CodeMap® CodeMap® Contractor Policy Detail

LCD	Effective Date	Revision Effective Date	Title	CPT Codes Covered in LCD
L32553	10/01/2015	11/02/2023	Allergy Immunotherapy
L33943	10/01/2015	12/01/2022	B-type Natriuretic Peptide (BNP) Testing
L33944	10/01/2015	11/02/2023	Blepharoplasty
L33945	10/01/2015	01/26/2023	Cerumen (Earwax) Removal
L33946	10/01/2015	11/02/2023	Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy
L33947	10/01/2015	10/05/2023	Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA)
L33949	10/01/2015	12/01/2022	Botulinum Toxins
L33950	10/01/2015	12/01/2022	Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography
L33952	10/01/2015	12/01/2022	Cardiac Event Detection
L33954	10/01/2015	01/05/2023	Cataract Extraction
L33959	10/01/2015	11/02/2023	Cardiac Catheterization and Coronary Angiography
L33960	10/01/2015	01/26/2023	Cardiovascular Nuclear Medicine
L33996	10/01/2015	08/03/2023	Vitamin D Assay Testing
L33999	10/01/2015	01/26/2023	Corneal Pachymetry
L34005	10/01/2015	01/26/2023	Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
L34008	10/01/2015	01/26/2023	Computerized Corneal Topography
L34032	10/01/2015	10/05/2023	Debridement Services
L34037	10/01/2015	03/02/2023	Flow Cytometry
L34045	10/01/2015	11/02/2023	Non-Invasive Vascular Studies
L34046	10/01/2015	08/03/2023	Speech-Language Pathology
L34049	10/01/2015	05/25/2023	Outpatient Physical and Occupational Therapy Services
L34055	10/01/2015	10/05/2023	Virtual Colonoscopy (CT Colonography)
L34056	10/01/2015	10/05/2023	Urodynamics
L34061	10/01/2015	08/04/2022	Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
L34062	10/01/2015	02/09/2023	Dialysis Access Maintenance
L34063	10/01/2015	08/03/2023	RAST Type Tests
L34064	10/01/2015	03/02/2023	Panretinal (Scatter) Laser Photocoagulation
L34081	10/01/2015	03/02/2023	Endoscopy by Capsule
L34082	10/01/2015	10/05/2023	Varicose Veins of the Lower Extremity, Treatment of
L34084	10/01/2015	09/07/2023	Transcatheter Infusion Therapy
L34085	10/01/2015	03/02/2023	Post-Void Residual Urine and/or Bladder Capacity by Ultrasound
L34087	10/01/2015	08/31/2023	Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs): Office, Hospital, Web, or Non-Web Based
L34090	10/01/2015	03/23/2023	Laser Ablation of the Prostate
L34171	10/01/2015	05/25/2023	Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation
L34175	10/01/2015	06/03/2021	Ophthalmic Angiography (Fluorescein and Indocyanine Green)
L34181	10/01/2015	05/25/2023	Ophthalmic Biometry for Intraocular Lens Power Calculation
L34183	10/01/2015	03/02/2023	Psychiatric Inpatient Hospitalization
L34195	10/01/2015	04/27/2023	Mohs Micrographic Surgery
L34196	10/01/2015	03/02/2023	Psychiatric Partial Hospitalization Programs
L34200	10/01/2015	08/03/2023	Removal of Benign Skin Lesions
L34246	10/01/2015	08/03/2023	Routine Foot Care and Debridement of Nails
L34337	10/01/2015	08/31/2023	Transesophageal Echocardiography (TEE)
L34338	10/01/2015	10/05/2023	Transthoracic Echocardiography (TTE)
L34353	10/01/2015	05/25/2023	Outpatient Psychiatry and Psychology Services
L34356	10/01/2015	03/02/2023	Erythropoiesis Stimulating Agents (ESA)
L34393	10/01/2015	04/27/2023	Ocular Photography - External
L34394	10/01/2015	10/05/2023	Visual Fields Testing
L34399	10/01/2015	05/25/2023	Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)
L34539	10/01/2015	03/02/2023	Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians
L34540	10/01/2015	08/31/2023	Stretta Procedure
L34541	10/01/2015	10/05/2023	Transtelephonic Spirometry
L35249	10/01/2015	04/27/2023	Nerve Blocks for Peripheral Neuropathy
L35442	10/01/2015	07/27/2023	MolDX: NRAS Genetic Testing
L35891	10/01/2015	03/23/2023	Intravenous Immune Globulin
L35897	10/01/2015	04/27/2023	Nerve Conduction Studies and Electromyography
L35906	10/01/2015	03/24/2023	Somatosensory Testing
L35984	10/01/2015	07/20/2023	MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)
L35986	10/01/2015	06/29/2023	Special Histochemical Stains and Immunohistochemical Stains
L36006	10/05/2015	04/21/2022	MolDX: ConfirmMDx Epigenetic Molecular Assay
L36021	10/01/2015	05/04/2023	MolDX: Molecular Diagnostic Tests (MDT)
L36029	10/05/2015	10/15/2023	Urine Drug Testing
L36113	10/05/2015	07/20/2023	MolDX: MGMT Promoter Methylation Analysis
L36117	10/05/2015	07/06/2023	MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease
L36139	10/05/2015	03/02/2023	MolDX: Biomarkers in Cardiovascular Risk Assessment
L36425	02/01/2016	03/02/2023	MolDX: Breast Cancer Assay: Prosigna®
L36460	02/01/2016	01/05/2023	Bone Mass Measurement
L36469	02/08/2016	01/05/2023	Transcranial Magnetic Stimulation (TMS)
L36485	02/15/2016	08/24/2023	*MolDX: HLA-DQB106:02 Testing for Narcolepsy**
L36494	02/01/2016	01/05/2023	Minimally-Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint
L36658	10/24/2016	10/05/2023	Proton Beam Therapy
L36675	10/10/2016	11/24/2022	ProMark® Risk Score
L36690	10/10/2016	09/01/2022	Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities
L36902	03/06/2017	01/26/2023	Polysomnography and Other Sleep Studies
L36906	03/06/2017	03/02/2022	GlycoMark® Testing for Glycemic Control
L36908	03/13/2017	09/28/2023	MolDX: Percepta® Bronchial Genomic Classifier
L36951	03/06/2017	09/28/2023	MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)
L36975	03/06/2017	01/26/2023	Bladder/Urothelial Tumor Markers
L37126	07/10/2017	01/26/2023	Coenzyme Q10 (CoQ10)
L37130	07/10/2017	05/18/2023	MolDX: DecisionDx-UM (Uveal Melanoma)
L37254	11/06/2017	01/26/2023	Chiropractic Services
L37352	11/06/2017	11/17/2022	MolDX: Prometheus IBD sgi Diagnostic® Policy
L37356	03/06/2018	04/27/2023	MolDX: EndoPredict Breast Cancer Gene Expression Test
L37364	01/07/2019	02/02/2023	Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs)
L37575	04/01/2019	01/26/2023	Frequency of Hemodialysis
L37578	03/19/2018	12/24/2023	Micro-Invasive Glaucoma Surgery (MIGS)
L37598	12/17/2018	06/09/2022	Cystatin C Measurement
L37608	05/06/2019	06/30/2022	MDS FISH
L37790	10/01/2018	09/07/2023	Magnetic Resonance Guided Focused Ultrasound Surgery System (MRgFUS) for the treatment of neurologic conditions
L37832	04/01/2019	11/02/2023	MolDX: Breast Cancer Index® (BCI) Gene Expression Test
L37903	05/13/2019	06/15/2023	MolDX: Inivata™, InVisionFirst®, Liquid Biopsy for Patients with Lung Cancer
L37905	05/20/2019	05/19/2022	MolDX: Envisia™, Veracyte™, Idiopathic Pulmonary Fibrosis Diagnostic Test
L38016	06/24/2019	05/18/2023	MolDX: Melanoma Risk Stratification Molecular Testing
L38065	07/27/2020	10/26/2023	MolDX: Plasma-Based Genomic Profiling in Solid Tumors
L38067	02/10/2020	06/08/2023	MolDX: Next-Generation Sequencing for Solid Tumors
L38070	02/10/2020	08/17/2023	MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies
L38111	03/30/2020	10/26/2023	MolDX: Pigmented Lesion Assay
L38201	11/18/2019	10/05/2023	Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
L38249	11/01/2020	04/27/2023	MolDX: Blood Product Molecular Antigen Typing
L38268	04/01/2020	03/02/2023	Immune Thrombocytopenia (ITP) Therapy
L38284	07/27/2020	10/20/2022	MolDX: Predictive Classifiers for Early Stage Non-small Cell Lung Cancer
L38288	06/07/2020	11/24/2022	MolDX: Repeat Germline Testing
L38303	11/09/2020	12/29/2022	MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease
L38307	04/01/2020	03/02/2023	Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
L38378	04/01/2020	10/22/2023	Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH)
L38394	08/03/2020	08/24/2023	MolDX: Pharmacogenomics Testing
L38582	06/06/2021	07/27/2023	MolDX: Molecular Testing for Solid Organ Allograft Rejection
L38584	07/25/2021	04/27/2023	MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells
L38586	07/18/2021	08/20/2023	MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer
L38662	11/02/2020	10/05/2023	Implantable Continuous Glucose Monitors (I-CGM)
L38694	11/02/2020		Computed Tomography Cerebral Perfusion Analysis (CTP)
L38771	04/25/2021	09/07/2023	Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease
L38773	05/02/2021	03/17/2022	Facet Joint Interventions for Pain Management
L38777	03/29/2021	01/30/2022	Colon Capsule Endoscopy (CCE)
L38822	12/26/2021	11/02/2023	MolDX: Minimal Residual Disease Testing for Cancer
L38920	08/08/2021	06/29/2023	Off-label Use of Rituximab and Rituximab Biosimilars
L38992	01/30/2022	01/12/2023	Electroretinography (ERG)
L38997	07/17/2022	07/27/2023	MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer
L39015	12/05/2021	11/09/2023	Epidural Steroid Injections for Pain Management
L39017	08/21/2022	03/30/2023	MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer
L39023	01/03/2022	07/21/2022	Platelet Rich Plasma Injections for Non-Wound Injections
L39038	04/17/2022	05/04/2023	MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
L39276	06/04/2023		MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia
L39284	11/20/2022	11/02/2023	Prostate Cancer Detection with IsoPSA®
L39383	03/19/2023		Sacroiliac Joint Injections and Procedures
L39389	08/06/2023		MolDX: Molecular Assays for the Diagnosis of Cutaneous Melanoma
L39427	10/15/2023		MolDX: Molecular Biomarker Testing to Guide Targeted Therapy Selection in Rheumatoid Arthritis
L39434	02/19/2023		Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin
L39506	05/28/2023		Cosmetic and Reconstructive Surgery
L39521	08/13/2023		Positron Emission Tomography (PET) Scan for Inflammation and Infection
L39575	12/10/2023		Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
L39616	10/08/2023		Urinary Biomarkers for Chronic Pain Management

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