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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
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"},}
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®)
6231bcf5-4396-4515-88c4-432018cd23be.aspx
  
2039Agalsidasebeta(Fabrazyme)andpegunigalsidasealfa-iwxj(Elfabrio)MA08.033dPharmacy (08)MA08.033dMA08.0336231bcf5-4396-4515-88c4-432018cd23beAgalsidase 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®)
02daebe8-ee3d-4c67-a09d-cd44d8a906e0.aspx
  
2486Alglucosidasealfa(e.g.,Lumizyme®),Avalglucosidasealfa-ngpt(Nexviazyme®),Cipaglucosidasealfa-atga(Pombiliti™)MA08.036gPharmacy (08)MA08.036gMA08.03602daebe8-ee3d-4c67-a09d-cd44d8a906e0Alglucosidase 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™ )
cd573c33-e030-4e47-a6b1-c2030d3bbd5a.aspx
  
2418AllergyImmunotherapyMA07.055eMedicine (07)MA07.055eMA07.055cd573c33-e030-4e47-a6b1-c2030d3bbd5aAllergy ImmunotherapyAllergy Immunotherapy
fbcfa6f7-0691-44f0-aafa-5acbe773946e.aspx
  
2084Alpha-1AntitrypsinTherapy(e.g.,Prolastin-C,AralastNP,Glassia,Zemaira)MA08.050cPharmacy (08)MA08.050cMA08.050fbcfa6f7-0691-44f0-aafa-5acbe773946eAlpha-1 Antitrypsin Therapy (e.g., Prolastin-C, Aralast NP, Glassia, Zemaira)Alpha-1 Antitrypsin Therapy (e.g., Prolastin-C, Aralast NP, Glassia, Zemaira)
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
f3aaa95b-fee9-4c87-8ab1-3dcf2a31ee19.aspx
  
2182Amivantamab-vmjw(Rybrevant®)MA08.148bPharmacy (08)MA08.148bMA08.148f3aaa95b-fee9-4c87-8ab1-3dcf2a31ee19Amivantamab-vmjw (Rybrevant®)Amivantamab-vmjw (Rybrevant®)
aff0945d-e39d-4f34-af77-ba0134af81cd.aspx
  
2409AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagementMA01.008dAnesthesia (01)MA01.008dMA01.008aff0945d-e39d-4f34-af77-ba0134af81cdAnesthesia 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
{"2410": {"Id":2410,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":9983,"PolicyAttachmentPageName":"c1f062b1-8bef-44cc-b31c-65cf5a254152"},}
1764d37e-6496-4102-b06e-5b688f422cd1.aspx
  
2031Anifrolumab-fnia(Saphnelo®)MA08.140cPharmacy (08)MA08.140cMA08.1401764d37e-6496-4102-b06e-5b688f422cd1Anifrolumab-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
0582269a-54f0-4322-a12a-8273d98b0dee.aspx
  
2311ApplicationandRemovalofTattoosMA11.072Surgery (11)MA11.072MA11.0720582269a-54f0-4322-a12a-8273d98b0deeApplication 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"},}
20bfef44-9a38-4200-939d-110ff12b4f25.aspx
  
2656AsparaginaseErwiniaChrysanthemi(recombinant)-rywn(Rylaze®)MA08.085kPharmacy (08)MA08.085kMA08.08520bfef44-9a38-4200-939d-110ff12b4f25Asparaginase 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"},}
8b321e27-7d29-44b8-9610-403a8cbc247e.aspx
  
2072AutonomicNervousSystemTestingMA07.027hMedicine (07)MA07.027hMA07.0278b321e27-7d29-44b8-9610-403a8cbc247eAutonomic 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®)
6524507b-ee4c-47a6-b2b9-3a015d24cf82.aspx
  
2183Axatilimab-csfr(Niktimvo™)forIntravenousUseMA08.180Pharmacy (08)MA08.180MA08.1806524507b-ee4c-47a6-b2b9-3a015d24cf82Axatilimab-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
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
45c5cf95-a635-46e7-9a79-6234c6f9712c.aspx
  
2491Bevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUseMA08.072oPharmacy (08)MA08.072oMA08.07245c5cf95-a635-46e7-9a79-6234c6f9712cBevacizumab (Avastin®) and Related Biosimilars For Oncologic UseBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
{"2492": {"Id":2492,"MPAttachmentLetter":"A","Title":"ICD 10 Diagnosis Codes","MPPolicyAttachmentInternalSourceId":10176,"PolicyAttachmentPageName":"a5f56ae7-15b7-4019-92db-43c173b626e5"},}
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"},}
2db933e2-9527-4772-94da-bf37c837322d.aspx
  
