CodeMap® CodeMap® Contractor Policy Detail

LCD	Effective Date	Revision Effective Date	Title	CPT Codes Covered in LCD
L34526	10/01/2015	12/01/2018	Surgical Treatment of Obstructive Sleep Apnea (OSA)	21110 21141 21145 21196 21199 21685 30140 30802 31600 31610 41512 41530 42145 42299 C9727
L34528	10/01/2015	10/01/2018	Blepharoplasty, Blepharoptosis and Brow Lift	15820 15821 15822 15823 67900 67901 67902 67903 67904 67906 67908
L34536	10/01/2015	10/01/2018	Treatment of Varicose Veins of the Lower Extremities	36465 36466 36468 36470 36471 36473 36474 36475 36476 36478 36479 36482 36483 37500 37700 37718 37722 37735 37760 37761 37765 37766 37780 37785 37799 93970 93971
L34588	10/01/2015	10/01/2018	Trigger Points, Local Injections	20552 20553
L34592	10/01/2015	11/01/2018	Vertebroplasty (Percutaneous) and Vertebral Augmentation including cavity creation	22510 22511 22512 22513 22514 22515
L34594	10/01/2015	12/01/2018	Nerve Conduction Studies and Electromyography	51785 92265 95860 95861 95863 95864 95865 95866 95867 95868 95869 95870 95872 95873 95874 95885 95886 95887 95905 95907 95908 95909 95910 95911 95912 95913 95933 95937 95999 G0255
L34596	10/01/2015	05/01/2018	Immunizations	90296 90476 90477 90581 90585 90586 90587 90620 90621 90625 90632 90633 90634 90636 90644 90647 90648 90649 90650 90651 90675 90676 90680 90681 90690 90691 90696 90697 90698 90700 90702 90707 90710 90713 90714 90715 90716 90717 90723 90733 and more.....
L34614	10/01/2015	03/28/2019	Colonoscopy and Sigmoidoscopy-Diagnostic	XX000
L34615	10/01/2015	10/01/2018	Visual Fields	92081 92082 92083
L34616	10/01/2015	10/01/2018	Psychiatry and Psychology Services	90785 90791 90792 90832 90833 90834 90836 90837 90838 90839 90840 90845 90846 90847 90849 90853 90865 90880 90885 90887 90889 90899
L34623	10/01/2015	01/01/2019	Intraoperative Neurophysiological Testing	95940 95941 G0453
L34624	10/01/2015	12/01/2018	Somatosensory Testing	95925 95926 95927 95938
L34633	10/01/2015	01/01/2019	Erythropoiesis Stimulating Agents (ESAs)	J0881 J0882 J0885 J0887 J0888 J0890 Q4081 Q5105 Q5106
L34635	10/01/2015	10/01/2018	Botulinum Toxin Type A & Type B	31513 31570 31571 43201 43236 46505 52287 64611 64612 64615 64616 64617 64642 64643 64644 64645 64646 64647 64650 64653 67345 92265 95873 95874 J0585 J0586 J0587 J0588
L34636	10/01/2015	12/01/2018	Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring)	0295T 0296T 0297T 0298T 93224 93225 93226 93227 93228 93229 93268 93270 93271 93272
L34641	10/01/2015	11/01/2018	Transcranial Magnetic Stimulation (TMS)	90867 90868 90869
L34645	10/01/2015	12/01/2018	Drug Testing	80305 80306 80307 80320 80321 80322 80323 80324 80325 80326 80327 80328 80329 80330 80331 80332 80333 80334 80335 80336 80337 80338 80339 80340 80341 80342 80343 80344 80345 80346 80347 80348 80349 80350 80351 80352 80353 80354 80355 80356 and more.....
L34646	10/01/2015	01/01/2019	Psychological and Neuropsychological Testing	96105 96112 96113 96116 96121 96125 96130 96131 96132 96133 96136 96137 96138 96139 96146
L34648	10/01/2015	12/01/2018	Bisphosphonate Drug Therapy	J1436 J1740 J2430 J3489
L34658	10/01/2015	10/01/2018	Vitamin D Assay Testing	82306 82652
L34659	10/01/2015	03/28/2019	Endoscopic Treatment of GERD	XX000
L34698	10/01/2015	12/01/2018	Cosmetic and Reconstructive Surgery	11920 11921 11922 15775 15776 15781 15788 15789 15792 15793 15828 15829 15830 19300 19316 19318 19324 19325 19328 19330 19340 19342 19350 19355 19357 19361 19364 19366 19367 19368 19369 19370 19371 19380 19396 30400 30410 30420 30430 30435 and more.....
