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f9cd203a-79ff-4e2b-a528-de895e67a9d1.aspx
  
1330Abatacept(Orencia®)forInjectionforIntravenousUseMA08.028jPharmacy (08)MA08.028jMA08.028f9cd203a-79ff-4e2b-a528-de895e67a9d1Abatacept (Orencia®) for Injection for Intravenous UseAbatacept (Orencia®) for Injection for Intravenous Use
{"1331": {"Id":1331,"MPAttachmentLetter":"A","Title":"ICD-10 codes","MPPolicyAttachmentInternalSourceId":8939,"PolicyAttachmentPageName":"4a383499-d68a-41de-adf6-497f157070a6"},}
d7835b48-c2c3-4028-b432-1aabba29e543.aspx
  
1785AbortionMA11.010dSurgery (11)MA11.010dMA11.010d7835b48-c2c3-4028-b432-1aabba29e543AbortionAbortion
90e3032a-cf8b-40a2-8ca1-d67f50a835c7.aspx
  
1778AcupunctureMA12.004eMiscellaneous (12)MA12.004eMA12.00490e3032a-cf8b-40a2-8ca1-d67f50a835c7AcupunctureAcupuncture
{"1779": {"Id":1779,"MPAttachmentLetter":"A","Title":"ICD-10 CM Codes Eligible to be Reported for Acupuncture","MPPolicyAttachmentInternalSourceId":9447,"PolicyAttachmentPageName":"c8b67115-84cc-43bd-a119-960afdae155d"},}
40a201d5-c72e-4858-8d07-5423c65af08d.aspx
  
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"},}
9bf1af05-ecaf-480f-a925-78a3aef533fd.aspx
  
1302Agalsidasebeta(Fabrazyme)andpegunigalsidasealfa-iwxj(Elfabrio)MA08.033dPharmacy (08)MA08.033dMA08.0339bf1af05-ecaf-480f-a925-78a3aef533fdAgalsidase beta (Fabrazyme) and pegunigalsidase alfa-iwxj (Elfabrio)Agalsidase beta (Fabrazyme) and pegunigalsidase alfa-iwxj (Elfabrio)
66c3e611-3717-4969-b891-61d21233a143.aspx
  
1148AirAmbulanceServicesMA12.007bMiscellaneous (12)MA12.007bMA12.00766c3e611-3717-4969-b891-61d21233a143Air Ambulance ServicesAir Ambulance Services
018d30d6-6325-4b17-b87a-a55ccc10f0d0.aspx
  
1893Alemtuzumab(Lemtrada®)MA08.015dPharmacy (08)MA08.015dMA08.015018d30d6-6325-4b17-b87a-a55ccc10f0d0Alemtuzumab (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™ )
7c1d9cf9-dd9c-4e19-924e-ad01a9b72bda.aspx
  
1024AllergyImmunotherapyMA07.055dMedicine (07)MA07.055dMA07.0557c1d9cf9-dd9c-4e19-924e-ad01a9b72bdaAllergy ImmunotherapyAllergy Immunotherapy
93d63acf-a8cc-41bc-a2c5-18238795ccfb.aspx
  
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)
48b9a780-b477-47b2-946e-4216cad4a46c.aspx
  
1988AlwaysBundledProcedureCodesMA00.026wAdministrative (00)MA00.026wMA00.02648b9a780-b477-47b2-946e-4216cad4a46cAlways Bundled Procedure CodesAlways Bundled Procedure Codes
{"1989": {"Id":1989,"MPAttachmentLetter":"B","Title":"Procedures/Services Not Eligible for Separate Reimbursement","MPPolicyAttachmentInternalSourceId":9403,"PolicyAttachmentPageName":"7a1f46cc-2c96-4598-bfc7-607920497e50"},"1990": {"Id":1990,"MPAttachmentLetter":"A","Title":"Always Bundled Procedures (MPFSD Indicator B)","MPPolicyAttachmentInternalSourceId":9404,"PolicyAttachmentPageName":"1b8ce7c7-ce97-4376-979f-eb0f265b31b4"},"1991": {"Id":1991,"MPAttachmentLetter":"C","Title":"Procedures/Services Not Eligible for Reimbursement","MPPolicyAttachmentInternalSourceId":9405,"PolicyAttachmentPageName":"1b782516-27a5-4620-956e-c33bbd9fa01c"},}
a691481d-7079-4c8c-b062-7a02e33d1bf3.aspx
  