1890BiofeedbackTherapyMA07.010cMedicine (07)MA07.010cMA07.0102db933e2-9527-4772-94da-bf37c837322dBiofeedback 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"},}
0882ade7-191d-41e3-9ac6-c57b5a25b941.aspx
  
1941CanesandCrutchesMA05.052cDME (05)MA05.052cMA05.0520882ade7-191d-41e3-9ac6-c57b5a25b941Canes and CrutchesCanes and Crutches
e53a1356-78fa-4090-a727-95e76f940dd6.aspx
  
2420CapsuleEndoscopyMA07.022fMedicine (07)MA07.022fMA07.022e53a1356-78fa-4090-a727-95e76f940dd6Capsule EndoscopyCapsule Endoscopy
5676b495-af81-4ab1-81c1-1148e3ea6d1e.aspx
  
2589CardiacContractilityModulationMA05.038DME (05)MA05.038MA05.0385676b495-af81-4ab1-81c1-1148e3ea6d1eCardiac Contractility ModulationCardiac Contractility Modulation
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"},}
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®)
{"2532": {"Id":2532,"MPAttachmentLetter":"A","Title":"Dosing and Frequency Requirements for Cerliponase alfa (Brineura®)","MPPolicyAttachmentInternalSourceId":10164,"PolicyAttachmentPageName":"4522d6ad-25c0-4a46-b64a-7a81c43c2eee"},}
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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
feb4f2f7-5ffb-4524-b624-dee20461f270.aspx
  
2429Cetuximab(Erbitux®)MA08.031gPharmacy (08)MA08.031gMA08.031feb4f2f7-5ffb-4524-b624-dee20461f270Cetuximab (Erbitux®)Cetuximab (Erbitux®)
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2569ChemicalPeelsMA11.103cSurgery (11)MA11.103cMA11.103d34c6839-4a07-4817-b0fe-90eaff5c23ceChemical 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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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
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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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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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1913CompressionGarmentsMA05.045fDME (05)MA05.045fMA05.045e0371515-155c-4c19-bd08-d054f07f03a4Compression 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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1072ConsultationServicesMA00.049bAdministrative (00)MA00.049bMA00.04981badbcb-c683-4b9d-a96f-79d468315497Consultation ServicesConsultation Services
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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
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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
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2186Cosibelimab-ipdl(Unloxcyt™)MA08.184Pharmacy (08)MA08.184MA08.1846faae685-625b-4ab8-bbfc-3ac992fabc00Cosibelimab-ipdl (Unloxcyt™)Cosibelimab-ipdl (Unloxcyt™)
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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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2543CranialElectrotherapyStimulationMA05.066dDME (05)MA05.066dMA05.066eb1e0f92-41df-4033-894b-9cbe6c29b894Cranial Electrotherapy StimulationCranial Electrotherapy Stimulation
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2179crizanlizumab-tmca(Adakveo®) MA08.109cPharmacy (08)MA08.109cMA08.1094a81549f-5ec6-49a9-aac6-5cf546195c50crizanlizumab-tmca (Adakveo®) crizanlizumab-tmca (Adakveo®)
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2009Crovalimab-akkz(PiaSky)MA08.178Pharmacy (08)MA08.178MA08.178167a066b-85de-4200-8a02-d49b264809f1Crovalimab-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
801605be-f9f1-4e6c-a5a6-ac2e14bec1bd.aspx
  
