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
|
12/28/2023
|
Blepharoplasty, Blepharoptosis and Brow Lift
|
|
L34536
|
10/01/2015
|
08/31/2023
|
Treatment of Varicose Veins of the Lower Extremities
|
|
L34594
|
10/01/2015
|
06/01/2023
|
Nerve Conduction Studies and Electromyography
|
|
L34596
|
10/01/2015
|
10/26/2023
|
Immunizations
|
|
L34614
|
10/01/2015
|
08/29/2024
|
Colonoscopy and Sigmoidoscopy-Diagnostic
|
|
L34615
|
10/01/2015
|
06/29/2023
|
Visual Fields
|
|
L34616
|
10/01/2015
|
10/31/2024
|
Psychiatry and Psychology Services
|
|
L34623
|
10/01/2015
|
02/01/2024
|
Intraoperative Neurophysiological Testing
|
|
L34624
|
10/01/2015
|
10/01/2023
|
Somatosensory Testing
|
|
L34633
|
10/01/2015
|
06/01/2023
|
Erythropoiesis Stimulating Agents (ESAs)
|
|
L34635
|
10/01/2015
|
10/01/2023
|
Botulinum Toxin Type A & Type B
|
|
L34636
|
10/01/2015
|
10/01/2023
|
Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring)
|
|
L34641
|
10/01/2015
|
04/25/2024
|
Transcranial Magnetic Stimulation (TMS)
|
|
L34645
|
10/01/2015
|
11/12/2023
|
Urine Drug Testing
|
|
L34646
|
10/01/2015
|
10/31/2024
|
Psychological and Neuropsychological Testing
|
|
L34648
|
10/01/2015
|
02/11/2024
|
Bisphosphonate Drug Therapy
|
|
L34658
|
10/01/2015
|
10/01/2023
|
Vitamin D Assay Testing
|
|
L34659
|
10/01/2015
|
08/29/2024
|
Endoscopic Treatment of GERD
|
|
L34760
|
10/01/2015
|
06/29/2023
|
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
|
|
L34761
|
10/01/2015
|
12/28/2023
|
Percutaneous Coronary Interventions
|
|
L34771
|
10/01/2015
|
02/29/2024
|
Immune Globulins
|
|
L35121
|
10/01/2015
|
11/30/2023
|
Coronary Computed Tomography Angiography (CCTA)
|
|
L35124
|
10/01/2015
|
10/26/2023
|
Autonomic Function Testing
|
|
L35222
|
10/01/2015
|
11/30/2023
|
Nerve Blocks for Peripheral Neuropathy
|
|
L35486
|
10/01/2015
|
10/26/2023
|
Pelvic Floor Dysfunction: Anorectal Manometry and EMG
|
|
L35490
|
10/01/2015
|
11/17/2024
|
Category III Codes
|
|
L35494
|
10/01/2015
|
10/31/2024
|
Mohs Micrographic Surgery
|
|
L35498
|
10/01/2015
|
10/26/2023
|
Removal of Benign Skin Lesions
|
|
L35751
|
10/01/2015
|
09/26/2024
|
Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies
|
|
L35753
|
10/01/2015
|
10/26/2023
|
Non-Invasive Cerebrovascular Studies
|
|
L35755
|
10/01/2015
|
11/30/2023
|
Non-Invasive Abdominal / Visceral Vascular Studies
|
|
L35761
|
10/01/2015
|
10/26/2023
|
Non-Invasive Peripheral Arterial Vascular Studies
|
|
L35998
|
10/01/2015
|
01/01/2023
|
Non-Coronary Vascular Stents
|
|
L36000
|
12/17/2015
|
06/27/2024
|
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
|
09/26/2024
|
Allergy Testing
|
|
L36408
|
03/18/2016
|
10/26/2023
|
Allergy Immunotherapy
|
|
L36523
|
06/16/2016
|
03/21/2024
|
MolDX: Biomarkers in Cardiovascular Risk Assessment
|
|
L36797
|
02/16/2017
|
07/27/2023
|
MolDX: NRAS Genetic Testing
|
|
L36805
|
02/16/2017
|
08/01/2024
|
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
|
12/28/2023
|
ProMark® Risk Score
|
|
L37015
|
07/17/2017
|
10/01/2023
|
Visual Electrophysiology Testing
|
|
L37199
|
09/16/2017
|
10/26/2023
|
MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)
|
|
L37205
|
09/16/2017
|
11/30/2023
|
Chemotherapy Drugs and their Adjuncts
|
|
L37210
|
09/16/2017
|
06/27/2024
|
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
|
03/28/2024
|
Frequency of Hemodialysis
|
|
L37539
|
03/19/2018
|
02/29/2024
|
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
|
11/30/2023
|
MolDX: Inivata™, InVisionFirst®, Liquid Biopsy for Patients with Lung Cancer
|
|
L38018
|
08/12/2019
|
06/20/2024
|
MolDX: Melanoma Risk Stratification Molecular Testing
|
|
L38158
|
02/09/2020
|
06/08/2023
|
MolDX: Next-Generation Sequencing for Solid Tumors
|
|
L38168
|
03/15/2020
|
10/26/2023
|
MolDX: Plasma-Based Genomic Profiling in Solid Tumors
|
|
L38176
|
02/09/2020
|
03/28/2024
|
MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies
|
|
L38178
|
04/12/2020
|
06/20/2024
|
MolDX: Pigmented Lesion Assay
|
|
L38211
|
10/14/2019
|
07/27/2023
|
Corneal Hysteresis
|
|
L38213
|
12/16/2019
|
08/01/2024
|
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
|
|
L38429
|
06/14/2020
|
04/25/2024
|
MolDX: Repeat Germline Testing
|
|
L38433
|
11/08/2020
|
02/01/2024
|
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
|
11/07/2024
|
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
|
04/25/2024
|
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
|
09/26/2024
|
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
|
08/01/2024
|
Implantable Continuous Glucose Monitors (I-CGM)
|
|
L38835
|
12/26/2021
|
10/26/2023
|
MolDX: Minimal Residual Disease Testing for Cancer
|
|
L38837
|
03/28/2021
|
02/23/2023
|
Colon Capsule Endoscopy (CCE)
|
|
L38839
|
04/25/2021
|
06/27/2024
|
Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease
|
|
L38841
|
04/25/2021
|
07/14/2024
|
Facet Joint Interventions for Pain Management
|
|
L39040
|
07/03/2022
|
04/18/2024
|
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
|
06/09/2022
|
MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
|
|
L39051
|
11/14/2021
|
10/13/2024
|
Cosmetic and Reconstructive Surgery
|
|
L39054
|
12/05/2021
|
02/01/2024
|
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
|
11/28/2024
|
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
|
08/01/2024
|
MolDX: Molecular Biomarker Testing to Guide Targeted Therapy Selection in Rheumatoid Arthritis
|
|
L39529
|
06/11/2023
|
|
Intraarticular Knee Injections of Hyaluronan
|
|