Data Coverage - Penelope

Penelope provides comprehensive coverage data from major US health insurers and Medicare:

Insurance Payers: such as UnitedHealthcare, Cigna, Aetna, Anthem, Humana, Blue Cross Blue Shield of Michigan, Blue Shield of California, CareFirst, Florida Blue…
Medicare: CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs)

For a full list of our payers, call the List Payers endpoint, and List LOBs for the lines of business under each payer.

CPT Codes (Current Procedural Terminology): ~10,000 procedure codes
CPT Modifiers: ~200 procedure modifiers
HCPCS Level 2 Codes: ~6,500 alphanumeric codes for services and supplies
HCPCS Modifiers: ~50 service modifiers
ICD-10-CM Codes (Diagnosis): ~72,000 diagnosis codes with hierarchical structure
ICD-10-PCS Codes (Procedures): ~78,000 inpatient procedure codes

Insurance Payers: the payers as per our List Payers endpoint, plus Medicare
Lines of Business: Hundreds of lines of business across commercial, Medicare, Medicaid, and exchange markets
Coverage Policies: Thousands of policies across both medical and pharmacy benefits. Topics we cover include:
- Medical benefit: infusion drugs and biologics, surgical procedures, radiology and advanced imaging, laboratory and genetic testing, and pain management
- Pharmacy benefit: GLP-1 receptor agonists for type 2 diabetes and weight loss, behavioral health such as ADHD medications, and other specialty drugs
Pharmacy Formularies: Drug prior-authorization requirements by plan and formulary
Medicare Contractors: 20+ Medicare Administrative Contractors (MACs) with state jurisdictions

Medicare data: Updated quarterly with CMS releases
Commercial policies: Monitored continuously, updated as payers publish revisions
Medical codes: Updated annually (CPT/HCPCS) or as CMS releases updates (ICD-10-CM)