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Effective
Date
Revision
Effective
Date
Title
CPT Codes Covered in Policy
L34822 10/01/2015 08/09/2018 Luteinizing Hormone-Releasing Hormone (LHRH) Analogs J1950 J3315 J9202 J9217 J9219 J9225 J9226
L34833 10/01/2015 10/01/2018 Cardiac Rhythm Device Evaluation 93260 93261 93279 93280 93281 93282 93283 93284 93286 93287 93288 93289 93292 93293 93294 93295 93296 93724
L34834 10/01/2015 05/11/2017 Blood Glucose Monitoring in a Skilled Nursing Facility (SNF) 82947 82948 82962
L34856 10/01/2015 10/01/2018 C-Reactive Protein High Sensitivity Testing (hsCRP) 86141
L34862 10/01/2015 10/01/2015 Co-Management of Surgical Procedures XX000
L34864 10/01/2015 01/04/2016 Loss-of-Heterozygosity Based Topographic Genotyping with PathfinderTG ® 81479
L34865 10/01/2015 10/01/2018 Magnetic Resonance Angiography (MRA) 70544 70545 70546 70547 70548 70549 71555 72159 72198 73225 73725 74185 C8900 C8901 C8902 C8909 C8910 C8911 C8912 C8913 C8914 C8918 C8919 C8920 C8931 C8932 C8933 C8934 C8935 C8936
L34887 10/01/2015 01/01/2017 Surgical Treatment of Nails 11730 11732 11750 11765
L34891 10/01/2015 03/29/2018 Speech-Language Pathology (SLP) Services: Dysphagia; Includes VitalStim® Therapy 92526 92610
L34892 10/01/2015 08/16/2018 Facet Joint Interventions for Pain Management 64490 64491 64492 64493 64494 64495 64633 64634 64635 64636 64999
L34914 10/01/2015 10/01/2018 Assays for Vitamins and Metabolic Function 82180 82306 82379 82607 82652 82746 83090 83698 84207 84252 84255 84425 84446 84590 84591 84597 84999 85385 86352
L34924 10/01/2015 05/17/2018 Treatment of Varicose Veins and Venous Stasis Disease of the Lower Extremities 36468 36470 36471 36475 36476 36478 36479 37500 37700 37718 37722 37735 37760 37761 37765 37766 37780 37785 76937 93970 93971
L34938 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.....
L34953 10/01/2015 10/04/2018 Cardiac Event Detection Monitoring 93268 93270 93271 93272
L34960 10/01/2015 03/08/2018 Hydration Therapy 96360 96361 J7030 J7040 J7042 J7050 J7060 J7070 J7120 J7121
L34961 10/01/2015 10/01/2018 Mohs Micrographic Surgery (MMS) 17311 17312 17313 17314 17315
L34975 10/01/2015 10/01/2018 Neurophysiology Evoked Potentials (NEPs) 92585 92586 95925 95926 95927 95928 95929 95930 95938 95939
L34977 10/01/2015 10/01/2016 Anorectal Manometry, Anal Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters 51784 51785 90901 90911 91117 91122
L34996 10/01/2015 10/01/2017 Neuromuscular Junction Testing 95937
L34997 10/01/2015 10/01/2015 Real-Time, Outpatient Cardiac Telemetry 93228 93229
L34998 10/01/2015 11/09/2017 Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder 90867 90868 90869
L35003 10/01/2015 10/01/2018 Intraoperative Neurophysiological Testing 95940 G0453
L35004 10/01/2015 10/01/2018 Surgery: Blepharoplasty 15820 15821 15822 15823 67900 67901 67902 67903 67904 67906 67908
