| LCD |
Effective
Date |
Revision
Effective
Date |
Title |
CPT Codes Covered in LCD |
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L34526
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10/01/2015
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07/29/2021
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Surgical Treatment of Obstructive Sleep Apnea (OSA)
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L34528
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10/01/2015
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04/28/2022
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Blepharoplasty, Blepharoptosis and Brow Lift
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L34536
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10/01/2015
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09/30/2021
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Treatment of Varicose Veins of the Lower Extremities
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L34588
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10/01/2015
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09/30/2021
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Trigger Points, Local Injections
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L34594
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10/01/2015
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10/28/2021
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Nerve Conduction Studies and Electromyography
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L34596
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10/01/2015
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09/30/2021
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Immunizations
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L34614
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10/01/2015
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10/01/2022
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Colonoscopy and Sigmoidoscopy-Diagnostic
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L34615
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10/01/2015
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10/01/2021
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Visual Fields
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L34616
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10/01/2015
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10/01/2022
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Psychiatry and Psychology Services
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L34623
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10/01/2015
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07/28/2022
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Intraoperative Neurophysiological Testing
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L34624
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10/01/2015
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10/28/2021
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Somatosensory Testing
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L34633
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10/01/2015
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07/01/2021
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Erythropoiesis Stimulating Agents (ESAs)
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L34635
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10/01/2015
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11/14/2021
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Botulinum Toxin Type A & Type B
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L34636
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10/01/2015
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10/28/2021
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Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring)
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L34641
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10/01/2015
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10/17/2022
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Transcranial Magnetic Stimulation (TMS)
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L34645
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10/01/2015
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10/01/2021
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Drug Testing
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L34646
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10/01/2015
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09/29/2022
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Psychological and Neuropsychological Testing
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L34648
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10/01/2015
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08/27/2020
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Bisphosphonate Drug Therapy
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L34658
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10/01/2015
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10/01/2021
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Vitamin D Assay Testing
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L34659
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10/01/2015
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09/29/2022
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Endoscopic Treatment of GERD
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L34760
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10/01/2015
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09/30/2021
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Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
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L34761
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10/01/2015
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12/30/2021
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Percutaneous Coronary Interventions
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L34771
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10/01/2015
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12/01/2022
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Immune Globulins
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L35121
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10/01/2015
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10/28/2021
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Coronary Computed Tomography Angiography (CCTA)
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L35124
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10/01/2015
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10/28/2021
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Autonomic Function Testing
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L35222
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10/01/2015
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12/30/2021
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Nerve Blocks for Peripheral Neuropathy
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L35486
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10/01/2015
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10/28/2021
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Pelvic Floor Dysfunction: Anorectal Manometry and EMG
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L35490
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10/01/2015
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06/12/2022
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Category III Codes
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L35494
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10/01/2015
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12/01/2022
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Mohs Micrographic Surgery
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L35498
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10/01/2015
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10/28/2021
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Removal of Benign Skin Lesions
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L35751
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10/01/2015
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01/27/2022
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Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies
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L35753
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10/01/2015
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10/01/2021
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Non-Invasive Cerebrovascular Studies
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L35755
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10/01/2015
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10/28/2021
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Non-Invasive Abdominal / Visceral Vascular Studies
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L35761
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10/01/2015
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10/01/2021
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Non-Invasive Peripheral Arterial Vascular Studies
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L35998
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10/01/2015
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10/28/2021
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Non-Coronary Vascular Stents
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L36000
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12/17/2015
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06/30/2022
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Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain
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L36400
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04/16/2016
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08/12/2021
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MolDX: Genetic Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)
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L36402
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03/18/2016
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10/01/2022
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Allergy Testing
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L36408
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03/18/2016
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10/01/2021
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Allergy Immunotherapy
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L36523
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06/16/2016
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04/22/2021
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MolDX: Biomarkers in Cardiovascular Risk Assessment
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L36797
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02/16/2017
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10/07/2021
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MolDX: NRAS Genetic Testing
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L36805
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02/16/2017
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09/29/2022
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Lab: Special Histochemical Stains and Immunohistochemical Stains
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L36807
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02/16/2017
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12/30/2021
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MolDX: Molecular Diagnostic Tests (MDT)
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L36811
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02/16/2017
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04/22/2021
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MolDX: Breast Cancer Assay: Prosigna®
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L36815
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02/16/2017
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06/30/2022
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MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease
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L36839
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02/16/2017
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07/29/2021
