Belantamab mafodotin-blmf (Blenrep)
f6210278-9476-4236-b143-3ebcbd8a360d.aspx
  
2044Belimumab(Benlysta®)forIntravenousUseMA08.057dPharmacy (08)MA08.057dMA08.057f6210278-9476-4236-b143-3ebcbd8a360dBelimumab (Benlysta®) for Intravenous UseBelimumab (Benlysta®) for Intravenous Use
93d1c3a1-5222-4336-b8f7-95217b0d3de8.aspx
  
2958Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUseMA08.072pPharmacy (08)MA08.072pMA08.07293d1c3a1-5222-4336-b8f7-95217b0d3de8Bevacizumab (Avastin®) and Related Biosimilars For Oncologic UseBevacizumab (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"},}
6b9e5927-e03b-425d-a58c-9b5b88b9ef97.aspx
  
2680BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampusMA00.037nAdministrative (00)MA00.037nMA00.0376b9e5927-e03b-425d-a58c-9b5b88b9ef97Billing 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
{"2681": {"Id":2681,"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":10319,"PolicyAttachmentPageName":"6a943845-e39d-4ad4-8727-4465062e7937"},}
96da06ed-00d9-4801-a10f-eca056e4efaa.aspx
  
2875BiofeedbackTherapyMA07.010cMedicine (07)MA07.010cMA07.01096da06ed-00d9-4801-a10f-eca056e4efaaBiofeedback TherapyBiofeedback Therapy
f4fcbb61-7295-44ee-b8cb-b86d7a9235b6.aspx
  
2475BioimpedancefortheDetectionofLymphedemaMA07.052aMedicine (07)MA07.052aMA07.052f4fcbb61-7295-44ee-b8cb-b86d7a9235b6Bioimpedance for the Detection of LymphedemaBioimpedance for the Detection of Lymphedema
8ca320a0-0572-4581-a68e-393fca7d4241.aspx
  
2419Blinatumomab(Blincyto®)MA08.058hPharmacy (08)MA08.058hMA08.0588ca320a0-0572-4581-a68e-393fca7d4241Blinatumomab (Blincyto®) Blinatumomab (Blincyto®)
639a0e4c-9fd6-4cf6-a8d6-a52b72001aca.aspx
  
2086Bone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAidsMA11.049hSurgery (11)MA11.049hMA11.049639a0e4c-9fd6-4cf6-a8d6-a52b72001acaBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing AidsBone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
49bb674e-5f06-4734-af15-2c14d19aa257.aspx
  
2306BotulinumToxinAgentsMA08.017mPharmacy (08)MA08.017mMA08.01749bb674e-5f06-4734-af15-2c14d19aa257Botulinum Toxin AgentsBotulinum Toxin Agents
{"2307": {"Id":2307,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":9955,"PolicyAttachmentPageName":"8c44de41-06d1-48c2-b57e-89954d58a89a"},}
08f7cd0d-e498-432e-a343-9dcd830131be.aspx
  
2424BrentuximabVedotin(Adcetris®)MA08.068lPharmacy (08)MA08.068lMA08.06808f7cd0d-e498-432e-a343-9dcd830131beBrentuximab Vedotin (Adcetris®)Brentuximab Vedotin (Adcetris®)
6d6e2dc1-5970-4a4e-8298-60b7e3d9f54e.aspx
  
1772BronchialValvesMA11.020Surgery (11)MA11.020MA11.0206d6e2dc1-5970-4a4e-8298-60b7e3d9f54eBronchial ValvesBronchial Valves
5f361c9d-2669-488d-abdb-6f3c1edece75.aspx
  
