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Date
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Date
Title
CPT Codes Covered in LCD
L32553 10/01/2015 10/01/2015 Allergy Immunotherapy 95115 95117 95144 95145 95146 95147 95148 95149 95165 95170 95180 95199
L33943 10/01/2015 10/01/2015 B-type Natriuretic Peptide (BNP) Testing 83880
L33944 10/01/2015 10/01/2018 Blepharoplasty 15820 15821 15822 15823 67900 67901 67902 67903 67904 67906 67908 67909 67911 67914 67915 67916 67917 67921 67922 67923 67924
L33945 10/01/2015 01/01/2016 Cerumen (Earwax) Removal 69209 69210 G0268
L33946 10/01/2015 10/01/2015 Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy 66820 66821
L33947 10/01/2015 10/01/2016 Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) 75571 75572 75573 75574
L33949 10/01/2015 10/01/2018 Botulinum Toxins 43201 43236 46505 52287 64611 64612 64615 64616 64617 64642 64643 64644 64645 64646 64647 64650 64653 67345 C9399 J0585 J0586 J0587 J0588 J3590
L33950 10/01/2015 01/01/2019 Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography 19030 76641 76642 77046 77047 77048 77049 77053 77054 77063 77065 77066 77067 C8903 C8905 C8906 C8908 G0279
L33952 10/01/2015 10/01/2018 Cardiac Event Detection 93228 93229 93268 93270 93271 93272 93799
L33954 10/01/2015 10/01/2016 Cataract Extraction 66840 66850 66852 66920 66930 66940 66982 66983 66984
L33959 10/01/2015 10/01/2018 Cardiac Catheterization and Coronary Angiography 36140 36200 36215 36216 36217 36218 36221 36222 36223 36224 36225 36226 36227 36228 36245 36246 36247 36248 75625 75630 75635 75705 75710 75716 92978 92979 93451 93452 93453 93454 93455 93456 93457 93458 93459 93460 93461 93462 93463 93464 and more.....
L33960 10/01/2015 10/01/2015 Cardiovascular Nuclear Medicine 78451 78452 78453 78454 78466 78468 78469 78472 78473 78481 78483 78494 78496 93015 93016 93017 93018 A9500 A9501 A9502 A9505 A9512 A9538 A9560 J0153 J1245 J1250 J2785 J3490
L33996 10/01/2015 05/01/2017 Vitamin D Assay Testing 82306
L33999 10/01/2015 10/01/2016 Corneal Pachymetry 76514
L34005 10/01/2015 10/01/2018 Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy 44388 44389 44390 44391 44392 44394 44401 44402 45300 45303 45305 45307 45308 45309 45315 45317 45320 45321 45327 45330 45331 45332 45333 45334 45335 45337 45338 45340 45341 45342 45346 45347 45378 45379 45380 45381 45382 45384 45385 45386 and more.....
L34008 10/01/2015 05/01/2018 Computerized Corneal Topography 92025
L34032 10/01/2015 10/01/2018 Debridement Services 11000 11001 11042 11043 11044 11045 11046 11047
L34037 10/01/2015 10/01/2018 Flow Cytometry 86355 86356 86357 86359 86360 86361 86367 88182 88184 88185 88187 88188 88189
L34045 10/01/2015 10/01/2018 Non-Invasive Vascular Studies 93880 93882 93886 93888 93890 93892 93893 93922 93923 93924 93925 93926 93930 93931 93970 93971 93975 93976 93978 93979 93990 G0365
L34046 10/01/2015 01/01/2019 Speech-Language Pathology 31579 92507 92508 92521 92522 92523 92524 92597 92607 92608 92609 92626 92627 96105 96110 96112 96113 96125 97533 G0515
L34048 10/01/2015 09/01/2018 Vertebroplasty and Vertebral Augmentation (Percutaneous) 22510 22511 22512 22513 22514 22515 76380
L34049 10/01/2015 01/01/2018 Outpatient Physical and Occupational Therapy Services 29065 29075 29085 29086 29105 29125 29126 29130 29131 29200 29240 29260 29280 29345 29355 29365 29405 29425 29445 29505 29515 29520 29530 29540 29550 29580 29799 90901 90911 95831 95832 95833 95834 95851 95852 96125 97010 97012 97016 97018 and more.....