L35006 10/01/2015 10/01/2018 Controlled Substance Monitoring and Drugs of Abuse Testing 80305 80306 80307 G0480 G0481 G0482 G0483 G0659
L35007 10/01/2015 12/14/2017 Vestibular and Audiologic Function Studies 92537 92538 92540 92541 92542 92544 92545 92546 92547 92550 92552 92553 92555 92556 92557 92561 92562 92563 92564 92565 92567 92568 92570 92571 92572 92575 92576 92577 92579 92582 92583 92584 92585 92586 92587 92588 92620 92621
L35009 10/01/2015 10/01/2016 Prostate Mapping Biopsy 55706
L35010 10/01/2015 10/01/2018 Trigger Point Injections 20552 20553 M0076
L35011 10/01/2015 01/12/2017 Surgery: Posterior Tibial Nerve Stimulation (PTNS) for Urinary Control 64566
L35013 10/01/2015 08/16/2018 Debridement of Mycotic Nails 11720 11721
L35014 10/01/2015 10/01/2017 Frequency of Dialysis 90999
L35015 10/01/2015 10/01/2018 Molecular Diagnostics: Genitourinary Infectious Disease Testing 87480 87481 87490 87491 87510 87590 87591 87660 87798
L35016 10/01/2015 10/01/2018 Transesophageal Echocardiography (TEE) 93312 93313 93314 93315 93316 93317 93318 93320 93321 93325 93355 C8925 C8926 C8927 Q9955 Q9956 Q9957
L35021 10/01/2015 04/01/2018 Hyperbaric Oxygen (HBO) Therapy 99183 G0277
L35022 10/01/2015 10/01/2018 Bariatric Surgical Management of Morbid Obesity 43644 43645 43659 43770 43771 43772 43773 43774 43775 43842 43843 43845 43846 43847 43848 43886 43887 43888 43999
L35032 10/01/2015 10/01/2017 Flow Cytometry 88182 88184 88185 88187 88188 88189
L35035 10/01/2015 10/01/2018 Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography 36222 36223 36224 36225 36226 36227 36228
L35036 10/01/2015 03/29/2018 Therapy and Rehabilitation Services (PT, OT) 95992 97012 97016 97018 97022 97024 97028 97032 97033 97034 97035 97036 97039 97110 97112 97113 97116 97124 97139 97140 97150 97161 97162 97163 97164 97165 97166 97167 97168 97530 97533 97535 97537 97542 97750 97755 97760 97761 97763 97799 and more.....
L35038 10/01/2015 01/25/2018 Scanning Computerized Ophthalmic Diagnostic Imaging 92132 92133 92134
L35041 10/01/2015 09/17/2018 Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds 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.....
L35049 10/01/2015 10/01/2018 Monitored Anesthesia Care 00100 00124 00148 00160 00164 00300 00322 00400 00410 00454 00520 00522 00524 00530 00532 00635 00640 00702 00731 00732 00842 00920 00921 01130 01380 01420 01490 01680 01730 01780 01782 01820 01829 01860 01916 01920 01922 01930 01935 01936 and more.....
L35050 10/01/2015 03/08/2018 Outpatient Sleep Studies 95782 95783 95800 95801 95805 95806 95807 95808 95810 95811 95999 G0398 G0399 G0400
L35062 10/01/2015 10/01/2018 Biomarkers Overview 0001U 81161 81200 81201 81202 81203 81205 81209 81220 81221 81222 81223 81224 81225 81226 81227 81228 81229 81240 81241 81242 81243 81244 81250 81251 81252 81253 81254 81255 81256 81257 81258 81259 81260 81265 81266 81267 81268 81269 81288 and more.....