2688BundledProcedureCodesMA00.026yAdministrative (00)MA00.026yMA00.0265f361c9d-2669-488d-abdb-6f3c1edece75Bundled Procedure CodesBundled Procedure Codes
{"2689": {"Id":2689,"MPAttachmentLetter":"B","Title":"Procedures/Services Not Eligible for Separate Reimbursement","MPPolicyAttachmentInternalSourceId":10324,"PolicyAttachmentPageName":"c9af3bc5-57db-45ac-8465-553cc963cfdb"},"2690": {"Id":2690,"MPAttachmentLetter":"A","Title":"Always Bundled and Bundled Procedures (MPFSDB Indicator B and T)","MPPolicyAttachmentInternalSourceId":10325,"PolicyAttachmentPageName":"4e184a47-4957-47c3-8f94-040bf2199f64"},"2691": {"Id":2691,"MPAttachmentLetter":"D","Title":"Procedures/Services Not Eligible for Separate Reimbursement when reported with another specific Procedure/Service","MPPolicyAttachmentInternalSourceId":10326,"PolicyAttachmentPageName":"18caa69c-1db8-496a-a939-1314d876b05d"},"2692": {"Id":2692,"MPAttachmentLetter":"C","Title":"Procedures/Services Not Eligible for Reimbursement","MPPolicyAttachmentInternalSourceId":10327,"PolicyAttachmentPageName":"687e3064-bfe3-48d5-b083-f87b4e2280cc"},}
b1689359-c40c-43eb-9601-d56233937dc3.aspx
  
2035Burosumab-twza(Crysvita®)MA08.099bPharmacy (08)MA08.099bMA08.099b1689359-c40c-43eb-9601-d56233937dc3Burosumab-twza (Crysvita®)Burosumab-twza (Crysvita®)
640e1009-3d23-4291-9c2f-b37a382ab426.aspx
  
2028Canakinumab(Ilaris®)MA08.101cPharmacy (08)MA08.101cMA08.101640e1009-3d23-4291-9c2f-b37a382ab426Canakinumab (Ilaris®)Canakinumab (Ilaris®)
{"2029": {"Id":2029,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":9690,"PolicyAttachmentPageName":"53353162-3261-4d61-a7fb-7e68dac80857"},}
962922a4-aef5-4689-9b1b-85ee11a271a2.aspx
  
2774CanesandCrutchesMA05.052cDME (05)MA05.052cMA05.052962922a4-aef5-4689-9b1b-85ee11a271a2Canes and CrutchesCanes and Crutches
dd600a4d-bbb5-4700-93b3-8514af6588df.aspx
  
2886CapsuleEndoscopyMA07.022fMedicine (07)MA07.022fMA07.022dd600a4d-bbb5-4700-93b3-8514af6588dfCapsule EndoscopyCapsule Endoscopy
f6dc6319-3385-4d84-b540-8de9cbd22e64.aspx
  
2854CardiacContractilityModulationMA05.038DME (05)MA05.038MA05.038f6dc6319-3385-4d84-b540-8de9cbd22e64Cardiac Contractility ModulationCardiac Contractility Modulation
7d312683-b02c-48b0-8137-f522cf439504.aspx
  
3015CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)ProgramsMA10.002gRehabilitation Services (10)MA10.002gMA10.0027d312683-b02c-48b0-8137-f522cf439504Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) ProgramsCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
{"3016": {"Id":3016,"MPAttachmentLetter":"A","Title":"Medically Necessary ICD-10 Codes","MPPolicyAttachmentInternalSourceId":10309,"PolicyAttachmentPageName":"4fbc93f0-83d7-41df-92e7-11fdd79574a2"},}
7b8cb0f1-d4c0-4cdf-8082-8150125cb66b.aspx
  
2686CareManagementandCarePlanningServicesMA00.006pAdministrative (00)MA00.006pMA00.0067b8cb0f1-d4c0-4cdf-8082-8150125cb66bCare Management and Care Planning ServicesCare Management and Care Planning Services
2cc54b39-ae64-4294-a882-94ec127233cc.aspx
  
2471Carfilzomib(Kyprolis®)MA08.062kPharmacy (08)MA08.062kMA08.0622cc54b39-ae64-4294-a882-94ec127233ccCarfilzomib (Kyprolis®)Carfilzomib (Kyprolis®)
baa5f89e-a39b-4277-bc0d-25cb3c212674.aspx
  
1321CastandSplintApplicationsandAssociatedSuppliesMA00.012cAdministrative (00)MA00.012cMA00.012baa5f89e-a39b-4277-bc0d-25cb3c212674Cast and Splint Applications and Associated SuppliesCast and Splint Applications and Associated Supplies
{"1322": {"Id":1322,"MPAttachmentLetter":"A","Title":"Procedures Related to Cast and Splint Applications and Associated Supplies","MPPolicyAttachmentInternalSourceId":8998,"PolicyAttachmentPageName":"f1396f83-4def-4eb7-b446-324bb3d5d1dd"},}
f157e0bf-e7e6-405d-ab31-947f31e9e753.aspx
  