L34055 10/01/2015 10/01/2017 Virtual Colonoscopy (CT Colonography) 74261 74262
L34056 10/01/2015 10/01/2018 Urodynamics 51725 51726 51727 51728 51729 51736 51741 51792 51797
L34061 10/01/2015 04/01/2018 Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) 92133 92134
L34062 10/01/2015 01/01/2018 Dialysis Access Maintenance 36005 36010 36140 36215 36216 36217 36218 36245 36246 36247 36593 36831 36832 36833 36901 36902 36903 36904 36905 36906 36907 37186 37211 37212 37213 37214 37236 37237 37246 37247 37248 37249 75710 75820 75822 75825 75827 93990
L34063 10/01/2015 10/01/2015 RAST Type Tests 86001 86003 86005
L34064 10/01/2015 10/01/2016 Panretinal (Scatter) Laser Photocoagulation 67228
L34081 10/01/2015 10/01/2017 Endoscopy by Capsule 91110 91111 91299
L34082 10/01/2015 01/01/2018 Varicose Veins of the Lower Extremity, Treatment of 36465 36466 36468 36470 36471 36475 36476 36478 36479 36482 36483 37700 37718 37722 37735 37760 37761 37765 37766 37780 37799 76942 93970 93971
L34084 10/01/2015 10/01/2018 Transcatheter Infusion Therapy 61650 61651
L34085 10/01/2015 10/01/2016 Post-Void Residual Urine and/or Bladder Capacity by Ultrasound 51798
L34087 10/01/2015 10/01/2015 Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs): Office, Hospital, Web, or Non-Web Based 93282 93283 93284 93287 93289 93292 93295 93296
L34089 10/01/2015 10/01/2015 Human Papillomavirus (HPV) Testing 87623 87624
L34090 10/01/2015 10/01/2015 Laser Ablation of the Prostate 52647 52648 52649
L34093 10/01/2015 01/01/2019 Chemotherapy and Biologicals XX000
L34171 10/01/2015 10/01/2015 Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation 68801 68810 68811 68815 68816 68840
L34175 10/01/2015 10/01/2016 Ophthalmic Angiography (Fluorescein and Indocyanine Green) 92235 92240
L34181 10/01/2015 10/01/2016 Ophthalmic Biometry for Intraocular Lens Power Calculation 76519 92136
L34183 10/01/2015 10/01/2018 Psychiatric Inpatient Hospitalization XX000
L34195 10/01/2015 10/01/2018 Mohs Micrographic Surgery 17311 17312 17313 17314 17315
L34196 10/01/2015 01/01/2019 Psychiatric Partial Hospitalization Programs 90785 90791 90792 90832 90833 90834 90836 90837 90838 90846 90847 90849 90853 90899 96116 96130 96131 96136 96137 96138 96139 96146 G0129 G0176 G0177 G0410 G0411
L34200 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 17000 17003 17004 17106 17107 17108 17110 17111 and more.....