L34741	10/01/2015	06/01/2018	Drugs and Biologics (Non-chemotherapy)	67028 C9257 J0129 J0178 J0180 J0256 J0257 J0364 J0490 J1300 J1745 J1931 J2001 J2323 J2357 J2503 J2562 J2778 J2796 J3396 J3590 Q5103 Q5104
L34760	10/01/2015	09/01/2018	Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)	92132 92133 92134
L34761	10/01/2015	03/01/2018	Percutaneous Coronary Interventions	92920 92921 92924 92925 92928 92929 92933 92934 92937 92938 92941 92943 92944 92973 92974 92975 92978 92979 93571 93572 C9600 C9601 C9602 C9603 C9604 C9605 C9606 C9607 C9608
L34771	10/01/2015	01/01/2019	Immune Globulins	90371 90375 90376 90393 90396 96365 96366 96372 J0840 J0850 J1459 J1460 J1556 J1557 J1560 J1561 J1566 J1568 J1569 J1571 J1572 J1573 J1575 J1599 J1670
L35121	10/01/2015	09/01/2018	Coronary Computed Tomography Angiography (CCTA)	75571 75572 75573 75574
L35124	10/01/2015	08/01/2018	Autonomic Function Testing	95921 95922 95923 95924 95943
L35222	10/01/2015	01/01/2019	Nerve Blocks for Peripheral Neuropathy	64450 76881 76882 76942 76999 97032 97139 G0282 G0283
L35486	10/01/2015	09/01/2018	Pelvic Floor Dysfunction: Anorectal Manometry and EMG	51784 51785 91122
L35490	10/01/2015	01/01/2019	Category III Codes	0075T 0076T 0184T 0191T 0249T 0253T 0275T 0295T 0296T 0297T 0298T 0308T 0376T 0394T 0395T 0398T 0449T 0450T 0474T 0501T 0502T 0503T 0504T
L35494	10/01/2015	01/01/2019	Mohs Micrographic Surgery	17311 17312 17313 17314 17315
L35498	10/01/2015	10/01/2018	Removal of Benign Skin Lesions	11200 11201 11300 11301 11302 11303 11305 11306 11307 11308 11310 11311 11312 11313 11400 11401 11402 11403 11404 11406 11420 11421 11422 11423 11424 11426 11440 11441 11442 11443 11444 11446 17106 17107 17108 17110 17111
L35751	10/01/2015	10/01/2018	Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies	93970 93971 93990 G0365
L35753	10/01/2015	10/01/2018	Non-Invasive Cerebrovascular Studies	93880 93882 93886 93888 93890 93892 93893 93895
L35755	10/01/2015	06/01/2018	Non-Invasive Abdominal / Visceral Vascular Studies	93975 93976 93978 93979 93980 93981
L35761	10/01/2015	06/01/2018	Non-Invasive Peripheral Arterial Vascular Studies	93922 93923 93924 93925 93926 93930 93931
L35996	10/01/2015	05/01/2018	Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy	64490 64491 64492 64493 64494 64495 64633 64634 64635 64636
L35998	10/01/2015	10/01/2018	Non-Coronary Vascular Stents	37221 37223 37226 37227 37230 37231 37234 37235 37236 37237 37238 37239
L36000	12/17/2015	09/01/2018	Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain	27279
L36398	04/16/2016	02/01/2019	MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing	0070U 81225 81226 81227 81355 81479
L36400	04/16/2016	01/01/2019	MolDX: Genetic Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)	81240 81241 81291
L36402	03/18/2016	01/01/2019	Allergy Testing	82785 86001 86003 86005 86008 95004 95017 95018 95024 95027 95028 95044 95052 95056 95060 95065 95070 95071 95076 95079
L36408	03/18/2016	10/01/2018	Allergy Immunotherapy	95115 95117 95144 95145 95146 95147 95148 95149 95165 95170 95180
L36521	06/16/2016	06/01/2018	Lumbar Epidural Injections	62322 62323 62326 62327 64483 64484
L36523	06/16/2016	03/01/2019	MolDX: Biomarkers in Cardiovascular Risk Assessment	82172 82610 83090 83695 83698 83700 83701 83704 83719 83721 83880 86141
L36787	02/16/2017	10/01/2018	MolDX: Prolaris™ Prostate Cancer Genomic Assay	81541
L36789	02/16/2017	07/01/2018	MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay	0047U
L36791	02/16/2017	11/01/2018	MolDX: Decipher® Prostate Cancer Classifier Assay	81479
L36793	02/16/2017	01/01/2019	MolDX: Genetic Testing for Lynch Syndrome	81210 81288 81292 81293 81294 81295 81296 81297 81298 81299 81300 81301 81317 81318 81319 81403 81435 81445 81455 81479
L36795	02/16/2017	10/01/2018	MolDX: Molecular RBC Phenotyping	0001U
L36797	02/16/2017	12/01/2018	MolDX: NRAS Genetic Testing	81311 81479
L36799	02/16/2017	12/01/2018	MolDX: GeneSight® Assay for Refractory Depression	81479
L36801	02/16/2017	11/01/2018	MolDX: HLA-B*15:02 Genetic Testing	81381
L36805	02/16/2017	03/01/2019	Lab: Special Histochemical Stains and Immunohistochemical Stains	88312 88313 88341 88342 88344 88360 88361
L36807	02/16/2017	01/01/2019	MolDX: Molecular Diagnostic Tests (MDT)	0001U 0002M 0002U 0003M 0003U 0004M 0005U 0006M 0006U 0007M 0007U 0008U 0009M 0009U 0010U 0011M 0011U 0012M 0012U 0013M 0013U 0014U 0016U 0017U 0018U 0019U 0021U 0022U 0023U 0024U 0025U 0026U 0027U 0029U 0030U 0031U 0032U 0033U 0034U 0035U and more.....
