| LCD |
Effective
Date |
Revision
Effective
Date |
Title |
CPT Codes Covered in LCD |
|
L33979
|
10/01/2015
|
10/01/2019
|
Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs)
|
|
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L34010
|
10/01/2015
|
12/01/2019
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Treatment of Varicose Veins of the Lower Extremities
|
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L34038
|
10/01/2015
|
10/01/2019
|
B-type Natriuretic Peptide (BNP) Testing
|
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L34040
|
10/01/2015
|
12/01/2019
|
Polysomnography and Other Sleep Studies
|
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L34051
|
10/01/2015
|
12/01/2019
|
Vitamin D Assay Testing
|
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L34066
|
10/01/2015
|
12/01/2019
|
MolDX: Circulating Tumor Cell Marker Assays
|
|
|
L34074
|
10/01/2015
|
02/01/2020
|
Immune Globulin Intravenous (IVIg)
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L34076
|
10/01/2015
|
10/01/2019
|
Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma
|
|
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L34080
|
10/01/2015
|
10/01/2019
|
Intensity Modulated Radiation Therapy (IMRT)
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L34106
|
10/01/2015
|
02/19/2020
|
Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF)
|
|
|
L34151
|
10/01/2015
|
12/01/2019
|
Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)
|
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|
L34199
|
10/01/2015
|
10/01/2019
|
Treatment of Ulcers & Symptomatic Hyperkeratoses
|
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|
L34980
|
10/01/2015
|
10/01/2019
|
Lumbar Epidural Injections
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|
|
L34995
|
10/01/2015
|
12/01/2019
|
Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
|
|
|
L35008
|
10/01/2015
|
12/01/2019
|
Non-Covered Services
|
|
|
L35172
|
10/01/2015
|
10/01/2019
|
Botulinum Toxin Types A and B
|
|
|
L35175
|
10/01/2015
|
10/01/2019
|
MRI and CT Scans of the Head and Neck
|
|
|
L35457
|
10/01/2015
|
12/01/2019
|
Nerve Blockade for Treatment of Chronic Pain and Neuropathy
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|
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L35704
|
10/01/2015
|
12/01/2019
|
Mohs Micrographic Surgery
|
|
|
L36094
|
10/01/2015
|
12/01/2019
|
Lab: Flow Cytometry
|
|
|
L36149
|
04/01/2016
|
11/01/2019
|
MolDX: HLA-B*15:02 Genetic Testing
|
|
|
L36159
|
06/16/2016
|
11/01/2019
|
MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)
|
|
|
L36163
|
04/15/2016
|
12/04/2019
|
MolDX: BRCA1 and BRCA2 Genetic Testing
|
|
|
L36171
|
04/01/2016
|
11/01/2019
|
MolDX: Molecular RBC Phenotyping
|
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|
L36186
|
04/19/2016
|
11/01/2019
|
MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease
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L36192
|
04/15/2016
|
11/01/2019
|
MolDX: MGMT Promoter Methylation Analysis
|
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L36204
|
06/01/2016
|
12/01/2019
|
Spinal Cord Stimulators for Chronic Pain
|
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|
L36256
|
10/01/2015
|
11/01/2019
|
MolDX: Molecular Diagnostic Tests (MDT)
|
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|
L36286
|
10/01/2015
|
10/01/2019
|
Blepharoplasty, Eyelid Surgery, and Brow Lift
|
|
|
L36312
|
10/01/2015
|
11/01/2019
|
MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing
|
|
|
L36325
|
10/01/2015
|
11/01/2019
|
MolDX: GeneSight® Assay for Refractory Depression
|
|
|
L36329
|
10/01/2015
|
11/01/2019
|
MolDX: ConfirmMDx Epigenetic Molecular Assay
|
|
|
L36339
|
07/05/2016
|
12/01/2019
|
MolDX: NRAS Genetic Testing
|
|
|
L36345
|
10/15/2015
|
12/01/2019
|
MolDX: Decipher® Prostate Cancer Classifier Assay
|
|
|
L36350
|
10/15/2015
|
12/01/2019
|
MolDX: Prolaris™ Prostate Cancer Genomic Assay
|
|
|
L36353
|
10/15/2015
|
12/01/2019
|
Lab: Special Histochemical Stains and Immunohistochemical Stains
|
|
|
L36362
|
06/01/2016
|
10/01/2019
|
MolDX: Biomarkers in Cardiovascular Risk Assessment
|
|
|
L36368
|
07/05/2016
|
11/01/2019
|
MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay
|
|
|
L36374
|
06/01/2016
|
11/01/2019
|
MolDX: Genetic Testing for Lynch Syndrome
|
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L36386
|
05/03/2016
|
11/01/2019
|
MolDX: Breast Cancer Assay: Prosigna
|
|
|
L36526
|
06/01/2016
|
12/01/2019
|
Nerve Conduction Studies and Electromyography
|
|
|
L36544
|
09/15/2016
|