L35068 10/01/2015 10/01/2015 Evaluation and Management Services Provided in a Nursing Facility 99304 99305 99306 99307 99308 99309 99310 99315 99316 99318
L35070 10/01/2015 03/29/2018 Speech - Language Pathology (SLP) Services: Communication Disorders 92507 92508 92521 92522 92523 92524 92597 92607 92608 92609 96105 96110 96111
L35081 10/01/2015 10/01/2018 Nerve Conduction Studies and Electromyography 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
L35083 10/01/2015 10/01/2017 Cardiovascular Nuclear Medicine 78451 78452 78453 78454 78466 78468 78469 78472 78473 78481 78483 78494 78496 93015 93016 93017 93018 A4641 A9500 A9501 A9502 A9505 A9512 A9538 A9560 J0153 J0395 J1245 J1250 J2785
L35084 10/01/2015 09/20/2018 Non-Coronary Vascular Stents 37221 37223 37226 37227 37230 37231 37234 37235 37236 37237 37238 37239 92997 92998
L35089 10/01/2015 03/08/2018 Wireless Capsule Endoscopy 91110 91111
L35090 10/01/2015 04/14/2017 Cosmetic and Reconstructive Surgery 11920 11921 11922 15775 15776 15780 15781 15782 15783 15830 15847 19316 19318 19324 19325 19328 19330 19340 19342 19350 19355 19357 19361 19364 19366 19367 19368 19369 19370 19371 19380 19396 30400 30410 30420 30430 30435 30450 30460 30462
L35091 10/01/2015 08/10/2017 Cataract Extraction (including Complex Cataract Surgery) 66840 66850 66852 66920 66940 66982 66983 66984
L35092 10/01/2015 05/10/2018 Diagnostic Abdominal Aortography and Renal Angiography 36245 36246 36247 36248 36251 36252 36253 36254 75625 75630 75726 G0278
L35093 10/01/2015 09/09/2018 Intravenous Immune Globulin (IVIG) J0850 J1459 J1556 J1557 J1561 J1566 J1568 J1569 J1572 J1573 J1599 J2788 J2790 J2792
L35094 10/01/2015 11/08/2018 Services That Are Not Reasonable and Necessary 0042T 0054T 0055T 0058T 0071T 0072T 0085T 0095T 0098T 0101T 0102T 0106T 0107T 0108T 0109T 0110T 0111T 0126T 0163T 0164T 0165T 0174T 0175T 0184T 0188T 0189T 0190T 0195T 0196T 0198T 0202T 0205T 0206T 0207T 0208T 0209T 0210T 0211T 0212T 0213T and more.....
L35095 10/01/2015 03/08/2018 Lacrimal Punctum Plugs 68761 A4262 A4263
L35099 10/01/2015 02/08/2018 Frequency of Laboratory Tests 80061 82465 82948 82962 82985 83036 83718 83721 84436 84439 84443 84478 84479
L35101 10/01/2015 10/01/2018 Psychiatric Codes 90785 90791 90792 90832 90833 90834 90836 90837 90838 90839 90840 90845 90846 90847 90853 90865 90870 90880 90889 90899 96101 96102 96103 96105 96111 96116 96118 96119 96120 G0451
L35111 10/01/2015 01/01/2018 Hemophilia Factor Products J7175 J7179 J7180 J7181 J7182 J7183 J7185 J7186 J7187 J7188 J7189 J7190 J7191 J7192 J7193 J7194 J7195 J7198 J7200 J7201 J7202 J7205 J7207 J7209 J7210 J7211
L35112 10/01/2015 01/01/2016 Implantable Infusion Pump 36260 36261 36262 62350 62351 62355 62361 62362 62365 62367 62368 62369 62370 95990 95991 96522 A4220 E0782 E0783 E0785 E0786
L35125 10/01/2015 11/09/2017 Wound Care 11000 11001 11004 11005 11006 11008 11010 11011 11012 11042 11043 11044 11045 11046 11047 29580 29581 97597 97598 97602 97605 97606 97607 97608 97610
L35130 10/01/2015 05/04/2017 Vertebroplasty, Vertebral Augmentation (Kyphoplasty) Percutaneous 0200T 0201T 22510 22511 22512 22513 22514 22515
L35138 10/01/2015 12/14/2017 Routine Foot Care 11055 11056 11057 11719 11720 11721 G0127
L35162 10/01/2015 07/16/2018 Ambulance Services (Ground Ambulance) A0425 A0426 A0427 A0428 A0429 A0433 A0434 A0888 A0999
L35350 10/01/2015 10/01/2018 Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) 43191 43192 43193 43194 43195 43196 43197 43198 43200 43201 43202 43204 43205 43206 43211 43212 43213 43214 43215 43216 43217 43220 43226 43227 43229 43231 43232 43233 43235 43236 43237 43238 43239 43240 43241 43242 43243 43244 43245 43246 and more.....
L35360 10/01/2015 10/01/2018 Pulmonary Function Testing 94010 94014 94015 94016 94060 94070 94200 94250 94375 94400 94450 94680 94681 94690 94726 94727 94728 94729 94750 94770
L35391 10/01/2015 12/07/2015 Multiple Imaging in Oncology 70450 70460 70470 70551 70552 70553 71250 71260 71270 71551 71552 72125 72126 72127 72128 72129 72130 72131 72132 72133 72141 72142 72146 72147 72148 72149 72156 72157 72158 72192 72193 72194 72195 72196 72197 74150 74160 74170 74176 74177 and more.....
