| LCD |
Effective
Date |
Revision
Effective
Date |
Title |
CPT Codes Covered in LCD |
|
L34526
|
10/01/2015
|
11/01/2019
|
Surgical Treatment of Obstructive Sleep Apnea (OSA)
|
|
|
L34528
|
10/01/2015
|
04/30/2020
|
Blepharoplasty, Blepharoptosis and Brow Lift
|
|
|
L34536
|
10/01/2015
|
11/01/2019
|
Treatment of Varicose Veins of the Lower Extremities
|
|
|
L34588
|
10/01/2015
|
11/01/2019
|
Trigger Points, Local Injections
|
|
|
L34594
|
10/01/2015
|
10/31/2019
|
Nerve Conduction Studies and Electromyography
|
|
|
L34596
|
10/01/2015
|
11/01/2019
|
Immunizations
|
|
|
L34614
|
10/01/2015
|
10/01/2020
|
Colonoscopy and Sigmoidoscopy-Diagnostic
|
|
|
L34615
|
10/01/2015
|
10/31/2019
|
Visual Fields
|
|
|
L34616
|
10/01/2015
|
10/01/2020
|
Psychiatry and Psychology Services
|
|
|
L34623
|
10/01/2015
|
07/30/2020
|
Intraoperative Neurophysiological Testing
|
|
|
L34624
|
10/01/2015
|
11/01/2019
|
Somatosensory Testing
|
|
|
L34633
|
10/01/2015
|
02/09/2020
|
Erythropoiesis Stimulating Agents (ESAs)
|
|
|
L34635
|
10/01/2015
|
01/30/2020
|
Botulinum Toxin Type A & Type B
|
|
|
L34636
|
10/01/2015
|
11/01/2019
|
Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring)
|
|
|
L34641
|
10/01/2015
|
07/30/2020
|
Transcranial Magnetic Stimulation (TMS)
|
|
|
L34645
|
10/01/2015
|
05/10/2020
|
Drug Testing
|
|
|
L34646
|
10/01/2015
|
10/01/2020
|
Psychological and Neuropsychological Testing
|
|
|
L34648
|
10/01/2015
|
08/27/2020
|
Bisphosphonate Drug Therapy
|
|
|
L34658
|
10/01/2015
|
10/31/2019
|
Vitamin D Assay Testing
|
|
|
L34659
|
10/01/2015
|
10/29/2020
|
Endoscopic Treatment of GERD
|
|
|
L34698
|
10/01/2015
|
10/31/2019
|
Cosmetic and Reconstructive Surgery
|
|
|
L34760
|
10/01/2015
|
11/01/2019
|
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
|
|
|
L34761
|
10/01/2015
|
10/31/2019
|
Percutaneous Coronary Interventions
|
|
|
L34771
|
10/01/2015
|
10/01/2020
|
Immune Globulins
|
|
|
L35121
|
10/01/2015
|
08/27/2020
|
Coronary Computed Tomography Angiography (CCTA)
|
|
|
L35124
|
10/01/2015
|
11/01/2019
|
Autonomic Function Testing
|
|
|
L35222
|
10/01/2015
|
07/30/2020
|
Nerve Blocks for Peripheral Neuropathy
|
|
|
L35486
|
10/01/2015
|
11/01/2019
|
Pelvic Floor Dysfunction: Anorectal Manometry and EMG
|
|
|
L35490
|
10/01/2015
|
10/29/2020
|
Category III Codes
|
|
|
L35494
|
10/01/2015
|
10/31/2019
|
Mohs Micrographic Surgery
|
|
|
L35498
|
10/01/2015
|
10/31/2019
|
Removal of Benign Skin Lesions
|
|
|
L35751
|
10/01/2015
|
12/26/2019
|
Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies
|
|
|
L35753
|
10/01/2015
|
12/26/2019
|
Non-Invasive Cerebrovascular Studies
|
|
|
L35755
|
10/01/2015
|
12/26/2019
|
Non-Invasive Abdominal / Visceral Vascular Studies
|
|
|
L35761