2523CataractSurgeryMA11.054eSurgery (11)MA11.054eMA11.054f157e0bf-e7e6-405d-ab31-947f31e9e753Cataract SurgeryCataract Surgery
{"2524": {"Id":2524,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":10189,"PolicyAttachmentPageName":"55226f9f-7725-47d5-9c92-006aafbd44bd"},}
253e24f0-874a-4935-b0b0-8b355d648426.aspx
  
2230CatheterAblationofCardiacArrhythmiasMA11.060hSurgery (11)MA11.060hMA11.060253e24f0-874a-4935-b0b0-8b355d648426Catheter Ablation of Cardiac ArrhythmiasCatheter Ablation of Cardiac Arrhythmias
193f5d5b-8093-4d08-804c-65da60b3134f.aspx
  
2577Cemiplimab-rwlc(Libtayo®)MA08.124ePharmacy (08)MA08.124eMA08.124193f5d5b-8093-4d08-804c-65da60b3134fCemiplimab-rwlc (Libtayo®)Cemiplimab-rwlc (Libtayo®)
069aa258-dddc-483b-9a65-2e9baee60a0b.aspx
  
2531Cerliponasealfa(Brineura®)MA08.089dPharmacy (08)MA08.089dMA08.089069aa258-dddc-483b-9a65-2e9baee60a0bCerliponase alfa (Brineura®)Cerliponase alfa (Brineura®)
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2530CervicalTractionDevicesforIn-homeUseMA05.009bDME (05)MA05.009bMA05.0094f290435-4662-446d-bbe8-26fa84229cc0Cervical Traction Devices for In-home UseCervical Traction Devices for In-home Use
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2429Cetuximab(Erbitux®)MA08.031gPharmacy (08)MA08.031gMA08.031feb4f2f7-5ffb-4524-b624-dee20461f270Cetuximab (Erbitux®)Cetuximab (Erbitux®)
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2779ChemicalPeelsMA11.103cSurgery (11)MA11.103cMA11.103d427612e-03ff-41cb-998f-d783a2860923Chemical PeelsChemical Peels
ed98942f-28e7-4647-896a-66a6f8dd7962.aspx
  