1948AmbulatoryBloodPressureMonitoring(ABPM)andHomeBloodPressureMonitoring(HBPM)DevicesMA07.005dMedicine (07)MA07.005dMA07.005a691481d-7079-4c8c-b062-7a02e33d1bf3Ambulatory 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
82bf3454-ff11-494a-82fc-4a277c9e2c6c.aspx
  
1081Amivantamab-vmjw(Rybrevant®)MA08.148aPharmacy (08)MA08.148aMA08.14882bf3454-ff11-494a-82fc-4a277c9e2c6cAmivantamab-vmjw (Rybrevant®)Amivantamab-vmjw (Rybrevant®)
5342b2c3-d175-483e-bbfd-63d920366304.aspx
  
1369AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagementMA01.008cAnesthesia (01)MA01.008cMA01.0085342b2c3-d175-483e-bbfd-63d920366304Anesthesia 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
{}
ffb29139-c6b9-4389-9ceb-5670bc56e674.aspx
  
1137Anifrolumab-fnia(Saphnelo®)MA08.140cPharmacy (08)MA08.140cMA08.140ffb29139-c6b9-4389-9ceb-5670bc56e674Anifrolumab-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"},}
82718d74-5f67-4a26-9e28-e7433bc3a5a0.aspx
  
1598ApheresisTherapyMA06.001fPathology and Laboratory (06)MA06.001fMA06.00182718d74-5f67-4a26-9e28-e7433bc3a5a0Apheresis TherapyApheresis Therapy
e3f4b785-821c-42a7-b608-7cfe7f542a0a.aspx
  
1542Apos®biomechanicalshoesystemMA05.070DME (05)MA05.070MA05.070e3f4b785-821c-42a7-b608-7cfe7f542a0aApos® 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
e09477ca-37b6-4df8-949c-3203118199db.aspx
  
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"},}
46d052a1-42e0-4afc-b47d-746e3ba72aa7.aspx
  
1673AsparaginaseErwiniaChrysanthemi(recombinant)-rywn(Rylaze®)MA08.085iPharmacy (08)MA08.085iMA08.08546d052a1-42e0-4afc-b47d-746e3ba72aa7Asparaginase Erwinia Chrysanthemi (recombinant)-rywn (Rylaze®)Asparaginase Erwinia Chrysanthemi (recombinant)-rywn (Rylaze®)
0f09f597-2f8f-46da-a496-e90ce9c9b442.aspx
  
1832Atezolizumab(Tecentriq®)andAtezolizumabwithHyaluronidase-tqjs(TecentriqHybrezaTM)MA08.127ePharmacy (08)MA08.127eMA08.1270f09f597-2f8f-46da-a496-e90ce9c9b442Atezolizumab (Tecentriq®) and Atezolizumab with Hyaluronidase-tqjs (Tecentriq Hybreza TM)Atezolizumab (Tecentriq®) and Atezolizumab with Hyaluronidase-tqjs (Tecentriq Hybreza TM)
{"1833": {"Id":1833,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":9572,"PolicyAttachmentPageName":"b0002088-fd2d-4630-bc34-b17d4fb4c04d"},}
1196f21f-3450-490c-852b-febc54f66776.aspx
  
1078AuricularProsthesesMA05.068DME (05)MA05.068MA05.0681196f21f-3450-490c-852b-febc54f66776Auricular 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"},}
ccbfb000-08b5-4105-8b07-392f2718ff25.aspx
  
1382AutonomicNervousSystemTestingMA07.027gMedicine (07)MA07.027gMA07.027ccbfb000-08b5-4105-8b07-392f2718ff25Autonomic Nervous System TestingAutonomic Nervous System Testing
6a987f55-f913-4da6-88e6-62b7b311252c.aspx
  