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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2275DebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNailsMA11.014hSurgery (11)MA11.014hMA11.014f02fb3d0-8dc2-4082-8c5d-87285850680eDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe NailsDebridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
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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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2586Denosumab(Prolia®,Xgeva®)andrelatedbiosimilars,andRomosozumab-aqqg(Evenity®)MA08.052oPharmacy (08)MA08.052oMA08.052412559a2-502b-4b7e-9a67-9b1f508be15eDenosumab (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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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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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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2435Drug-ElutingBeadsandBlandEmbolizationfortheTreatmentofHepaticMalignanciesMA07.041cMedicine (07)MA07.041cMA07.041722a9e5b-e490-4e1d-a016-0ad76c2a5aeeDrug-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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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
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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®)
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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
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2658Efbemalenograstimalfa-vuxw(Ryzneuta®),Eflapegrastim-xnst(Rolvedon™),Pegfilgrastim(Neulasta®)andRelatedBiosimilarsMA08.082oPharmacy (08)MA08.082oMA08.082cf343454-bace-4317-9371-01e2ea152a83Efbemalenograstim alfa-vuxw (Ryzneuta®), Eflapegrastim-xnst (Rolvedon™), Pegfilgrastim (Neulasta®) and Related BiosimilarsEfbemalenograstim alfa-vuxw (Ryzneuta®), Eflapegrastim-xnst (Rolvedon™), Pegfilgrastim (Neulasta®) and Related Biosimilars
{"2659": {"Id":2659,"MPAttachmentLetter":"A","Title":"EXAMPLES OF DISEASE SETTINGS AND CHEMOTHERAPY REGIMENS WITH A HIGH (>20%) OR INTERMEDIATE (10-20%) RISK FOR FEBRILE NEUTROPENIA","MPPolicyAttachmentInternalSourceId":9901,"PolicyAttachmentPageName":"8f87cec3-b403-48ad-bc72-71d8f4bcd40b"},}
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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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2132ElectroconvulsiveTherapy(ECT)MA14.001aBehavioral Health (14)MA14.001aMA14.001eed3bc6f-8114-4aef-bab0-20260e467da0Electroconvulsive Therapy (ECT)Electroconvulsive Therapy (ECT)
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2358Electromyography(EMG)Studies,NerveConductionStudies(NCS),andRelatedElectrodiagnosticStudiesMA07.050nMedicine (07)MA07.050nMA07.0507eb78c4c-492d-48ac-b16f-dd8c1911da3eElectromyography (EMG) Studies, Nerve Conduction Studies (NCS), and Related Electrodiagnostic StudiesElectromyography (EMG) Studies, Nerve Conduction Studies (NCS), and Related Electrodiagnostic Studies
{"2359": {"Id":2359,"MPAttachmentLetter":"A","Title":"Recommended Guidelines for Electrodiagnostic (EDX) Studies","MPPolicyAttachmentInternalSourceId":10029,"PolicyAttachmentPageName":"56ce8992-677b-4eaa-b8ae-6be7a6789123"},"2360": {"Id":2360,"MPAttachmentLetter":"E","Title":"ICD10 Codes - Neuromuscular Junction Testing (NJT)","MPPolicyAttachmentInternalSourceId":10030,"PolicyAttachmentPageName":"a7247e84-d22d-4635-9298-4b7f56da2b47"},"2361": {"Id":2361,"MPAttachmentLetter":"D","Title":"ICD-10 Codes - Needle Electromyography (NEMG) for Guidance in Conjunction with Chemodenervation","MPPolicyAttachmentInternalSourceId":10031,"PolicyAttachmentPageName":"1ac16813-cc8e-4cfa-a0c3-f7b1d6f62f80"},"2362": {"Id":2362,"MPAttachmentLetter":"C","Title":"ICD10 Codes - Electromyography (EMG) of Anal or Urethral Sphincter","MPPolicyAttachmentInternalSourceId":10032,"PolicyAttachmentPageName":"d4170210-0e74-4227-9d88-1d95201dadaa"},"2363": {"Id":2363,"MPAttachmentLetter":"B","Title":"ICD10 Codes - Needle Electromyography (NEMG) and Nerve Conduction Studies (NCS)","MPPolicyAttachmentInternalSourceId":10033,"PolicyAttachmentPageName":"df928d7a-766a-4aba-9367-30e55f787645"},"2364": {"Id":2364,"MPAttachmentLetter":"H","Title":"ICD10 Codes - Visual Evoked Potentials​ (VEP)","MPPolicyAttachmentInternalSourceId":10034,"PolicyAttachmentPageName":"037afb8b-e6bf-46c5-9365-b253e9a30039"},"2365": {"Id":2365,"MPAttachmentLetter":"F","Title":"ICD10 Codes - Somatosensory Evoked Potentials (SEP) and Central Motor Evoked Potentials (CMEP)","MPPolicyAttachmentInternalSourceId":10035,"PolicyAttachmentPageName":"92617a80-177d-4614-82cc-5852d77f5061"},"2366": {"Id":2366,"MPAttachmentLetter":"G","Title":"ICD10 Codes - Brainstem Auditory Evoked Potentials (BAEP)","MPPolicyAttachmentInternalSourceId":10036,"PolicyAttachmentPageName":"bd80df95-572d-4304-9e4f-a85ac70fb984"},}
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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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