L34246 10/01/2015 10/01/2018 Routine Foot Care and Debridement of Nails 11055 11056 11057 11719 11720 11721 G0127
L34337 10/01/2015 10/01/2018 Transesophageal Echocardiography (TEE) 76376 76377 93312 93313 93314 93315 93316 93317 93318 93320 93321 93325 C8925 C8926 C8927
L34338 10/01/2015 10/01/2018 Transthoracic Echocardiography (TTE) 76376 76377 93303 93304 93306 93307 93308 93320 93321 93325 93350 93351 93352 A9700 C8921 C8922 C8923 C8924 C8928 C8929 C8930 C9399 J0153 J0280 J0461 J1245 J1250 J2785 J3490 Q9955 Q9956 Q9957
L34353 10/01/2015 01/01/2019 Outpatient Psychiatry and Psychology Services 90785 90791 90792 90832 90833 90834 90836 90837 90838 90839 90840 90845 90846 90847 90849 90853 90863 90865 90870 90880 90885 90887 90889 90899 96105 96110 96112 96113 96116 96130 96131 96136 96137 96138 96139 96146
L34356 10/01/2015 10/01/2018 Erythropoiesis Stimulating Agents (ESA) J0881 J0882 J0885 J0890 Q4081 Q5105 Q5106
L34370 10/01/2015 03/18/2018 Category III CPT® Codes XX000
L34393 10/01/2015 10/01/2018 Ocular Photography - External 92285
L34394 10/01/2015 10/01/2018 Visual Fields Testing 92081 92082 92083
L34399 10/01/2015 10/01/2017 Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) 92225 92226 92227 92228 92250
L34539 10/01/2015 10/01/2015 Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians 90785 90832 90833 90834 90836 90837 90838 90839 90840 90846 90847 90849 90853 90863 90880 90899
L34540 10/01/2015 10/01/2015 Stretta Procedure 43257
L34541 10/01/2015 10/01/2015 Transtelephonic Spirometry 94014 94015 94016
L34807 10/01/2015 10/01/2018 Lumbar Epidural Steroid Injections (ESI) 62323 62327 64483 64484
L34832 10/01/2015 10/01/2016 Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy 64490 64491 64492 64493 64494 64495 64633 64634 64635 64636
L35249 10/01/2015 10/01/2015 Nerve Blocks for Peripheral Neuropathy 64450 76881 76882 76942 76999 97032 97139 G0282 G0283
L35332 10/01/2015 01/01/2019 MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing 0070U 81225 81226 81227 81355 81479
L35349 10/01/2015 09/03/2018 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
L35442 10/01/2015 01/19/2017 MolDX: NRAS Genetic Testing 81311 81479
L35443 10/01/2015 03/08/2018 MolDX: GeneSight ® Assay for Refractory Depression 81479
L35891 10/01/2015 03/01/2018 Intravenous Immune Globulin J1459 J1556 J1557 J1561 J1566 J1568 J1569 J1572
L35897 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
L35906 10/01/2015 10/01/2018 Somatosensory Testing 95925 95926 95927 95928
L35984 10/01/2015 12/31/2015 MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) 81240 81241 81291
L35986 10/01/2015 08/31/2017 Special Histochemical Stains and Immunohistochemical Stains 88312 88313 88341 88342 88344 88360 88361
L36002 10/05/2015 01/01/2018 MolDX: Prolaris™ Prostate Cancer Genomic Assay 81541
L36006 10/05/2015 01/01/2018 MolDX-CDD: ConfirmMDx Epigenetic Molecular Assay 81551
L36011 10/05/2015 01/01/2018 MolDX: Molecular RBC Phenotyping 0001U
L36021 10/01/2015 10/01/2018 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.....
L36029 10/05/2015 10/01/2018 Controlled Substance Monitoring and Drugs of Abuse Testing 80305 80306 80307 G0480 G0481 G0482 G0483 G0659
L36048 10/05/2015 02/26/2018 MolDX: HLA-B*15:02 Genetic Testing 81381
L36113 10/05/2015 10/05/2017 MolDX: MGMT Promoter Methylation Analysis 81287
L36117 10/05/2015 10/05/2017 MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease 81206 81207 81208 81219 81270 81402 81403 81445 81450 81455 81479
L36139 10/05/2015 10/01/2018 MolDX: Biomarkers in Cardiovascular Risk Assessment 82172 82610 83090 83695 83698 83700 83701 83704 83719 83721 86141
L36206 10/05/2015 01/01/2018 MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay 81479