1621Avelumab(Bavencio®)MA08.122dPharmacy (08)MA08.122dMA08.1226a987f55-f913-4da6-88e6-62b7b311252cAvelumab (Bavencio®)Avelumab (Bavencio®)
{"1622": {"Id":1622,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":9268,"PolicyAttachmentPageName":"90877462-36a1-41c2-ab95-3654a49366d5"},}
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
ea8f920a-fc0b-497b-ad5e-a25e4944e36f.aspx
  
1069Belimumab(Benlysta®)forIntravenousUseMA08.057dPharmacy (08)MA08.057dMA08.057ea8f920a-fc0b-497b-ad5e-a25e4944e36fBelimumab (Benlysta®) for Intravenous UseBelimumab (Benlysta®) for Intravenous Use
e4ff28c3-83f1-406d-9641-86b5d2ff1b53.aspx
  
1603Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUseMA08.072oPharmacy (08)MA08.072oMA08.072e4ff28c3-83f1-406d-9641-86b5d2ff1b53Bevacizumab (Avastin®) and Related Biosimilars For Oncologic UseBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
{"1604": {"Id":1604,"MPAttachmentLetter":"A","Title":"ICD 10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":9219,"PolicyAttachmentPageName":"de59b461-e300-469f-8fcd-afe265d2bc65"},}
2b9d85e2-3b38-4ae7-ad89-c2c270c9cc25.aspx
  
1718BillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampusMA00.037mAdministrative (00)MA00.037mMA00.0372b9d85e2-3b38-4ae7-ad89-c2c270c9cc25Billing 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
{"1719": {"Id":1719,"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":9410,"PolicyAttachmentPageName":"2c6979e7-123a-4d8d-a616-d378fc479869"},}
2db933e2-9527-4772-94da-bf37c837322d.aspx
  
1890BiofeedbackTherapyMA07.010cMedicine (07)MA07.010cMA07.0102db933e2-9527-4772-94da-bf37c837322dBiofeedback TherapyBiofeedback Therapy
7afcb7bb-2baf-4668-9a41-2b522051ffec.aspx
  
1292BioimpedancefortheDetectionofLymphedemaMA07.052Medicine (07)MA07.052MA07.0527afcb7bb-2baf-4668-9a41-2b522051ffecBioimpedance for the Detection of LymphedemaBioimpedance for the Detection of Lymphedema
21145f4c-ee33-4aad-917a-30695c515a2d.aspx
  
1532Blinatumomab(Blincyto®)MA08.058gPharmacy (08)MA08.058gMA08.05821145f4c-ee33-4aad-917a-30695c515a2dBlinatumomab (Blincyto®) Blinatumomab (Blincyto®)
2098fab0-09bc-4325-aba2-2b77632a83b2.aspx
  
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
258aa92f-57d7-4af8-a540-d6b10011a2c9.aspx
  
1951BotulinumToxinAgentsMA08.017lPharmacy (08)MA08.017lMA08.017258aa92f-57d7-4af8-a540-d6b10011a2c9Botulinum Toxin AgentsBotulinum Toxin Agents
{"1952": {"Id":1952,"MPAttachmentLetter":"A","Title":"ICD-10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":9475,"PolicyAttachmentPageName":"9dd4bfb1-de1c-428c-8f86-abfce570b715"},}
c104ca59-b0c0-4ba7-9b1c-853112eb5e7f.aspx
  
1549BrentuximabVedotin(Adcetris®)MA08.068kPharmacy (08)MA08.068kMA08.068c104ca59-b0c0-4ba7-9b1c-853112eb5e7fBrentuximab Vedotin (Adcetris®)Brentuximab Vedotin (Adcetris®)
{"1550": {"Id":1550,"MPAttachmentLetter":"A","Title":"ICD 10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":9002,"PolicyAttachmentPageName":"dc4f21e7-0c13-4061-afec-f7eb829ab68e"},}
6d6e2dc1-5970-4a4e-8298-60b7e3d9f54e.aspx
  
1772BronchialValvesMA11.020Surgery (11)MA11.020MA11.0206d6e2dc1-5970-4a4e-8298-60b7e3d9f54eBronchial 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®)
24718575-f0ad-4bb7-a298-4cf311b11f9b.aspx
  