|
10/01/2015
|
11/01/2019
|
Non-Invasive Peripheral Arterial Vascular Studies
|
|
|
L35996
|
10/01/2015
|
11/01/2019
|
Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
|
|
|
L35998
|
10/01/2015
|
08/27/2020
|
Non-Coronary Vascular Stents
|
|
|
L36000
|
12/17/2015
|
06/25/2020
|
Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain
|
|
|
L36400
|
04/16/2016
|
11/01/2019
|
MolDX: Genetic Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)
|
|
|
L36402
|
03/18/2016
|
10/31/2019
|
Allergy Testing
|
|
|
L36408
|
03/18/2016
|
05/28/2020
|
Allergy Immunotherapy
|
|
|
L36521
|
06/16/2016
|
11/01/2019
|
Lumbar Epidural Injections
|
|
|
L36523
|
06/16/2016
|
11/01/2019
|
MolDX: Biomarkers in Cardiovascular Risk Assessment
|
|
|
L36787
|
02/16/2017
|
11/01/2019
|
MolDX: Prolaris™ Prostate Cancer Genomic Assay
|
|
|
L36789
|
02/16/2017
|
08/27/2020
|
MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay
|
|
|
L36793
|
02/16/2017
|
12/26/2019
|
MolDX: Genetic Testing for Lynch Syndrome
|
|
|
L36797
|
02/16/2017
|
11/01/2019
|
MolDX: NRAS Genetic Testing
|
|
|
L36805
|
02/16/2017
|
08/27/2020
|
Lab: Special Histochemical Stains and Immunohistochemical Stains
|
|
|
L36807
|
02/16/2017
|
01/01/2020
|
MolDX: Molecular Diagnostic Tests (MDT)
|
|
|
L36811
|
02/16/2017
|
11/01/2019
|
MolDX: Breast Cancer Assay: Prosigna
|
|
|
L36813
|
02/16/2017
|
11/01/2019
|
MolDX: BRCA1 and BRCA2 Genetic Testing
|
|
|
L36815
|
02/16/2017
|
10/01/2020
|
MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease
|
|
|
L36839
|
02/16/2017
|
11/01/2019
|
Polysomnography and Other Sleep Studies
|
|
|
L37001
|
07/17/2017
|
10/29/2020
|
MolDX: MGMT Promoter Methylation Analysis
|
|
|
L37003
|
07/17/2017
|
11/01/2019
|
MolDX: HLA-DQB1*06:02 Testing for Narcolepsy
|
|
|
L37005
|
07/17/2017
|
11/01/2019
|
MolDX: ConfirmMDx Epigenetic Molecular Assay
|
|
|
L37011
|
07/17/2017
|
10/29/2020
|
MolDX: ProMark Risk Score
|
|
|
L37013
|
07/17/2017
|
11/01/2019
|
MolDX: 4Kscore Assay
|
|
|
L37015
|
07/17/2017
|
11/01/2019
|
Visual Electrophysiology Testing
|
|
|
L37195
|
09/16/2017
|
11/01/2019
|
MolDX: Percepta® Bronchial Genomic Classifier
|
|
|
L37199
|
09/16/2017
|
11/01/2019
|
MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)
|
|
|
L37205
|
09/16/2017
|
11/28/2019
|
Chemotherapy Drugs and their Adjuncts
|
|
|
L37210
|
09/16/2017
|
01/01/2020
|
MolDX: Decision Dx-UM (Uveal Melanoma)
|
|
|
L37216
|
09/16/2017
|
11/19/2020
|
MolDX: BDX-XL2
|
|
|
L37224
|
09/16/2017
|
11/01/2019
|
MolDX: APC and MUTYH Gene Testing
|
|
|
L37226
|
09/16/2017
|
11/01/2019
|
MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease
|
|
|
L37228
|
04/16/2018
|
02/09/2020
|
Wound Care
|
|
|
L37537
|
03/01/2019
|
10/01/2020
|
