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Noridian Healthcare Solutions, LLC
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03202

Currently Active LCDs87
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All LCDs Laboratory LCDs Radiology LCDs
LCD
Effective
Date
Revision
Effective
Date
Title
CPT Codes Covered in LCD
L33979 10/01/2015 10/01/2018 Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs) 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 17110 17111
L34009 10/01/2015 10/01/2018 Chiropractic Services 98940 98941 98942 98943
L34010 10/01/2015 01/01/2018 Treatment of Varicose Veins of the Lower Extremities 36299 36465 36466 36470 36471 36473 36474 36475 36476 36478 36479 36482 36483 37700 37718 37722 37735 37760 37761 37765 37766 37780 37785 37799 93970 93971
L34038 10/01/2015 10/01/2017 B-type Natriuretic Peptide (BNP) Testing 83880
L34040 10/01/2015 10/01/2017 Polysomnography and Other Sleep Studies 95782 95783 95800 95801 95803 95805 95806 95807 95808 95810 95811 G0398 G0399 G0400
L34051 10/01/2015 10/01/2018 Vitamin D Assay Testing 82306 82652
L34066 10/01/2015 09/24/2018 MolDX: Circulating Tumor Cell Marker Assays 86152 86153
L34074 10/01/2015 07/01/2018 Immune Globulin Intravenous (IVIg) J1459 J1556 J1557 J1561 J1566 J1568 J1569 J1572 J1599
L34076 10/01/2015 05/22/2017 Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma 20526 20527 20550 20551 20612 26341 28899 64455 64632
L34080 10/01/2015 10/01/2018 Intensity Modulated Radiation Therapy (IMRT) 77301 77338 G6015 G6016
L34106 10/01/2015 10/01/2015 Percutaneous Vertebral Augmentation 0200T 0201T 22510 22511 22512 22513 22514 22515
L34151 10/01/2015 10/01/2018 Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) 77371 77372 77373 77373 77432 77435 77435 G0339 G0339 G0340 G0340
L34199 10/01/2015 10/01/2017 Treatment of Ulcers & Symptomatic Hyperkeratoses 11042 11043 11044 11045 11046 11047 11055 11056 11057 97597 97598
L34980 10/01/2015 10/01/2017 Lumbar Epidural Injections 62322 62323 62326 62327 64483 64484
L34995 10/01/2015 11/02/2016 Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy 0213T 0214T 0215T 0216T 0217T 0218T 64490 64491 64492 64493 64494 64495 64633 64634 64635 64636
L35008 10/01/2015 01/01/2019 Non-Covered Services 0042T 0054T 0055T 0071T 0072T 0098T 0100T 0101T 0102T 0106T 0107T 0108T 0109T 0110T 0111T 0126T 0163T 0165T 0174T 0175T 0198T 0202T 0205T 0206T 0207T 0208T 0209T 0210T 0211T 0212T 0219T 0220T 0221T 0222T 0232T 0234T 0235T 0236T 0237T 0238T and more.....
L35172 10/01/2015 10/01/2018 Botulinum Toxin Types A and B 31513 31570 43201 43236 43499 46505 52287 64611 64612 64615 64616 64617 64640 64642 64643 64644 64645 64646 64647 64650 64653 64999 67345 95873 95874 J0585 J0586 J0587 J0588
L35175 10/01/2015 10/08/2018 MRI and CT Scans of the Head and Neck 70336 70450 70460 70470 70480 70481 70482 70486 70487 70488 70490 70491 70492 70540 70542 70543 70551 70552 70553 70557 70558 70559 72125 72126 72127 72141 72142 72156
L35457 10/01/2015 01/01/2019 Nerve Blockade for Treatment of Chronic Pain and Neuropathy 62281 62320 62321 62324 62325 64402 64405 64408 64410 64413 64415 64417 64418 64420 64421 64425 64430 64435 64445 64446 64447 64448 64449 64450 64450 64461 64462 64463 64479 64480 64505 64510 64517 64520 64530 64620 64640 76881 76882 76942 and more.....
L35704 10/01/2015 10/01/2018 Mohs Micrographic Surgery 17311 17312 17313 17314 17315
L36094 10/01/2015 10/01/2018 Lab: Flow Cytometry 86355 86356 86357 86359 86360 86361 86367 88182 88184 88185 88187 88188 88189
L36149 04/01/2016 MolDX: HLA-B*15:02 Genetic Testing 81381
L36159 06/16/2016 MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) 81240 81241 81291
L36163 04/15/2016 01/01/2019 MolDX: BRCA1 and BRCA2 Genetic Testing 81162 81163 81164 81165 81166 81167 81212 81215 81216 81217 81432 81445 81455 81479
L36171 04/01/2016 02/01/2017 MolDX: Molecular RBC Phenotyping 0001U 81403
L36186 04/19/2016 10/01/2017 MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease 81206 81207 81208 81219 81270 81402 81403 81445 81450 81455 81479
L36192 04/15/2016 01/01/2018 MolDX: MGMT Promoter Methylation Analysis 81287
L36204 06/01/2016 10/01/2017 Spinal Cord Stimulators for Chronic Pain 63650 63655 63663 63664 63685
L36256 10/01/2015 01/01/2019 MolDX: Molecular Diagnostic Tests (MDT) 0001U 0002M 0002U 0003M 0003U 0004M 0005U 0006M 0006U 0007M 0007U 0008U 0009M 0009U 0010U 0011M 0011U 0012M 0012U 0013M 0013U 0014U 0016U 0017U 0018U 0019U 0021U 0022U 0023U 0024U 0025U 0026U 0027U 0029U 0030U 0031U 0032U 0033U 0034U 0035U and more.....