1608Canakinumab(Ilaris®)MA08.101cPharmacy (08)MA08.101cMA08.10124718575-f0ad-4bb7-a298-4cf311b11f9bCanakinumab (Ilaris®)Canakinumab (Ilaris®)
{"1609": {"Id":1609,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":9271,"PolicyAttachmentPageName":"26c77500-4891-4873-9e46-706be27bdbd2"},}
0882ade7-191d-41e3-9ac6-c57b5a25b941.aspx
  
1941CanesandCrutchesMA05.052cDME (05)MA05.052cMA05.0520882ade7-191d-41e3-9ac6-c57b5a25b941Canes and CrutchesCanes and Crutches
dabf0152-819f-40c4-8150-035de6fa9461.aspx
  
788CapsuleEndoscopyMA07.022eMedicine (07)MA07.022eMA07.022dabf0152-819f-40c4-8150-035de6fa9461Capsule EndoscopyCapsule Endoscopy
3dcc63c3-3983-4784-b10b-0d9355a1bb7f.aspx
  
1877CardiacRehabilitation(CR)andIntensiveCardiacRehabilitation(ICR)ProgramsMA10.002fRehabilitation Services (10)MA10.002fMA10.0023dcc63c3-3983-4784-b10b-0d9355a1bb7fCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) ProgramsCardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
{"1878": {"Id":1878,"MPAttachmentLetter":"A","Title":"Medically Necessary ICD-10 Codes","MPPolicyAttachmentInternalSourceId":9407,"PolicyAttachmentPageName":"01f239ec-1df4-496e-9cd7-1172288c6531"},}
baf706da-50b3-4865-aaca-f619ddd95374.aspx
  
1707CareManagementandCarePlanningServicesMA00.006oAdministrative (00)MA00.006oMA00.006baf706da-50b3-4865-aaca-f619ddd95374Care Management and Care Planning ServicesCare Management and Care Planning Services
5a2dd532-c36f-483f-9348-8600916ede19.aspx
  
1548Carfilzomib(Kyprolis®)MA08.062jPharmacy (08)MA08.062jMA08.0625a2dd532-c36f-483f-9348-8600916ede19Carfilzomib (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"},}
6d9edd1a-96ab-4fe5-b196-e98b567febd4.aspx
  
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"},}
f43f47dc-2ebc-4123-9180-843422b7186b.aspx
  
1652CatheterAblationofCardiacArrhythmiasMA11.060hSurgery (11)MA11.060hMA11.060f43f47dc-2ebc-4123-9180-843422b7186bCatheter Ablation of Cardiac ArrhythmiasCatheter Ablation of Cardiac Arrhythmias
96b211e5-6d32-4c5f-b8af-35d9af3bde2f.aspx
  
1553Cemiplimab-rwlc(Libtayo®)MA08.124dPharmacy (08)MA08.124dMA08.12496b211e5-6d32-4c5f-b8af-35d9af3bde2fCemiplimab-rwlc (Libtayo®)Cemiplimab-rwlc (Libtayo®)
8136c93c-9de8-4cec-be5d-15788042a569.aspx
  
1570Cerliponasealfa(Brineura®)MA08.089dPharmacy (08)MA08.089dMA08.0898136c93c-9de8-4cec-be5d-15788042a569Cerliponase alfa (Brineura®)Cerliponase alfa (Brineura®)
{"1571": {"Id":1571,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements for Cerliponase alfa (Brineura®)","MPPolicyAttachmentInternalSourceId":9270,"PolicyAttachmentPageName":"e68f969d-b0be-41fc-812a-b94d6ef808bc"},}
8c9283e5-d136-42ad-9c04-beff05592e40.aspx
  