L36425 02/01/2016 01/01/2018 MolDX: Breast Cancer Assay: Prosigna 81520
L36456 02/15/2016 01/01/2019 MolDX: BRCA1 and BRCA2 Genetic Testing 81162 81163 81164 81165 81166 81167 81212 81215 81216 81217 81432 81445 81455 81479
L36458 02/01/2016 01/01/2019 MolDX: Breast Cancer Index℠ Genetic Assay 81518
L36460 02/01/2016 03/01/2018 Bone Mass Measurement 76977 77078 77080 77081 77085 78350 78351 G0130
L36469 02/08/2016 02/08/2016 Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder 90867 90868 90869
L36485 02/15/2016 03/06/2017 MolDX: HLA-DQB1*06:02 Testing for Narcolepsy 81383
L36494 02/01/2016 02/01/2016 Minimally-Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint 27279
L36656 10/10/2016 03/08/2018 MolDX: Decipher® Prostate Cancer Classifier Assay 81479
L36658 10/24/2016 10/01/2018 Proton Beam Therapy 77520 77522 77523 77525
L36675 10/10/2016 10/17/2017 MolDX- CDD: ProMark Risk Score 81479
L36690 10/10/2016 01/01/2019 Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities 15002 15003 15004 15005 15040 15050 15271 15272 15273 15274 15275 15276 15277 15278 C5271 C5272 C5273 C5274 C5275 C5276 C5277 C5278 Q4100 Q4101 Q4102 Q4103 Q4104 Q4105 Q4106 Q4107 Q4108 Q4110 Q4111 Q4115 Q4117 Q4118 Q4121 Q4122 Q4123 Q4124 and more.....
L36902 03/06/2017 03/06/2017 Polysomnography and Other Sleep Studies 95782 95783 95800 95801 95803 95805 95806 95807 95808 95810 95811 G0398 G0399 G0400
L36906 03/06/2017 03/06/2017 GlycoMark Testing for Glycemic Control 84378 84999
L36908 03/13/2017 07/20/2017 MolDX: Percepta© Bronchial Genomic Classifier 81479
L36910 03/13/2017 03/08/2018 MolDX: APC and MUTYH Gene Testing 81201 81202 81203 81401 81403 81406 81435 81479
L36951 03/06/2017 10/01/2018 MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) 0045U
L36973 03/06/2017 07/20/2017 MolDX: Circulating Tumor Cell Marker Assays 86152 86153
L36975 03/06/2017 03/23/2017 Bladder/Urothelial Tumor Markers 86294 86316 86386 88120 88121
L36979 03/13/2017 03/13/2017 MolDX: 4Kscore Assay 81539
L37126 07/10/2017 02/07/2019 Coenzyme Q10 (CoQ10) XX000
L37130 07/10/2017 07/20/2017 MolDX: DecisionDx-UM (Uveal Melanoma) 81599
L37134 07/10/2017 01/01/2019 MolDX: BDX-XL2 0080U
L37142 07/10/2017 01/01/2018 MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease 81541
L37254 11/06/2017 01/16/2018 Chiropractic Services 98940 98941 98942
L37348 12/03/2018 12/03/2018 MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels 87631 87632 87633
L37352 11/06/2017 03/08/2018 MolDX: Prometheus IBD sgi Diagnostic Policy 81479 82397 83520 86140
L37354 03/06/2018 01/01/2019 MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer 0047U
L37356 03/06/2018 08/23/2018 MolDX: EndoPredict Breast Cancer Gene Expression Test 81599
L37362 03/06/2018 03/06/2018 MolDX: AlloSure® Donor-Derived Cell-Free DNA Test 81479
L37364 01/07/2019 01/07/2019 MolDX: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs) 87505 87506 87507
L37366 11/19/2018 MolDX: Guardant360® Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC) 81479
L37575 04/01/2019 Frequency of Hemodialysis 90999
L37578 03/19/2018 11/08/2018 Micro-Invasive Glaucoma Surgery (MIGS) 0191T 0376T 0449T 0450T
L37598 12/17/2018 MolDX: Cystatin C Measurement 82610
L37608 05/06/2019 MolDX: MDS FISH 88271 88273 88274 88275 88291
L37787 11/12/2018 MolDX: Corus® CAD Assay 81493
L37790 10/01/2018 10/01/2018 Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor 0398T
L37832 04/01/2019 04/01/2019 MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test 81518
L37834 04/29/2019 MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease 81479
L37836 03/25/2019 MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC) 81479



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