CodeMap® CodeMap® Contractor Policy Detail

LCD	Effective Date	Revision Effective Date	Title	CPT Codes Covered in LCD
L32553	10/01/2015	11/07/2019	Allergy Immunotherapy
L33943	10/01/2015	11/28/2019	B-type Natriuretic Peptide (BNP) Testing
L33944	10/01/2015	11/07/2019	Blepharoplasty
L33945	10/01/2015	09/19/2019	Cerumen (Earwax) Removal
L33946	10/01/2015	11/07/2019	Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy
L33947	10/01/2015	09/19/2019	Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA)
L33949	10/01/2015	11/28/2019	Botulinum Toxins
L33950	10/01/2015	11/28/2019	Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography
L33952	10/01/2015	09/19/2019	Cardiac Event Detection
L33954	10/01/2015	12/26/2019	Cataract Extraction
L33959	10/01/2015	11/07/2019	Cardiac Catheterization and Coronary Angiography
L33960	10/01/2015	09/19/2019	Cardiovascular Nuclear Medicine
L33996	10/01/2015	11/28/2019	Vitamin D Assay Testing
L33999	10/01/2015	09/19/2019	Corneal Pachymetry
L34005	10/01/2015	09/19/2019	Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
L34008	10/01/2015	09/19/2019	Computerized Corneal Topography
L34032	10/01/2015	09/12/2019	Debridement Services
L34037	10/01/2015	10/31/2019	Flow Cytometry
L34045	10/01/2015	11/28/2019	Non-Invasive Vascular Studies
L34046	10/01/2015	09/26/2019	Speech-Language Pathology
L34049	10/01/2015	11/14/2019	Outpatient Physical and Occupational Therapy Services
L34055	10/01/2015	09/26/2019	Virtual Colonoscopy (CT Colonography)
L34056	10/01/2015	09/26/2019	Urodynamics
L34061	10/01/2015	10/03/2019	Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
L34062	10/01/2015	09/19/2019	Dialysis Access Maintenance
L34063	10/01/2015	12/05/2019	RAST Type Tests
L34064	10/01/2015	10/03/2019	Panretinal (Scatter) Laser Photocoagulation
L34081	10/01/2015	09/19/2019	Endoscopy by Capsule
L34082	10/01/2015	09/26/2019	Varicose Veins of the Lower Extremity, Treatment of
L34084	10/01/2015	12/05/2019	Transcatheter Infusion Therapy
L34085	10/01/2015	10/01/2016	Post-Void Residual Urine and/or Bladder Capacity by Ultrasound
L34087	10/01/2015	09/26/2019	Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs): Office, Hospital, Web, or Non-Web Based
L34089	10/01/2015	09/19/2019	Human Papillomavirus (HPV) Testing
L34090	10/01/2015	09/19/2019	Laser Ablation of the Prostate
L34171	10/01/2015	09/26/2019	Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation
L34175	10/01/2015	10/31/2019	Ophthalmic Angiography (Fluorescein and Indocyanine Green)
L34181	10/01/2015	12/05/2019	Ophthalmic Biometry for Intraocular Lens Power Calculation
L34183	10/01/2015	09/26/2019	Psychiatric Inpatient Hospitalization
L34195	10/01/2015	08/08/2019	Mohs Micrographic Surgery
L34196	10/01/2015	11/07/2019	Psychiatric Partial Hospitalization Programs
L34200	10/01/2015	09/26/2019	Removal of Benign Skin Lesions
L34246	10/01/2015	11/28/2019	Routine Foot Care and Debridement of Nails
L34337	10/01/2015	09/26/2019	Transesophageal Echocardiography (TEE)
L34338	10/01/2015	09/26/2019	Transthoracic Echocardiography (TTE)
L34353	10/01/2015	11/07/2019	Outpatient Psychiatry and Psychology Services
L34356	10/01/2015	10/03/2019	Erythropoiesis Stimulating Agents (ESA)
L34393	10/01/2015	10/31/2019	Ocular Photography - External
L34394	10/01/2015	09/26/2019	Visual Fields Testing
L34399	10/01/2015	12/05/2019	Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)
L34539	10/01/2015	11/28/2019	Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians
L34540	10/01/2015	09/26/2019	Stretta Procedure
L34541	10/01/2015	09/26/2019	Transtelephonic Spirometry
L34807	10/01/2015	12/26/2019	Lumbar Epidural Steroid Injections (ESI)
L34832	10/01/2015	12/26/2019	Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
L35249	10/01/2015	10/31/2019	Nerve Blocks for Peripheral Neuropathy
L35332	10/01/2015	09/23/2019	MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing
L35349	10/01/2015	12/05/2019	MolDX: Genetic Testing for Lynch Syndrome
L35442	10/01/2015	11/28/2019	MolDX: NRAS Genetic Testing
L35443	10/01/2015	11/28/2019	MolDX: GeneSight ® Assay for Refractory Depression
L35891	10/01/2015	09/19/2019	Intravenous Immune Globulin
L35897	10/01/2015	10/24/2019	Nerve Conduction Studies and Electromyography
L35906	10/01/2015	09/26/2019	Somatosensory Testing
L35984	10/01/2015	10/31/2019	MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)
L35986	10/01/2015	10/31/2019	Special Histochemical Stains and Immunohistochemical Stains
L36002	10/05/2015	11/07/2019	MolDX: Prolaris™ Prostate Cancer Genomic Assay
L36006	10/05/2015	11/07/2019	MolDX: ConfirmMDx Epigenetic Molecular Assay