1611CervicalTractionDevicesforIn-homeUseMA05.009bDME (05)MA05.009bMA05.0098c9283e5-d136-42ad-9c04-beff05592e40Cervical 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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1427ChemicalPeelsMA11.103bSurgery (11)MA11.103bMA11.103867f33b5-7c1c-44d5-b3a7-7681208400e1Chemical PeelsChemical Peels
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1757ChimericAntigenReceptor(CAR)TherapyMA08.093pPharmacy (08)MA08.093pMA08.0931d2f3b07-4552-4271-b5b6-2c6d8868560fChimeric Antigen Receptor (CAR) TherapyChimeric Antigen Receptor (CAR) Therapy
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1852ChiropracticServicesMA10.004iRehabilitation Services (10)MA10.004iMA10.004e3c7eb95-2bfd-4ddb-9bf2-f438b078b797Chiropractic ServicesChiropractic Services
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1835CoagulationFactorsMA08.004xPharmacy (08)MA08.004xMA08.004e589816c-b7b7-4c1b-9723-e98c980cb24dCoagulation 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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1862CochlearImplantationMA11.039eSurgery (11)MA11.039eMA11.0399a7459bb-83c5-4d00-8b5f-771907d1b7feCochlear 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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1942CommodeChairsMA05.036cDME (05)MA05.036cMA05.0360a4d21a1-bc4c-4353-b6ee-213475869ebeCommode 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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1913CompressionGarmentsMA05.045fDME (05)MA05.045fMA05.045e0371515-155c-4c19-bd08-d054f07f03a4Compression GarmentsCompression Garments
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1300Computer-AidedDetection(CAD)SystemforUsewithChestRadiographsMA09.014bRadiology (09)MA09.014bMA09.014a3add4cc-055a-4e9d-9dfc-2b2c583f3862Computer-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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1813ContinuousGlucoseMonitorsandHomeBloodGlucoseMonitorsandSuppliesMA00.002rAdministrative (00)MA00.002rMA00.0020e7c7a7f-15e9-49f3-8a67-e924101e0e07Continuous Glucose Monitors and Home Blood Glucose Monitors and SuppliesContinuous Glucose Monitors and Home Blood Glucose Monitors and Supplies
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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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1163CornealPachymetryUsingUltrasoundMA07.046gMedicine (07)MA07.046gMA07.04634c18a0b-a842-405a-8e20-c6cadd85ed9eCorneal Pachymetry Using UltrasoundCorneal Pachymetry Using Ultrasound
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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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1130CranialElectrotherapyStimulationMA05.066dDME (05)MA05.066dMA05.066e50b9ce8-e5d2-4d1b-8d9d-90ad574baf5dCranial Electrotherapy StimulationCranial Electrotherapy Stimulation
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1555CriteriaforReimbursementofEmergencyRoomServicesMA00.044dAdministrative (00)MA00.044dMA00.044cc15a385-6a4a-4ac8-9be9-35719baa321bCriteria 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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1602Crovalimab-akkz(PiaSky)MA08.178Pharmacy (08)MA08.178MA08.1787537366c-2749-4ef1-9800-d753b3903800Crovalimab-akkz (PiaSky) Crovalimab-akkz (PiaSky)
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1895CryosurgicalAblationoftheProstateGlandMA11.022aSurgery (11)MA11.022aMA11.02278b090ad-9c6b-4f69-9686-aedb354f6316Cryosurgical 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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1478DayRehabilitationMA10.005bRehabilitation Services (10)MA10.005bMA10.005b77328f5-879d-4c4f-9440-7bf227a4df4eDay RehabilitationDay Rehabilitation
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1863DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNailsMA11.014gSurgery (11)MA11.014gMA11.014d9483739-3363-48d5-930b-0c6ab7dcd958Debridement 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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1755Denosumab(Prolia®,Xgeva®)andrelatedbiosimilars,andRomosozumab-aqqg(Evenity®)MA08.052nPharmacy (08)MA08.052nMA08.0526fcb9ac3-8280-4297-86d1-98f6ad9fc92aDenosumab (Prolia®, Xgeva®) and related biosimilars, and Romosozumab-aqqg (Evenity®) Denosumab (Prolia®, Xgeva®) and related biosimilars, and Romosozumab-aqqg (Evenity®)