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Polysomnography and Other Sleep Studies
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L37001
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07/17/2017
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10/14/2021
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MolDX: MGMT Promoter Methylation Analysis
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L37003
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07/17/2017
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07/08/2021
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MolDX: HLA-DQB1*06:02 Testing for Narcolepsy
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L37011
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07/17/2017
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02/24/2022
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ProMark® Risk Score
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L37015
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07/17/2017
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05/26/2022
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Visual Electrophysiology Testing
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L37195
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09/16/2017
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10/28/2021
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MolDX: Percepta® Bronchial Genomic Classifier
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L37199
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09/16/2017
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10/28/2021
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MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)
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L37205
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09/16/2017
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05/26/2022
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Chemotherapy Drugs and their Adjuncts
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L37210
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09/16/2017
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06/30/2022
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MolDX: Decision Dx-UM (Uveal Melanoma)
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L37216
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09/16/2017
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09/30/2021
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BDX-XL2
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L37228
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04/16/2018
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02/24/2022
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Wound Care
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L37537
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03/01/2019
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07/28/2022
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Frequency of Hemodialysis
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L37539
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03/19/2018
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12/29/2022
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MolDX: Prometheus IBD sgi Diagnostic® Policy
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L37663
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08/16/2018
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07/04/2021
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MolDX: EndoPredict® Breast Cancer Gene Expression Test
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L37772
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05/13/2019
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09/01/2022
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MDS FISH
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L37913
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04/15/2019
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10/28/2021
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MolDX: Breast Cancer Index® (BCI) Gene Expression Test
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L37919
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05/13/2019
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06/24/2021
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MolDX: Envisia™, Veracyte™, Idiopathic Pulmonary Fibrosis Diagnostic Test
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L37921
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04/15/2019
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10/14/2021
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MolDX: Inivata™, InVisionFirst®, Liquid Biopsy for Patients with Lung Cancer
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L37923
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06/10/2019
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12/30/2021
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MolDX: myPath® Melanoma Assay
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L38018
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08/12/2019
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07/03/2022
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MolDX: Melanoma Risk Stratification Molecular Testing
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L38158
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02/09/2020
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06/24/2021
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MolDX: Next-Generation Sequencing for Solid Tumors
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L38168
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03/15/2020
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12/30/2021
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MolDX: Plasma-Based Genomic Profiling in Solid Tumors
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L38176
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02/09/2020
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07/08/2021
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MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies
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L38178
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04/12/2020
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12/30/2021
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MolDX: Pigmented Lesion Assay
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L38211
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10/14/2019
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09/30/2021
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Corneal Hysteresis
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L38213
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12/16/2019
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09/01/2022
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Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
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L38429
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06/14/2020
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12/30/2021
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MolDX: Repeat Germline Testing
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L38433
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11/08/2020
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01/27/2022
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MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease
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L38435
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07/26/2020
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09/29/2022
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MolDX: Pharmacogenomics Testing
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L38441
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10/25/2020
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05/26/2022
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MolDX: Blood Product Molecular Antigen Typing
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L38443
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06/14/2020
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01/06/2022
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MolDX: Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer
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L38528
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06/14/2020
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04/28/2022
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Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
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L38678
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07/25/2021
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05/26/2022
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MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells
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L38680
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06/06/2021
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MolDx: Molecular Testing for Solid Organ Allograft Rejection
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L38682
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12/27/2020
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10/27/2022
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Transurethral Waterjet Ablation of the Prostate
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L38684
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07/18/2021
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MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer
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L38686
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10/11/2020
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02/28/2022
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Implantable Continuous Glucose Monitors (I-CGM)
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L38835
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12/26/2021
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12/26/2021
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MolDX: Minimal Residual Disease Testing for Cancer
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L38837
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03/28/2021
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Colon Capsule Endoscopy (CCE)
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L38839
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04/25/2021
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08/14/2022
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Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease
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L38841
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04/25/2021
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04/25/2021
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Facet Joint Interventions for Pain Management
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L39040
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07/03/2022
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07/03/2022
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MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer
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L39042
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07/03/2022
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MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer
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L39044
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04/17/2022
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04/17/2022
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MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
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L39051
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11/14/2021
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Cosmetic and Reconstructive Surgery
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L39054
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12/05/2021
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06/30/2022
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Epidural Steroid Injections for Pain Management
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L39477
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02/12/2023
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Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin
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