2746ChimericAntigenReceptor(CART)Therapy:YescartaTecartus,Breyanzi,KymriahandAucatzylMA08.093qPharmacy (08)MA08.093qMA08.093ed98942f-28e7-4647-896a-66a6f8dd7962Chimeric Antigen Receptor (CART) Therapy: Yescarta Tecartus, Breyanzi, Kymriah and AucatzylChimeric Antigen Receptor (CART) Therapy: Yescarta Tecartus, Breyanzi, Kymriah and Aucatzyl
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2747ChimericAntigenReceptorT-cell(CAR-T)Therapy:Carvykti®andAbecma®MA08.190Pharmacy (08)MA08.190MA08.190051cfa01-4c48-4aaf-9372-77bcc638a5e7Chimeric Antigen Receptor T-cell (CAR-T) Therapy: Carvykti® and Abecma®Chimeric Antigen Receptor T-cell (CAR-T) Therapy: Carvykti® and Abecma®
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1852ChiropracticServicesMA10.004iRehabilitation Services (10)MA10.004iMA10.004e3c7eb95-2bfd-4ddb-9bf2-f438b078b797Chiropractic ServicesChiropractic Services
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2642CoagulationFactorsMA08.004zPharmacy (08)MA08.004zMA08.0044abbc724-be9c-450f-a8f6-5fbe74484033Coagulation FactorsCoagulation Factors
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2487Cobalamin(VitaminB12),FolicAcid,andHomocysteineTestingMA06.032aPathology and Laboratory (06)MA06.032aMA06.03247d731d2-4723-459c-a2dd-59763d549daaCobalamin (Vitamin B12), Folic Acid, and Homocysteine TestingCobalamin (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"},}
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1862CochlearImplantationMA11.039eSurgery (11)MA11.039eMA11.0399a7459bb-83c5-4d00-8b5f-771907d1b7feCochlear ImplantationCochlear Implantation
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2043Collagenaseclostridiumhistolyticum(Xiaflex®),collagenaseclostridiumhistolyticum-aaes(Qwo®)MA08.128Pharmacy (08)MA08.128MA08.1285fa34a20-7955-477d-8d20-85cddb01d491Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo®)Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo®)
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2782CommodeChairsMA05.036cDME (05)MA05.036cMA05.0369ca7eb73-e72f-4330-ad21-8b3e938e736aCommode 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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2962CompositeTissueAllotransplantationoftheHand(s)andFaceMA11.112Surgery (11)MA11.112MA11.112facb0f10-08fc-40d7-a080-d5460193a804Composite Tissue Allotransplantation of the Hand(s) and FaceComposite Tissue Allotransplantation of the Hand(s) and Face
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2851CompressionGarmentsMA05.045gDME (05)MA05.045gMA05.045e93980e0-b6dc-4121-9661-8eebf434d026Compression GarmentsCompression Garments
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2432Computer-AidedDetection(CAD)SystemforUsewithChestRadiographsMA09.014bRadiology (09)MA09.014bMA09.0148088583e-f0c9-4816-b5b1-791305f874f2Computer-Aided Detection (CAD) System for Use with Chest RadiographsComputer-Aided Detection (CAD) System for Use with Chest Radiographs
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2765Computer-AssistedMusculoskeletalSurgicalNavigationalOrthopedicProcedureMA11.088cSurgery (11)MA11.088cMA11.0886afaf555-2468-484e-8413-2dff01ca6a41Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic ProcedureComputer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
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2533ContinuousGlucoseMonitorsandHomeBloodGlucoseMonitorsandSuppliesMA00.002rAdministrative (00)MA00.002rMA00.002f4b8f2f1-6050-4811-bfab-63b97470b602Continuous Glucose Monitors and Home Blood Glucose Monitors and SuppliesContinuous Glucose Monitors and Home Blood Glucose Monitors and Supplies
{"2534": {"Id":2534,"MPAttachmentLetter":"B","Title":"Implantable Continuous Glucose Monitors (I-CGM)","MPPolicyAttachmentInternalSourceId":10161,"PolicyAttachmentPageName":"65e970c1-5f62-4f23-ae90-4c2fa67f77d8"},"2535": {"Id":2535,"MPAttachmentLetter":"A","Title":"ICD10: Long-Term Interstitial CGMS (Non-Implantable)","MPPolicyAttachmentInternalSourceId":10162,"PolicyAttachmentPageName":"f017c273-e8f3-45a6-a7a0-57a1c65a4ed9"},}
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1780ContrastAgentsUsedinConjunctionwithEchocardiographyMA09.004cRadiology (09)MA09.004cMA09.004842dcaa2-0a33-4711-a694-34e27677d4f9Contrast Agents Used in Conjunction with EchocardiographyContrast Agents Used in Conjunction with Echocardiography
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2356CornealPachymetryUsingUltrasoundMA07.046hMedicine (07)MA07.046hMA07.046cb783ed8-5d0b-4f59-a626-bab1aae62a9bCorneal Pachymetry Using UltrasoundCorneal Pachymetry Using Ultrasound
{"2357": {"Id":2357,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes Eligible to be Reported for Corneal Pachymetry Using Ultrasound","MPPolicyAttachmentInternalSourceId":9946,"PolicyAttachmentPageName":"d693db6c-8969-4973-a7ae-b70e21839a73"},}
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2186Cosibelimab-ipdl(Unloxcyt™)MA08.184Pharmacy (08)MA08.184MA08.1846faae685-625b-4ab8-bbfc-3ac992fabc00Cosibelimab-ipdl (Unloxcyt™)Cosibelimab-ipdl (Unloxcyt™)
1d270f54-4dcc-4a52-94bb-ee5dbfa926b5.aspx
  
1713CosmeticProceduresMA12.009aMiscellaneous (12)MA12.009aMA12.0091d270f54-4dcc-4a52-94bb-ee5dbfa926b5Cosmetic ProceduresCosmetic Procedures
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1506CoverageofMedicalDevicesMA05.040bDME (05)MA05.040bMA05.0406c112be2-1a7e-41f5-904b-82a4223bec8bCoverage of Medical DevicesCoverage of Medical Devices
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2543CranialElectrotherapyStimulationMA05.066dDME (05)MA05.066dMA05.066eb1e0f92-41df-4033-894b-9cbe6c29b894Cranial Electrotherapy StimulationCranial Electrotherapy Stimulation
4a81549f-5ec6-49a9-aac6-5cf546195c50.aspx
  
