CodeMap® CodeMap® Contractor Policy Detail

LCD	Effective Date	Revision Effective Date	Title	CPT Codes Covered in LCD
L34526	10/01/2015	07/27/2023	Surgical Treatment of Obstructive Sleep Apnea (OSA)
L34528	10/01/2015	04/28/2022	Blepharoplasty, Blepharoptosis and Brow Lift
L34536	10/01/2015	08/31/2023	Treatment of Varicose Veins of the Lower Extremities
L34588	10/01/2015	08/31/2023	Trigger Points, Local Injections
L34594	10/01/2015	06/01/2023	Nerve Conduction Studies and Electromyography
L34596	10/01/2015	09/30/2021	Immunizations
L34614	10/01/2015	10/01/2022	Colonoscopy and Sigmoidoscopy-Diagnostic
L34615	10/01/2015	06/29/2023	Visual Fields
L34616	10/01/2015	10/01/2022	Psychiatry and Psychology Services
L34623	10/01/2015	07/28/2022	Intraoperative Neurophysiological Testing
L34624	10/01/2015	10/28/2021	Somatosensory Testing
L34633	10/01/2015	06/01/2023	Erythropoiesis Stimulating Agents (ESAs)
L34635	10/01/2015	11/14/2021	Botulinum Toxin Type A & Type B
L34636	10/01/2015	10/28/2021	Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring)
L34641	10/01/2015	10/17/2022	Transcranial Magnetic Stimulation (TMS)
L34645	10/01/2015	10/01/2021	Drug Testing
L34646	10/01/2015	09/29/2022	Psychological and Neuropsychological Testing
L34648	10/01/2015	08/27/2020	Bisphosphonate Drug Therapy
L34658	10/01/2015	10/01/2021	Vitamin D Assay Testing
L34659	10/01/2015	09/29/2022	Endoscopic Treatment of GERD
L34760	10/01/2015	06/29/2023	Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
L34761	10/01/2015	12/30/2021	Percutaneous Coronary Interventions
L34771	10/01/2015	12/01/2022	Immune Globulins
L35121	10/01/2015	10/28/2021	Coronary Computed Tomography Angiography (CCTA)
L35124	10/01/2015	10/28/2021	Autonomic Function Testing
L35222	10/01/2015	12/30/2021	Nerve Blocks for Peripheral Neuropathy
L35486	10/01/2015	10/28/2021	Pelvic Floor Dysfunction: Anorectal Manometry and EMG
L35490	10/01/2015	04/27/2023	Category III Codes
L35494	10/01/2015	12/01/2022	Mohs Micrographic Surgery
L35498	10/01/2015	10/28/2021	Removal of Benign Skin Lesions
L35751	10/01/2015	01/27/2022	Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies
L35753	10/01/2015	10/01/2021	Non-Invasive Cerebrovascular Studies
L35755	10/01/2015	10/28/2021	Non-Invasive Abdominal / Visceral Vascular Studies
L35761	10/01/2015	10/01/2021	Non-Invasive Peripheral Arterial Vascular Studies
L35998	10/01/2015	01/01/2023	Non-Coronary Vascular Stents
L36000	12/17/2015	06/30/2022	Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain
L36400	04/16/2016	07/20/2023	MolDX: Genetic Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)
L36402	03/18/2016	10/01/2022	Allergy Testing
L36408	03/18/2016	10/01/2021	Allergy Immunotherapy
L36523	06/16/2016	03/30/2023	MolDX: Biomarkers in Cardiovascular Risk Assessment
L36797	02/16/2017	07/27/2023	MolDX: NRAS Genetic Testing
L36805	02/16/2017	09/29/2022	Lab: Special Histochemical Stains and Immunohistochemical Stains
L36807	02/16/2017	04/27/2023	MolDX: Molecular Diagnostic Tests (MDT)
L36811	02/16/2017	03/30/2023	MolDX: Breast Cancer Assay: Prosigna®
L36815	02/16/2017	07/06/2023	MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease
L36839	02/16/2017	07/27/2023	Polysomnography and Other Sleep Studies
L37001	07/17/2017	08/31/2023	MolDX: MGMT Promoter Methylation Analysis
L37003	07/17/2017	08/24/2023	MolDX: HLA-DQB1*06:02 Testing for Narcolepsy
L37011	07/17/2017	02/24/2022	ProMark® Risk Score
L37015	07/17/2017	05/26/2022	Visual Electrophysiology Testing