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1374DermabrasionforRhinophyma,Septoplasty,Rhinoplasty,andSeptorhinoplastyMA11.099eSurgery (11)MA11.099eMA11.0996d686768-2451-450f-b5ff-39c3d07a51bdDermabrasion 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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1597DirectEndoscopicNecrosectomy(DEN)fortheTreatmentofPancreaticNecrosisMA11.115Surgery (11)MA11.115MA11.115bd96e219-dbb7-4a2d-8759-1897b4ce0ab6Direct Endoscopic Necrosectomy (DEN) for the Treatment of Pancreatic NecrosisDirect Endoscopic Necrosectomy (DEN) for the Treatment of Pancreatic Necrosis
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1784Dofetilide(Tikosyn®)UseintheInpatientSettingMA08.021cPharmacy (08)MA08.021cMA08.02104c1db59-08d0-435e-8e84-b7009bba127eDofetilide (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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1501Drug-ElutingBeadsandBlandEmbolizationfortheTreatmentofHepaticMalignanciesMA07.041cMedicine (07)MA07.041cMA07.0416313f185-3f19-4b75-9ec3-10abc52ba10aDrug-Eluting Beads and Bland Embolization for the Treatment of Hepatic MalignanciesDrug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
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1838DurableMedicalEquipment(DME)MA05.044tDME (05)MA05.044tMA05.044f2512d0b-11cd-4f9d-acdd-3476145ccb7dDurable 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
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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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1829Eculizumab(Soliris®)andRelatedBiosimilars,Ravulizumab-cwvz(Ultomiris™)forintravenousadministrationMA08.044kPharmacy (08)MA08.044kMA08.0445028febe-d815-4e88-86a7-e8c04d01510fEculizumab (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
{"1195": {"Id":1195,"MPAttachmentLetter":"A","Title":"EXAMPLES OF DISEASE SETTINGS AND CHEMOTHERAPY REGIMENS WITH A HIGH (>20%) OR INTERMEDIATE (10-20%) RISK FOR FEBRILE NEUTROPENIA","MPPolicyAttachmentInternalSourceId":8752,"PolicyAttachmentPageName":"4bdddc59-fc86-407e-be6c-910d24083c4e"},}
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1439Efgartigimodalfa-fcab(Vyvgart)andefgartigimodalfaandhyaluronidase-qvfc(VyvgartHytrulo)MA08.142dPharmacy (08)MA08.142dMA08.1427989c8e0-524a-45f4-8de4-0a624fa1dd92Efgartigimod 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
{"866": {"Id":866,"MPAttachmentLetter":"A","Title":"Recommended Guidelines for Electrodiagnostic Studies","MPPolicyAttachmentInternalSourceId":8120,"PolicyAttachmentPageName":"38375e9f-5b33-4cc7-a30e-fa5853aed7fb"},"867": {"Id":867,"MPAttachmentLetter":"D","Title":"ICD-10 Codes - Needle Electromyography for Guidance in Conjunction with Chemodenervation","MPPolicyAttachmentInternalSourceId":8436,"PolicyAttachmentPageName":"551e073c-1c77-42d7-93f9-b88c29738efc"},"868": {"Id":868,"MPAttachmentLetter":"B","Title":"ICD10 Codes - Needle Electromyography and Nerve Conduction Studies","MPPolicyAttachmentInternalSourceId":8441,"PolicyAttachmentPageName":"23be52a8-9a0e-4d4a-861b-f9d1aa616df1"},"869": {"Id":869,"MPAttachmentLetter":"C","Title":"ICD10 Codes - Electromyography of Anal or Urethral Sphincter","MPPolicyAttachmentInternalSourceId":8498,"PolicyAttachmentPageName":"8f609a7a-c5a2-4912-b97a-58215fff334e"},"870": {"Id":870,"MPAttachmentLetter":"E","Title":"ICD10 Codes - Neuromuscular Junction Testing","MPPolicyAttachmentInternalSourceId":8499,"PolicyAttachmentPageName":"965d952f-a21a-4976-9f65-1ac04edb8f9d"},"871": {"Id":871,"MPAttachmentLetter":"F","Title":"ICD10 Codes - Somatosensory Evoked Potentials (SSEPs)","MPPolicyAttachmentInternalSourceId":8502,"PolicyAttachmentPageName":"b5527a94-6a17-4515-888a-c6a7ce1f7273"},}
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1908Elranatamab-bcmm(Elrexfio™)MA08.168Pharmacy (08)MA08.168MA08.168fac5a9fe-b5ac-49e5-95b0-0d5328d7f528Elranatamab-bcmm (Elrexfio™)Elranatamab-bcmm (Elrexfio™)
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