L36811	02/16/2017	12/01/2018	MolDX: Breast Cancer Assay: Prosigna	81520
L36813	02/16/2017	01/01/2019	MolDX: BRCA1 and BRCA2 Genetic Testing	81162 81163 81164 81165 81166 81167 81212 81215 81216 81217 81432 81445 81455 81479
L36815	02/16/2017	01/01/2019	MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease	81206 81207 81208 81219 81270 81402 81403 81445 81450 81455 81479
L36839	02/16/2017	12/01/2018	Polysomnography and Other Sleep Studies	95782 95783 95800 95801 95803 95805 95806 95807 95808 95810 95811 G0398 G0399 G0400
L37001	07/17/2017	01/01/2019	MolDX: MGMT Promoter Methylation Analysis	81287
L37003	07/17/2017	04/01/2018	MolDX: HLA-DQB1*06:02 Testing for Narcolepsy	81383
L37005	07/17/2017	12/01/2018	MolDX: ConfirmMDx Epigenetic Molecular Assay	81551
L37011	07/17/2017	11/01/2018	MolDX: ProMark Risk Score	81479
L37013	07/17/2017	06/01/2018	MolDX: 4Kscore Assay	81539
L37015	07/17/2017	01/01/2019	Visual Electrophysiology Testing	92273 92274 95930
L37195	09/16/2017	07/01/2018	MolDX: Percepta© Bronchial Genomic Classifier	81479
L37199	09/16/2017	07/01/2018	MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)	0045U
L37205	09/16/2017	08/01/2018	Chemotherapy Drugs and their Adjuncts	XX000
L37210	09/16/2017	03/28/2019	MolDX: Decision Dx-UM (Uveal Melanoma)	0081U
L37216	09/16/2017	01/01/2019	MolDX: BDX-XL2	0080U
L37224	09/16/2017	01/01/2019	MolDX: APC and MUTYH Gene Testing	81201 81202 81203 81401 81403 81406 81435 81479
L37226	09/16/2017	07/01/2018	MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease	81541
L37228	04/16/2018	03/28/2019	Wound Care	XX000
L37537	03/01/2019		Frequency of Hemodialysis	90999
L37539	03/19/2018	03/01/2019	MolDX: Prometheus IBD sgi Diagnostic Policy	81479 82397 83520 86140
L37663	08/16/2018	02/01/2019	MolDX: EndoPredict® Breast Cancer Gene Expression Test	81599
L37665	08/16/2018		MolDX: AlloSure Donor-Derived Cell-Free DNA Test	81479
L37667	08/16/2018	01/01/2019	MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer	0047U
L37671	10/17/2018	10/17/2018	MolDX: Guardant360® Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC)	81479
L37764	12/17/2018		MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels	87631 87632 87633
L37766	02/16/2019	03/19/2019	Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs)	87505 87506 87507
L37768	12/17/2018		MolDX: CYSTATIN C Measurement	82610
L37770	12/17/2018		MolDX: CORUS® CAD ASSAY	81493
L37772	05/13/2019		MolDX: MDS FISH	88271 88273 88274 88275 88291
L37911	05/13/2019		MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease	81479
L37913	04/15/2019		MolDX: Breast Cancer Index™ (BCI) Gene Expression Test	XX000
L37915	02/16/2019		MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC)	81479
L37919	05/13/2019		MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test	81479
L37921	04/15/2019	04/15/2019	MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer	XX000
L37923	06/10/2019		MolDX: myPath Melanoma Assay	81479

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