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LCD
Effective
Date
Revision
Effective
Date
Title
CPT Codes Covered in Policy
L34436 10/01/2015 04/01/2018 Posterior Tibial Nerve Stimulation (PTNS) 64566
L34525 10/01/2015 04/01/2018 Intra-articular Injections of Hyaluronan 20610 20611 J7320 J7321 J7322 J7323 J7324 J7325 J7326 J7327 J7328
L34526 10/01/2015 01/01/2018 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
L34585 10/01/2015 10/01/2018 Chiropractic Services 98940 98941 98942
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 10/01/2018 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 11/01/2018 Colonoscopy and Sigmoidoscopy-Diagnostic 44388 44389 44390 44391 44392 44394 44401 44402 44403 44404 44405 44406 44407 44408 45330 45331 45332 45333 45334 45335 45337 45338 45340 45341 45342 45378 45379 45380 45381 45382 45384 45385 45386 45391 45392
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 10/01/2018 Intraoperative Neurophysiological Testing 95940 95941 G0453
L34624 10/01/2015 10/01/2018 Somatosensory Testing 95925 95926 95927 95938
L34633 10/01/2015 10/01/2018 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 03/01/2018 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 10/01/2018 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 02/01/2018 Psychological and Neuropsychological Testing 96101 96102 96103 96105 96111 96116 96118 96119 96120 96125
L34648 10/01/2015 04/01/2018 Bisphosphonate Drug Therapy J1436 J1740 J2430 J3489
L34651 10/01/2015 10/01/2018 Flow Cytometry 88182 88184 88185 88187 88188 88189
L34658 10/01/2015 10/01/2018 Vitamin D Assay Testing 82306 82652
L34659 10/01/2015 01/01/2018 Endoscopic Treatment of GERD 43210 43257 43499 43999 49999
L34698 10/01/2015 01/01/2018 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.....
L34699 10/01/2015 10/01/2018 Human Granulocyte/Macrophage Colony Stimulating Factors J1442 J1447 J2505 J2820 Q5101
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 01/01/2018 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 04/01/2018 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 09/01/2018 Category III Codes 0075T 0076T 0184T 0191T 0249T 0253T 0275T 0295T 0296T 0297T 0298T 0308T 0376T 0387T 0389T 0390T 0391T 0394T 0395T 0398T 0449T 0450T 0474T 0501T 0502T 0503T 0504T
L35494 10/01/2015 10/01/2018 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 10/01/2018 MolDX: Genetic Testing for CYP2C19, CYP2D6, CYP2C9, and VKORC1 81225 81226 81227 81355 81479
L36400 04/16/2016 02/01/2018 MolDX: Genetic Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) 81240 81241 81291
L36402 03/18/2016 10/01/2018 Allergy Testing 82785 86001 86003 86005 86008 95004 95017 95018 95024 95027 95028 95044 95052 95056 95060 95065 95070 95071 95076 95079
L36404 02/16/2016 09/01/2018 Foot Care 11055 11056 11057 11719 11720 11721 G0127
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 10/01/2018 MolDX: Biomarkers in Cardiovascular Risk Assessment 82172 82610 83090 83695 83698 83700 83701 83704 83719 83721 83880 86141
L36785 02/16/2017 11/01/2018 MolDX: Breast Cancer Index℠ Genetic Assay 81479
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 09/01/2018 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 01/01/2018 MolDX: NRAS Genetic Testing 81311 81479
L36799 02/16/2017 06/01/2018 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 10/01/2018 Special Histochemical Stains and Immunohistochemical Stains 88312 88313 88341 88342 88344 88360 88361
L36807 02/16/2017 10/01/2018 MolDX: Molecular Diagnostic Tests (MDT) 0001M 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 and more.....
L36811 02/16/2017 01/01/2018 MolDX: Breast Cancer Assay: Prosigna 81520
L36813 02/16/2017 10/01/2018 MolDX: BRCA1 and BRCA2 Genetic Testing 81162 81211 81212 81213 81214 81215 81216 81217 81432 81445 81455 81479
L36815 02/16/2017 10/01/2018 MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease 81206 81207 81208 81219 81270 81402 81403 81445 81450 81455 81479
L36839 02/16/2017 01/01/2018 Polysomnography and Other Sleep Studies 95782 95783 95800 95801 95803 95805 95806 95807 95808 95810 95811 G0398 G0399 G0400
L37001 07/17/2017 11/01/2018 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 05/01/2018 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 06/01/2018 Visual Electrophysiology Testing 92275 95930
L37193 10/17/2017 09/01/2018 Coenzyme Q10 Testing XX000
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 07/01/2018 MolDX: Decision Dx-UM (Uveal Melanoma) 81599
L37216 09/16/2017 07/01/2018 MolDX: Xpresys Lung 81599
L37224 09/16/2017 05/01/2018 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 04/16/2018 Wound Care XX000
L37539 03/19/2018 03/19/2018 MolDX: Prometheus IBD sgi Diagnostic Policy 81479 82397 83520 86140
L37663 08/16/2018 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 09/01/2018 MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer 81479
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
L37768 12/17/2018 MolDX: CYSTATIN C Measurement 82610
L37770 12/17/2018 MolDX: CORUS® CAD ASSAY 81493



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