| LCD |
Effective
Date |
Revision
Effective
Date |
Title |
CPT Codes Covered in LCD |
|
L32553
|
10/01/2015
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11/07/2019
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Allergy Immunotherapy
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L33943
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10/01/2015
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11/28/2019
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B-type Natriuretic Peptide (BNP) Testing
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L33944
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10/01/2015
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11/07/2019
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Blepharoplasty
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L33945
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10/01/2015
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09/19/2019
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Cerumen (Earwax) Removal
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L33946
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10/01/2015
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11/07/2019
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Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy
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L33947
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10/01/2015
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09/19/2019
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Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA)
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L33949
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10/01/2015
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11/28/2019
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Botulinum Toxins
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L33950
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10/01/2015
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11/28/2019
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Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography
|
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L33952
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10/01/2015
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09/19/2019
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Cardiac Event Detection
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L33954
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10/01/2015
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12/24/2020
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Cataract Extraction
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L33959
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10/01/2015
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11/07/2019
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Cardiac Catheterization and Coronary Angiography
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L33960
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10/01/2015
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09/19/2019
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Cardiovascular Nuclear Medicine
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L33996
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10/01/2015
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09/07/2020
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Vitamin D Assay Testing
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L33999
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10/01/2015
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09/19/2019
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Corneal Pachymetry
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L34005
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10/01/2015
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09/19/2019
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Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
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L34008
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10/01/2015
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09/19/2019
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Computerized Corneal Topography
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L34032
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10/01/2015
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09/12/2019
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Debridement Services
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L34037
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10/01/2015
|
10/31/2019
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Flow Cytometry
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L34045
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10/01/2015
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11/28/2019
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Non-Invasive Vascular Studies
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L34046
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10/01/2015
|
09/26/2019
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Speech-Language Pathology
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L34049
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10/01/2015
|
11/14/2019
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Outpatient Physical and Occupational Therapy Services
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L34055
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10/01/2015
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09/26/2019
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Virtual Colonoscopy (CT Colonography)
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L34056
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10/01/2015
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09/26/2019
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Urodynamics
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L34061
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10/01/2015
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10/03/2019
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Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
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L34062
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10/01/2015
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09/19/2019
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Dialysis Access Maintenance
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L34063
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10/01/2015
|
12/05/2019
|
RAST Type Tests
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L34064
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10/01/2015
|
10/03/2019
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Panretinal (Scatter) Laser Photocoagulation
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L34081
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10/01/2015
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09/19/2019
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Endoscopy by Capsule
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L34082
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10/01/2015
|
09/26/2019
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Varicose Veins of the Lower Extremity, Treatment of
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L34084
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10/01/2015
|
12/05/2019
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Transcatheter Infusion Therapy
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L34085
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10/01/2015
|
10/01/2016
|
Post-Void Residual Urine and/or Bladder Capacity by Ultrasound
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L34087
|
10/01/2015
|
09/26/2019
|
Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs): Office, Hospital, Web, or Non-Web Based
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|
|
L34089
|
10/01/2015
|
09/19/2019
|
Human Papillomavirus (HPV) Testing
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|
L34090
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10/01/2015
|
09/19/2019
|
Laser Ablation of the Prostate
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L34171
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10/01/2015
|
09/26/2019
|
Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation
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L34175
|
10/01/2015
|
10/31/2019
|
Ophthalmic Angiography (Fluorescein and Indocyanine Green)
|
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|
L34181
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10/01/2015
|
12/05/2019
|
Ophthalmic Biometry for Intraocular Lens Power Calculation
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L34183
|
10/01/2015
|
09/26/2019
|
Psychiatric Inpatient Hospitalization
|
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L34195
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10/01/2015
|
08/08/2019
|
Mohs Micrographic Surgery
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L34196
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10/01/2015
|
11/07/2019
|
Psychiatric Partial Hospitalization Programs
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L34200
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10/01/2015
|
09/26/2019
|
Removal of Benign Skin Lesions
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|
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L34246
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10/01/2015
|
11/28/2019
|
Routine Foot Care and Debridement of Nails
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L34337
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10/01/2015
|
09/26/2019
|
Transesophageal Echocardiography (TEE)
|
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L34338
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10/01/2015
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09/26/2019
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Transthoracic Echocardiography (TTE)
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L34353
|
10/01/2015
|
11/07/2019
|
Outpatient Psychiatry and Psychology Services
|
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|
L34356
|
10/01/2015
|
10/03/2019
|
Erythropoiesis Stimulating Agents (ESA)
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L34393
|
10/01/2015
|
10/31/2019
|
Ocular Photography - External
|
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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)
|
|
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L34539
|
10/01/2015
|
11/28/2019
|
Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians
|
|
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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)
|
|
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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
|
|
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L35349
|
10/01/2015
|
12/05/2019
|
MolDX: Genetic Testing for Lynch Syndrome
|
|
|
L35442
|
10/01/2015
|
11/28/2019
|
MolDX: NRAS Genetic Testing
|
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|
L35891
|
10/01/2015
|
09/19/2019
|
Intravenous Immune Globulin
|
|
|
L35897
|
10/01/2015
|
10/24/2019
|
Nerve Conduction Studies and Electromyography
|
|
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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
|
|
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L36485
|
02/15/2016
|
12/24/2020
|
MolDX: HLA-DQB1*06:02 Testing for Narcolepsy
|
|
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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
|
|
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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)
|
|
