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
|
12/24/2020
|
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
|
09/07/2020
|
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
|
12/31/2020
|
Lumbar Epidural Steroid Injections (ESI)
|
|
L34832
|
10/01/2015
|
12/31/2020
|
Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
|
|
L35249
|
10/01/2015
|
10/31/2019
|
Nerve Blocks for Peripheral Neuropathy
|
|
L35349
|
10/01/2015
|
12/05/2019
|
MolDX: Genetic Testing for Lynch Syndrome
|
|
L35442
|
10/01/2015
|
11/28/2019
|
MolDX: NRAS Genetic Testing
|
|
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
|
12/17/2020
|
MolDX: ConfirmMDx Epigenetic Molecular Assay
|
|
L36021
|
10/01/2015
|
12/19/2019
|
MolDX: Molecular Diagnostic Tests (MDT)
|
|
L36029
|
10/05/2015
|
03/08/2021
|
Controlled Substance Monitoring and Drugs of Abuse 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
|
12/24/2020
|
MolDX: BRCA1 and BRCA2 Genetic Testing
|
|
L36460
|
02/01/2016
|
12/24/2020
|
Bone Mass Measurement
|
|
L36469
|
02/08/2016
|
01/07/2021
|
Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder
|
|
L36485
|
02/15/2016
|
12/24/2020
|
MolDX: HLA-DQB1*06:02 Testing for Narcolepsy
|
|
L36494
|
02/01/2016
|
12/24/2020
|
Minimally-Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint
|
|
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
|
11/19/2020
|
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
|
11/30/2020
|
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
|
|
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
|
12/10/2020
|
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
|
03/08/2021
|
Magnetic Resonance Guided Focused Ultrasound Surgery System (MRgFUS) for the treatment of neurologic conditions
|
|
L37832
|
04/01/2019
|
10/31/2019
|
MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test
|
|
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
|
12/21/2020
|
MolDX: Melanoma Risk Stratification Molecular Testing
|
|
L38053
|
12/30/2019
|
12/24/2020
|
MolDX: TruGraf Blood Gene Expression Test
|
|
L38059
|
03/10/2020
|
12/24/2020
|
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
|
|
L38111
|
03/30/2020
|
|
MolDX: Pigmented Lesion Assay
|
|
L38201
|
11/18/2019
|
|
Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF)
|
|
L38249
|
11/01/2020
|
12/10/2020
|
MolDX: Blood Product Molecular Antigen Typing
|
|
L38268
|
04/01/2020
|
|
Immune Thrombocytopenia (ITP) Therapy
|
|
L38272
|
12/28/2020
|
|
MolDX: AlloSure® or Equivalent Cell-Free DNA Testing for Kidney and Heart Allografts
|
|
L38284
|
07/27/2020
|
|
MolDX: Predictive Classifiers for Early Stage Non-small Cell Lung Cancer
|
|
L38288
|
06/07/2020
|
|
MolDX: Repeat Germline Testing
|
|
L38303
|
11/09/2020
|
|
MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease
|
|
L38305
|
10/19/2020
|
|
MolDX: Minimal Residual Disease Testing for Colorectal Cancer
|
|
L38307
|
04/01/2020
|
04/01/2020
|
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
|
|
L38378
|
04/01/2020
|
11/09/2020
|
Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH)
|
|
L38394
|
08/03/2020
|
|
MolDX: Pharmacogenomics Testing
|
|
L38662
|
11/02/2020
|
|
Implantable Continuous Glucose Monitors (I-CGM)
|
|
L38694
|
11/02/2020
|
|
Computed Tomography Cerebral Perfusion Analysis (CTP)
|
|