11/01/2019
|
MolDX: HLA-DQB1*06:02 Testing for Narcolepsy
|
|
|
L36569
|
07/12/2016
|
11/01/2019
|
Treatment of Males with Low Testosterone
|
|
|
L36573
|
09/07/2016
|
12/01/2019
|
Total Hip Arthroplasty
|
|
|
L36577
|
09/07/2016
|
12/01/2019
|
Total Knee Arthroplasty
|
|
|
L36680
|
05/16/2017
|
10/01/2019
|
Lab: Bladder/Urothelial Tumor Markers
|
|
|
L36700
|
03/13/2017
|
10/01/2019
|
Serum Magnesium
|
|
|
L36706
|
06/01/2017
|
12/01/2019
|
MolDX: ProMark Risk Score
|
|
|
L36707
|
06/28/2016
|
10/01/2019
|
Lab: Controlled Substance Monitoring and Drugs of Abuse Testing
|
|
|
L36857
|
07/21/2017
|
11/01/2019
|
Measurement of Salivary Hormones
|
|
|
L36859
|
05/26/2017
|
12/01/2019
|
Trigger Point Injections
|
|
|
L36866
|
08/01/2017
|
10/01/2019
|
GlycoMark Testing for Glycemic Control
|
|
|
L36868
|
07/17/2017
|
10/01/2019
|
Diagnostic and Therapeutic Colonoscopy
|
|
|
L36884
|
05/15/2017
|
11/01/2019
|
MolDX: APC and MUTYH Gene Testing
|
|
|
L36889
|
07/17/2017
|
10/01/2019
|
Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography
|
|
|
L36891
|
05/15/2017
|
12/01/2019
|
MolDX: Percepta© Bronchial Genomic Classifier
|
|
|
L36947
|
03/27/2017
|
12/01/2019
|
MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)
|
|
|
L37020
|
10/10/2017
|
10/01/2019
|
Plastic Surgery
|
|
|
L37027
|
10/10/2017
|
10/01/2019
|
Cataract Surgery in Adults
|
|
|
L37062
|
09/29/2017
|
11/01/2019
|
MolDX: BDX-XL2
|
|
|
L37068
|
10/02/2017
|
01/01/2020
|
Lab: Coenzyme Q10 (CoQ10)
|
|
|
L37072
|
09/22/2017
|
12/01/2019
|
MolDX: DecisionDx-UM (Uveal Melanoma)
|
|
|
L37082
|
09/25/2017
|
12/01/2019
|
MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease
|
|
|
L37088
|
05/14/2018
|
12/01/2019
|
Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder
|
|
|
L37122
|
01/13/2019
|
11/01/2019
|
MolDX: 4Kscore Assay
|
|
|
L37281
|
08/27/2018
|
10/01/2019
|
Lumbar MRI
|
|
|
L37283
|
03/26/2018
|
10/01/2019
|
Electrocardiograms
|
|
|
L37293
|
07/09/2018
|
10/01/2019
|
Respiratory Care (Respiratory Therapy)
|
|
|
L37311
|
01/30/2018
|
11/01/2019
|
MolDX: EndoPredict® Breast Cancer Gene Expression Test
|
|
|
L37313
|
01/30/2018
|
12/01/2019
|
MolDX: Prometheus IBD sgi Diagnostic Policy
|
|
|
L37315
|
05/13/2019
|
10/01/2019
|
MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels
|
|
|
L37321
|
03/18/2018
|
11/01/2019
|
MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer
|
|
|
L37358
|
12/11/2017
|
11/01/2019
|
MolDX: AlloSure® Donor-Derived Cell-Free DNA Test
|
|
|
L37360
|
08/27/2018
|
12/01/2019
|
Peripheral Nerve Stimulation
|
|
|
L37368
|
02/11/2019
|
10/01/2019
|
Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs)
|
|
|
L37504
|
02/18/2019
|
10/01/2019
|
Frequency of Hemodialysis
|
|
|
L37549
|
06/22/2018
|
11/01/2019
|
Chest X-Ray Policy
|
|
|
L37618
|
02/11/2019
|
11/01/2019
|
MolDX: Cystatin C Measurement
|
|
|
L37622
|
06/03/2019
|
11/01/2019
|
MolDX: MDS FISH
|
|
|
L37626
|
05/27/2019
|
10/01/2019
|
Helicobacter Pylori Infection Testing
|
|
|
L37630
|
10/01/2018
|
12/01/2019
|
In Vitro Chemosensitivity & Chemoresistance Assays
|
|
|
L37675
|
02/10/2019
|
11/01/2019
|
MolDX: Corus® CAD Assay
|
|
|
L37738
|
04/01/2019
|
11/01/2019
|
Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor
|
|
|
L37744
|
03/02/2019
|
12/01/2019
|
MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC)
|
|
|
L37748
|
02/10/2019
|
11/01/2019
|
MolDX: DecisionDx-Melanoma
|
|
|
L37820
|
05/27/2019
|
11/01/2019
|
MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease
|
|
|
L37824
|
04/16/2019
|
01/01/2020
|
MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test
|
|
|
L37881
|
06/03/2019
|
11/01/2019
|
MolDX: myPath Melanoma Assay
|
|
|
L37891
|
05/27/2019
|
11/01/2019
|
MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test
|
|
|
L37899
|
06/03/2019
|
11/01/2019
|
MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer
|
|
|
L38121
|
05/17/2020
|
|
MolDX: Next-Generation Sequencing for Solid Tumors
|
|
|
L38125
|
05/17/2020
|
|
MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies
|
|
|
L38137
|
01/05/2020
|
01/05/2020
|
MolDX: TruGraf Blood Gene Expression Test
|
|
|
L38149
|
05/04/2020
|
|
MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Intermediate Risk Disease
|
|
|
L38153
|
06/07/2020
|
|
MolDX: Pigmented Lesion Assay
|
|
|
L38301
|
03/23/2020
|
03/23/2020
|
Micro-Invasive Glaucoma Surgery (MIGS)
|
|
|
L38312
|
03/15/2020
|
|
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
|
|
|
L38337
|
08/17/2020
|
|
MolDX: Pharmacogenomics Testing
|
|
|
L38353
|
08/03/2020
|
|
MolDX: Repeat Germline Testing
|
|