L36011	10/05/2015	11/07/2019	MolDX: Molecular RBC Phenotyping
L36021	10/01/2015	12/19/2019	MolDX: Molecular Diagnostic Tests (MDT)
L36029	10/05/2015	11/21/2019	Controlled Substance Monitoring and Drugs of Abuse Testing
L36048	10/05/2015	11/07/2019	MolDX: HLA-B*15:02 Genetic Testing
L36113	10/05/2015	06/04/2020	MolDX: MGMT Promoter Methylation Analysis
L36117	10/05/2015	12/19/2019	MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease
L36139	10/05/2015	11/14/2019	MolDX: Biomarkers in Cardiovascular Risk Assessment
L36206	10/05/2015	11/14/2019	MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay
L36425	02/01/2016	09/23/2019	MolDX: Breast Cancer Assay: Prosigna
L36456	02/15/2016	01/09/2020	MolDX: BRCA1 and BRCA2 Genetic Testing
L36460	02/01/2016	12/26/2019	Bone Mass Measurement
L36469	02/08/2016	12/26/2019	Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder
L36485	02/15/2016	12/26/2019	*MolDX: HLA-DQB106:02 Testing for Narcolepsy**
L36494	02/01/2016	12/26/2019	Minimally-Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint
L36656	10/10/2016	11/14/2019	MolDX: Decipher® Prostate Cancer Classifier Assay
L36658	10/24/2016	09/26/2019	Proton Beam Therapy
L36675	10/10/2016	11/28/2019	MolDX- CDD: ProMark Risk Score
L36690	10/10/2016	10/31/2019	Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities
L36902	03/06/2017	09/26/2019	Polysomnography and Other Sleep Studies
L36906	03/06/2017	10/31/2019	GlycoMark Testing for Glycemic Control
L36908	03/13/2017	11/28/2019	MolDX: Percepta® Bronchial Genomic Classifier
L36910	03/13/2017	11/28/2019	MolDX: APC and MUTYH Gene Testing
L36951	03/06/2017	11/28/2019	MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)
L36973	03/06/2017	11/07/2019	MolDX: Circulating Tumor Cell Marker Assays
L36975	03/06/2017	10/31/2019	Bladder/Urothelial Tumor Markers
L36979	03/13/2017	10/31/2019	MolDX: 4Kscore Assay
L37126	07/10/2017	09/19/2019	Coenzyme Q10 (CoQ10)
L37130	07/10/2017	10/31/2019	MolDX: DecisionDx-UM (Uveal Melanoma)
L37134	07/10/2017	06/04/2020	MolDX: BDX-XL2
L37142	07/10/2017	06/04/2020	MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease
L37254	11/06/2017	09/19/2019	Chiropractic Services
L37348	12/03/2018	11/28/2019	MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels
L37352	11/06/2017	11/14/2019	MolDX: Prometheus IBD sgi Diagnostic Policy
L37354	03/06/2018	11/14/2019	MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer
L37356	03/06/2018	11/14/2019	MolDX: EndoPredict Breast Cancer Gene Expression Test
L37362	03/06/2018	10/31/2019	MolDX: AlloSure® Donor-Derived Cell-Free DNA Test
L37364	01/07/2019	11/28/2019	Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs)
L37575	04/01/2019	10/01/2019	Frequency of Hemodialysis
L37578	03/19/2018	12/30/2019	Micro-Invasive Glaucoma Surgery (MIGS)
L37598	12/17/2018	11/28/2019	MolDX: Cystatin C Measurement
L37608	05/06/2019	11/07/2019	MolDX: MDS FISH
L37787	11/12/2018	09/19/2019	MolDX: Corus® CAD Assay
L37790	10/01/2018	09/19/2019	Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor
L37832	04/01/2019	10/31/2019	MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test
L37834	04/29/2019	01/09/2020	MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease
L37836	03/25/2019	11/21/2019	MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC)
L37903	05/13/2019	03/05/2020	MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer
L37905	05/20/2019	11/07/2019	MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test
L37907	06/03/2019	10/31/2019	MolDX: myPath Melanoma Assay
L38016	06/24/2019	10/03/2019	MolDX: DecisionDx-Melanoma
L38053	12/30/2019		MolDX: TruGraf Blood Gene Expression Test
L38059	03/10/2020		MolDX: Prospera
L38065	07/27/2020		MolDX: Plasma-Based Genomic Profiling in Solid Tumors
L38067	02/10/2020	03/05/2020	MolDX: Next-Generation Sequencing for Solid Tumors
L38070	02/10/2020	03/05/2020	MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies
L38077	04/06/2020		MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Intermediate Risk Disease
L38111	03/30/2020		MolDX: Pigmented Lesion Assay
L38201	11/18/2019		Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF)
L38268	04/01/2020		Immune Thrombocytopenia (ITP) Therapy
L38284	07/27/2020		MolDX: Predictive Classifiers for Early Stage Non-small Cell Lung Cancer
L38288	06/07/2020		MolDX: Repeat Germline Testing
L38307	04/01/2020	04/01/2020	Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
L38378	04/01/2020	09/01/2020	Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH)
L38394	08/03/2020		MolDX: Pharmacogenomics Testing

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