L37195	09/16/2017	10/28/2021	MolDX: Percepta® Bronchial Genomic Classifier
L37199	09/16/2017	10/28/2021	MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)
L37205	09/16/2017	05/26/2022	Chemotherapy Drugs and their Adjuncts
L37210	09/16/2017	06/30/2022	MolDX: Decision Dx-UM (Uveal Melanoma)
L37216	09/16/2017	03/30/2023	BDX-XL2
L37228	04/16/2018	04/27/2023	Wound Care
L37537	03/01/2019	07/28/2022	Frequency of Hemodialysis
L37539	03/19/2018	12/29/2022	MolDX: Prometheus IBD sgi Diagnostic® Policy
L37663	08/16/2018	04/27/2023	MolDX: EndoPredict® Breast Cancer Gene Expression Test
L37772	05/13/2019	06/01/2023	MDS FISH
L37913	04/15/2019	02/23/2023	MolDX: Breast Cancer Index® (BCI) Gene Expression Test
L37919	05/13/2019	06/29/2023	MolDX: Envisia™, Veracyte™, Idiopathic Pulmonary Fibrosis Diagnostic Test
L37921	04/15/2019	10/14/2021	MolDX: Inivata™, InVisionFirst®, Liquid Biopsy for Patients with Lung Cancer
L38018	08/12/2019	07/03/2022	MolDX: Melanoma Risk Stratification Molecular Testing
L38158	02/09/2020	06/08/2023	MolDX: Next-Generation Sequencing for Solid Tumors
L38168	03/15/2020	12/30/2021	MolDX: Plasma-Based Genomic Profiling in Solid Tumors
L38176	02/09/2020	06/01/2023	MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies
L38178	04/12/2020	12/30/2021	MolDX: Pigmented Lesion Assay
L38211	10/14/2019	07/27/2023	Corneal Hysteresis
L38213	12/16/2019	09/01/2022	Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
L38429	06/14/2020	12/30/2021	MolDX: Repeat Germline Testing
L38433	11/08/2020	01/27/2022	MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease
L38435	07/26/2020	08/24/2023	MolDX: Pharmacogenomics Testing
L38441	10/25/2020	05/26/2022	MolDX: Blood Product Molecular Antigen Typing
L38443	06/14/2020	07/20/2023	MolDX: Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer
L38528	06/14/2020	04/28/2022	Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
L38678	07/25/2021	05/26/2022	MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells
L38680	06/06/2021	07/27/2023	MolDx: Molecular Testing for Solid Organ Allograft Rejection
L38682	12/27/2020	10/15/2023	Transurethral Waterjet Ablation of the Prostate
L38684	07/18/2021	08/13/2023	MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer
L38686	10/11/2020	02/28/2022	Implantable Continuous Glucose Monitors (I-CGM)
L38835	12/26/2021	12/26/2021	MolDX: Minimal Residual Disease Testing for Cancer
L38837	03/28/2021	02/23/2023	Colon Capsule Endoscopy (CCE)
L38839	04/25/2021	08/14/2022	Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease
L38841	04/25/2021	03/30/2023	Facet Joint Interventions for Pain Management
L39040	07/03/2022	07/03/2022	MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer
L39042	07/03/2022	07/27/2023	MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer
L39044	04/17/2022	04/17/2022	MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
L39051	11/14/2021	08/31/2023	Cosmetic and Reconstructive Surgery
L39054	12/05/2021	06/30/2022	Epidural Steroid Injections for Pain Management
L39356	05/14/2023		MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia
L39475	03/19/2023	08/31/2023	Sacroiliac Joint Injections and Procedures
L39477	02/12/2023		Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin
L39479	08/13/2023		MolDX: Molecular Assays for the Diagnosis of Cutaneous Melanoma
L39481	10/15/2023		MolDX: Molecular Biomarker Testing to Guide Targeted Therapy Selection in Rheumatoid Arthritis
L39529	06/11/2023		Intraarticular Knee Injections of Hyaluronan

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