2179crizanlizumab-tmca(Adakveo®) MA08.109cPharmacy (08)MA08.109cMA08.1094a81549f-5ec6-49a9-aac6-5cf546195c50crizanlizumab-tmca (Adakveo®) crizanlizumab-tmca (Adakveo®)
167a066b-85de-4200-8a02-d49b264809f1.aspx
  
2009Crovalimab-akkz(PiaSky)MA08.178Pharmacy (08)MA08.178MA08.178167a066b-85de-4200-8a02-d49b264809f1Crovalimab-akkz (PiaSky) Crovalimab-akkz (PiaSky)
5ae0b794-81ea-43b8-800e-25a499d06b74.aspx
  
2706CryosurgicalAblationoftheProstateGlandMA11.022aSurgery (11)MA11.022aMA11.0225ae0b794-81ea-43b8-800e-25a499d06b74Cryosurgical Ablation of the Prostate GlandCryosurgical Ablation of the Prostate Gland
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2249Daratumumab(Darzalex®),DaratumumabandHyaluronidase-fihj(DarzalexFaspro®)MA08.079mPharmacy (08)MA08.079mMA08.079801605be-f9f1-4e6c-a5a6-ac2e14bec1bdDaratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®)Daratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®)
af2c5712-4282-4d3d-93f4-696bca4e9650.aspx
  
2443Datopotamabderuxtecan(Datroway®)MA08.185Pharmacy (08)MA08.185MA08.185af2c5712-4282-4d3d-93f4-696bca4e9650Datopotamab deruxtecan (Datroway®)Datopotamab deruxtecan (Datroway®)
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2563DayRehabilitationMA10.005cRehabilitation Services (10)MA10.005cMA10.005ef75cd35-0ac2-4d0f-81cc-b74f9829c6cdDay RehabilitationDay Rehabilitation
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2879DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNailsMA11.014hSurgery (11)MA11.014hMA11.014c4598c0d-e799-43f8-ae81-7582556a6d1fDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe NailsDebridement 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"},}
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2513DeepBrainStimulation(DBS)MA11.005hSurgery (11)MA11.005hMA11.005b55227d0-61bf-4b01-9a40-c37a28aebd9eDeep Brain Stimulation (DBS)Deep Brain Stimulation (DBS)
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2889Denosumab(Prolia®,Xgeva®)andrelatedbiosimilars,andRomosozumab-aqqg(Evenity®)MA08.052pPharmacy (08)MA08.052pMA08.05222490df6-0dee-4e63-bfc2-646a29884810Denosumab (Prolia®, Xgeva®) and related biosimilars, and Romosozumab-aqqg (Evenity®) Denosumab (Prolia®, Xgeva®) and related biosimilars, and Romosozumab-aqqg (Evenity®)
{"2890": {"Id":2890,"MPAttachmentLetter":"A","Title":"ICD-10-CM Codes","MPPolicyAttachmentInternalSourceId":10558,"PolicyAttachmentPageName":"8440da2f-d845-48a5-994c-0d5974677bb5"},}
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2810DermabrasionforRhinophyma,Septoplasty,Rhinoplasty,andSeptorhinoplastyMA11.099fSurgery (11)MA11.099fMA11.099088da914-5d67-479b-9eb7-24338beb3b25Dermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and SeptorhinoplastyDermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and Septorhinoplasty
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2693DirectAccesstoObstetrics/Gynecology(OB/GYN)ServicesMA00.032hAdministrative (00)MA00.032hMA00.0324c30fb48-2d01-4abe-81b8-817317bf3763Direct Access to Obstetrics/Gynecology (OB/GYN) ServicesDirect Access to Obstetrics/Gynecology (OB/GYN) Services
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2229DirectEndoscopicNecrosectomy(DEN)fortheTreatmentofPancreaticNecrosisMA11.115Surgery (11)MA11.115MA11.115b98d1c91-bff9-4ad0-b69d-53a420043362Direct Endoscopic Necrosectomy (DEN) for the Treatment of Pancreatic NecrosisDirect Endoscopic Necrosectomy (DEN) for the Treatment of Pancreatic Necrosis
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2905Dofetilide(Tikosyn®)UseintheInpatientSettingMA08.021cPharmacy (08)MA08.021cMA08.021266d6272-4353-40bb-b1bd-66cf0b68ea74Dofetilide (Tikosyn®) Use in the Inpatient SettingDofetilide (Tikosyn®) Use in the Inpatient Setting
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1999Dostarlimab-gxly(Jemperli)MA08.136fPharmacy (08)MA08.136fMA08.136ff5e7a17-1598-4d46-9cb4-d0ea21aa945cDostarlimab-gxly (Jemperli)Dostarlimab-gxly (Jemperli)
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2827Drug-ElutingBeadsandBlandEmbolizationfortheTreatmentofHepaticMalignanciesMA07.041cMedicine (07)MA07.041cMA07.041c29718ec-3d4d-489b-8417-cdfc26f95a25Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic MalignanciesDrug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
9b4b85f5-5d32-41e2-9f04-5f1e429a4d2f.aspx
  