Frequency of Hemodialysis
|
|
|
L37539
|
03/19/2018
|
11/01/2019
|
MolDX: Prometheus IBD sgi Diagnostic Policy
|
|
|
L37663
|
08/16/2018
|
11/01/2019
|
MolDX: EndoPredict® Breast Cancer Gene Expression Test
|
|
|
L37667
|
08/16/2018
|
06/25/2020
|
MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer
|
|
|
L37764
|
12/17/2018
|
10/29/2020
|
MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels
|
|
|
L37766
|
02/16/2019
|
11/01/2019
|
Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs)
|
|
|
L37768
|
12/17/2018
|
10/29/2020
|
MolDX: CYSTATIN C Measurement
|
|
|
L37770
|
12/17/2018
|
10/29/2020
|
MolDX: CORUS® CAD ASSAY
|
|
|
L37772
|
05/13/2019
|
11/01/2019
|
MolDX: MDS FISH
|
|
|
L37913
|
04/15/2019
|
11/01/2019
|
MolDX: Breast Cancer Index™ (BCI) Gene Expression Test
|
|
|
L37915
|
02/16/2019
|
11/01/2020
|
MolDX: Androgen Receptor Variant (AR-V7) Protein Test
|
|
|
L37919
|
05/13/2019
|
11/01/2019
|
MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test
|
|
|
L37921
|
04/15/2019
|
04/30/2020
|
MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer
|
|
|
L37923
|
06/10/2019
|
07/01/2019
|
MolDX: myPath Melanoma Assay
|
|
|
L38018
|
08/12/2019
|
11/22/2020
|
MolDX: Melanoma Risk Stratification Molecular Testing
|
|
|
L38158
|
02/09/2020
|
04/30/2020
|
MolDX: Next-Generation Sequencing for Solid Tumors
|
|
|
L38160
|
12/16/2019
|
12/16/2019
|
MolDX: TruGraf® Blood Gene Expression Test
|
|
|
L38168
|
03/15/2020
|
05/28/2020
|
MolDX: Plasma-Based Genomic Profiling in Solid Tumors
|
|
|
L38174
|
04/12/2020
|
|
MolDX: Prospera™
|
|
|
L38176
|
02/09/2020
|
04/30/2020
|
MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies
|
|
|
L38178
|
04/12/2020
|
|
MolDX: Pigmented Lesion Assay
|
|
|
L38211
|
10/14/2019
|
11/01/2019
|
Corneal Hysteresis
|
|
|
L38213
|
12/16/2019
|
10/01/2020
|
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
|
|
|
L38429
|
06/14/2020
|
|
MolDX: Repeat Germline Testing
|
|
|
L38431
|
10/18/2020
|
|
MolDX: Minimal Residual Disease Testing for Colorectal Cancer
|
|
|
L38433
|
11/08/2020
|
|
MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease
|
|
|
L38435
|
07/26/2020
|
08/06/2020
|
MolDX: Pharmacogenomics Testing
|
|
|
L38439
|
11/15/2020
|
|
MolDX: AlloSure® or Equivalent Cell-Free DNA Testing for Kidney and Heart Allografts
|
|
|
L38441
|
10/25/2020
|
|
MolDX: Blood Product Molecular Antigen Typing
|
|
|
L38443
|
06/14/2020
|
|
MolDX: Predictive Classifiers for Early Stage Non-small Cell Lung Cancer
|
|
|
L38528
|
06/14/2020
|
|
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
|
|
|
L38682
|
12/27/2020
|
|
Transurethral Waterjet Ablation of the Prostate
|
|
|
L38686
|
10/11/2020
|
|
Implantable Continuous Glucose Monitors (I-CGM)
|
|