L35395 10/01/2015 10/01/2017 Autonomic Function Tests 95921 95922 95923 95924 95943
L35396 10/01/2015 10/04/2018 Biomarkers for Oncology 0002U 0003U 0005U 0009U 0013U 0014U 0016U 0017U 0022U 0026U 81120 81121 81170 81175 81176 81206 81207 81208 81210 81218 81219 81235 81245 81246 81261 81262 81263 81270 81272 81273 81275 81276 81287 81292 81293 81294 81301 81310 81311 81313 and more.....
L35397 10/01/2015 10/01/2018 Non-Invasive Cerebrovascular Arterial Studies 93880 93882 93886 93888 93890 93892 93893
L35408 10/01/2015 10/01/2018 3D Interpretation and Reporting of Imaging Studies 76376 76377
L35409 10/01/2015 06/14/2018 Non-Vascular Extremity Ultrasound 76881 76882
L35424 10/01/2015 10/01/2018 Chiropractic Services 98940 98941 98942
L35427 10/01/2015 07/12/2018 Hyaluronan Acid Therapies for Osteoarthritis of the Knee J7320 J7321 J7322 J7323 J7324 J7325 J7326 J7327 J7328
L35428 10/01/2015 10/01/2018 Thrombolytic Agents 36593 37195 37211 37212 37213 37214 61645 92975 92977 J0350 J2993 J2995 J2997 J3101 J3364 J3365
L35433 10/01/2015 10/01/2018 Barium Swallow Studies, Modified 70370 70371 74230
L35434 10/01/2015 10/01/2018 Oximetry Services 94760 94761 94762
L35448 10/01/2015 07/12/2018 Independent Diagnostic Testing Facility (IDTF) 0159T 0295T 0296T 0297T 0298T 20501 23350 24220 25246 27093 27095 27370 27648 42550 43754 43755 51600 51610 51725 51726 51727 51728 51729 51736 51741 51784 51785 51792 51797 51798 54240 54250 58340 59025 62284 62302 62303 62304 62305 70010 and more.....
L35449 10/01/2015 09/14/2017 Sacral Nerve Stimulation 64561 64581 64585 A4290
L35450 10/01/2015 11/09/2017 Spinal Cord Stimulation (Dorsal Column Stimulation) 63650 63655 63685
L35451 10/01/2015 07/12/2018 Non-Invasive Peripheral Venous Studies 93970 93971 G0365
L36007 10/01/2015 08/09/2018 Lower Extremity Major Joint Replacement (Hip and Knee) 27130 27132 27134 27137 27138 27445 27447 27486 27487
L36240 10/01/2015 10/01/2015 Allergen Immunotherapy 95115 95117 95144 95145 95146 95147 95148 95149 95165 95170 95180 95199
L36241 10/01/2015 01/01/2018 Allergy Testing 82785 86001 86003 86005 86008 95004 95017 95018 95024 95027 95028 95044 95052 95056 95060 95065 95076 95079
L36419 04/07/2016 06/08/2017 Outpatient Wireless Pulmonary Artery Pressure Monitoring for Heart Failure 93799 C2624 C9741
L36423 04/07/2016 10/01/2017 Strapping 29200 29240 29260 29280 29520 29530 29540 29550
L36434 04/07/2016 04/07/2016 Microvascular Therapy 97039 97139
L36634 04/11/2016 04/11/2016 In Vitro Chemosensitivity & Chemoresistance Assays 81535 81536 84999 89240
L36711 12/01/2016 10/01/2018 Intensity Modulated Radiation Therapy (IMRT) 77385 77386 G6015 G6016
L36713 12/01/2016 10/01/2018 Corus® CAD Test 81493
L36715 12/01/2016 05/18/2018 BRCA1 and BRCA2 Genetic Testing 81162 81211 81212 81213 81214 81215 81216 81217 81432 81433 81445 81455
L36920 05/04/2017 01/01/2018 Epidural Injections for Pain Management 62321 62323 62325 62327 64479 64480 64483 64484
L37371 01/25/2018 05/10/2018 Electroretinography (ERG) 92275
L37375 01/25/2018 Reflectance Confocal Microscopy 96931 96932 96933 96934 96935 96936
L37682 09/14/2018 Nusinersen (Spinraza) J2326



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