2411DurableMedicalEquipment(DME)MA05.044vDME (05)MA05.044vMA05.0449b4b85f5-5d32-41e2-9f04-5f1e429a4d2fDurable Medical Equipment (DME)Durable Medical Equipment (DME)
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1507DurableMedicalEquipment(DME)NotSubjecttoaRentaltoPurchaseMaximumMA05.028eDME (05)MA05.028eMA05.0287961a20b-70b6-4d08-a362-6da61ef8bc97Durable Medical Equipment (DME) Not Subject to a Rental to Purchase MaximumDurable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
edad7d5d-fe8a-4fa9-b413-dff4b33b314d.aspx
  
2184Durvalumab(Imfinzi®)andTremelimumab-actl(Imjudo®)MA08.123ePharmacy (08)MA08.123eMA08.123edad7d5d-fe8a-4fa9-b413-dff4b33b314dDurvalumab (Imfinzi®) and Tremelimumab-actl (Imjudo®)Durvalumab (Imfinzi®) and Tremelimumab-actl (Imjudo®)
7eb67545-5ee7-49de-b585-13a7a9c40941.aspx
  
2619Eculizumab(Soliris®)andRelatedBiosimilars,Ravulizumab-cwvz(Ultomiris™)forintravenousadministrationMA08.044lPharmacy (08)MA08.044lMA08.0447eb67545-5ee7-49de-b585-13a7a9c40941Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™) for intravenous  administrationEculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™) for intravenous administration
{"2620": {"Id":2620,"MPAttachmentLetter":"A","Title":"Dosing and Frequency","MPPolicyAttachmentInternalSourceId":10174,"PolicyAttachmentPageName":"d676fcf2-189e-4a9c-938e-8c4a3476c136"},}
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2970Efbemalenograstimalfa-vuxw(Ryzneuta®),Eflapegrastim-xnst(Rolvedon™),Pegfilgrastim(Neulasta®)andRelatedBiosimilarsMA08.082pPharmacy (08)MA08.082pMA08.08234a8d705-6f68-4956-86e4-e1cae3f8cdcfEfbemalenograstim alfa-vuxw (Ryzneuta®), Eflapegrastim-xnst (Rolvedon™), Pegfilgrastim (Neulasta®) and Related BiosimilarsEfbemalenograstim alfa-vuxw (Ryzneuta®), Eflapegrastim-xnst (Rolvedon™), Pegfilgrastim (Neulasta®) and Related Biosimilars
{"2971": {"Id":2971,"MPAttachmentLetter":"A","Title":"EXAMPLES OF DISEASE SETTINGS AND CHEMOTHERAPY REGIMENS WITH A HIGH (>20%) OR INTERMEDIATE (10-20%) RISK FOR FEBRILE NEUTROPENIA","MPPolicyAttachmentInternalSourceId":10508,"PolicyAttachmentPageName":"4ee0805d-ee34-42b0-85d5-b3176cd90780"},}
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2631Efgartigimodalfa-fcab(Vyvgart)andefgartigimod-alfaandhyaluronidase-qvfc(VyvgartHytrulo)MA08.142ePharmacy (08)MA08.142eMA08.1423acedbcd-aa91-492d-924e-7916309a00cbEfgartigimod 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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