CodeMap® CodeMap® Contractor Policy Detail

LCD	Effective Date	Revision Effective Date	Title	CPT Codes Covered in LCD
L32553	10/01/2015	03/28/2019	Allergy Immunotherapy	XX000
L33943	10/01/2015	03/28/2019	B-type Natriuretic Peptide (BNP) Testing	XX000
L33944	10/01/2015	03/28/2019	Blepharoplasty	XX000
L33945	10/01/2015	04/04/2019	Cerumen (Earwax) Removal	XX000
L33946	10/01/2015	04/18/2019	Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy	XX000
L33947	10/01/2015	04/04/2019	Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA)	XX000
L33949	10/01/2015	04/04/2019	Botulinum Toxins	XX000
L33950	10/01/2015	01/01/2019	Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography	XX000
L33952	10/01/2015	04/04/2019	Cardiac Event Detection	XX000
L33954	10/01/2015	10/01/2016	Cataract Extraction	66840 66850 66852 66920 66930 66940 66982 66983 66984
L33959	10/01/2015	04/18/2019	Cardiac Catheterization and Coronary Angiography	XX000
L33960	10/01/2015	04/18/2019	Cardiovascular Nuclear Medicine	XX000
L33996	10/01/2015	05/01/2017	Vitamin D Assay Testing	82306
L33999	10/01/2015	04/04/2019	Corneal Pachymetry	XX000
L34005	10/01/2015	04/04/2019	Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy	XX000
L34008	10/01/2015	05/01/2018	Computerized Corneal Topography	92025
L34032	10/01/2015	04/04/2019	Debridement Services	XX000
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	04/04/2019	Dialysis Access Maintenance	XX000
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	04/11/2019	Laser Ablation of the Prostate	XX000
L34093	10/01/2015	05/16/2019	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	04/11/2019	Lumbar Epidural Steroid Injections (ESI)	XX000
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
L36460	02/01/2016	07/01/2018	Bone Mass Measurement	0508T 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-DQB106:02 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	04/04/2019	Bladder/Urothelial Tumor Markers	XX000
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	01/01/2019	MolDX: DecisionDx-UM (Uveal Melanoma)	0081U
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	04/04/2019	Chiropractic Services	XX000
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	05/06/2019	MolDX: MDS FISH	88271 88273 88274 88275 88291
L37787	11/12/2018		MolDX: Corus® CAD Assay	81493
L37790	10/01/2018	04/11/2019	Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor	XX000
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
L37903	05/13/2019	05/13/2019	MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer	81479
L37905	05/20/2019	05/20/2019	MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test	81479
L37907	06/03/2019		MolDX: myPath Melanoma Assay	81479
L38016	06/24/2019		MolDX: DecisionDx-Melanoma	81599

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