L36286 10/01/2015 10/01/2018 Blepharoplasty, Eyelid Surgery, and Brow Lift 15822 15823 67900 67901 67902 67903 67904 67906 67908 67909
L36312 10/01/2015 01/01/2019 MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing 0070U 81225 81226 81227 81355 81479
L36316 10/01/2015 01/01/2019 MolDX: Breast Cancer Index?; Genetic Assay 81518
L36325 10/01/2015 03/08/2018 MolDX: GeneSight® Assay for Refractory Depression 81479
L36329 10/01/2015 05/21/2018 MolDX: ConfirmMDx Epigenetic Molecular Assay 81551
L36339 07/05/2016 01/19/2017 MolDX: NRAS Genetic Testing 81311 81479
L36345 10/15/2015 12/21/2017 MolDX: Decipher® Prostate Cancer Classifier Assay 81479
L36350 10/15/2015 01/01/2018 MolDX: Prolaris™ Prostate Cancer Genomic Assay 81541
L36353 10/15/2015 08/31/2017 Lab: Special Histochemical Stains and Immunohistochemical Stains 88312 88313 88341 88342 88344 88360 88361
L36362 06/01/2016 01/31/2019 MolDX: Biomarkers in Cardiovascular Risk Assessment 82172 82610 83090 83695 83698 83700 83701 83704 83719 83721 86141
L36368 07/05/2016 07/01/2018 MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay 0047U
L36374 06/01/2016 04/16/2019 MolDX: Genetic Testing for Lynch Syndrome 81210 81288 81292 81293 81294 81295 81296 81297 81298 81299 81300 81301 81317 81318 81319 81403 81435 81445 81455 81479
L36386 05/03/2016 01/01/2018 MolDX: Breast Cancer Assay: Prosigna 0008M 81520
L36526 06/01/2016 10/01/2018 Nerve Conduction Studies and Electromyography 51785 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
L36544 09/15/2016 10/01/2016 MolDX: HLA-DQB1*06:02 Testing for Narcolepsy 81383
L36569 07/12/2016 10/01/2017 Treatment of Males with Low Testosterone 11980 84410 96372 J1071 J3121 J3145 J3490
L36573 09/07/2016 10/01/2016 Total Hip Arthroplasty 27130 27132 27134 27137 27138
L36577 09/07/2016 10/01/2016 Total Knee Arthroplasty 27445 27447 27486 27487
L36680 05/16/2017 05/16/2017 Lab: Bladder/Urothelial Tumor Markers 86294 86316 86386 88120 88121
L36700 03/13/2017 10/01/2017 Serum Magnesium 83735
L36706 06/01/2017 01/01/2018 MolDX: ProMark Risk Score 81479
L36707 06/28/2016 12/27/2018 Lab:Controlled Substance Monitoring and Drugs of Abuse Testing 80305 80306 80307 G0480 G0481 G0482 G0483 G0659
L36857 07/21/2017 10/01/2017 Measurement of Salivary Hormones 84999
L36859 05/26/2017 10/01/2018 Trigger Point Injections 20552 20553
L36866 08/01/2017 12/21/2017 GlycoMark Testing for Glycemic Control 84378
L36868 07/17/2017 10/01/2017 Diagnostic and Therapeutic Colonoscopy 44388 44389 44390 44391 44392 44394 44401 44402 44404 44405 44406 44407 45378 45379 45380 45381 45382 45384 45385 45386 45388 45389 45391 45392 45393
L36884 05/15/2017 05/15/2017 MolDX: APC and MUTYH Gene Testing 81201 81202 81203 81401 81403 81406 81435 81479
L36889 07/17/2017 10/01/2018 Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography 93015 93016 93017 93018 93320 93321 93325 93350 93351 93352 J0153 J0395 J1245 J1250 J3490
L36891 05/15/2017 08/25/2017 MolDX: Percepta© Bronchial Genomic Classifier 81479
L36947 03/27/2017 07/01/2018 MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) 0045U
L37020 10/10/2017 10/10/2017 Plastic Surgery 15780 15781 15782 15783 15830 15832 15833 15834 15835 15836 15837 15838 15839 15847 15876 15877 15878 15879 19316 19318 19324 19325 19328 19330 19340 19342 19350 19355 19357 19361 19364 19366 19367 19368 19369 19370 19371 19380 19396 30400 and more.....
L37027 10/10/2017 Cataract Surgery in Adults 66830 66840 66850 66852 66920 66940 66982 66983 66984
L37062 09/29/2017 MolDX: Xpresys Lung 81599
L37068 10/02/2017 04/30/2018 Lab: Coenzyme Q10 (CoQ10) XX000
L37072 09/22/2017 02/21/2019 MolDX: DecisionDx-UM (Uveal Melanoma) 0081U
L37082 09/25/2017 01/01/2018 MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease 81541
L37088 05/14/2018 Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder 90867 90868 90869
L37122 01/13/2019 MolDX: 4Kscore Assay 81539
L37281 08/27/2018 10/01/2018 Lumbar MRI 72148 72149 72158 A9585 Q9953
L37283 03/26/2018 10/01/2018 Electrocardiograms 93000 93005 93010 93040 93041 93042
L37293 07/09/2018 10/01/2018 Respiratory Care (Respiratory Therapy ) 31502 31720 94002 94003 94004 94010 94011 94012 94013 94060 94070 94150 94200 94250 94375 94400 94450 94617 94618 94621 94640 94642 94660 94662 94664 94667 94668 94669 94726 94727 94728 94729 94750 94772 G0237 G0238 G0239
L37311 01/30/2018 01/30/2018 MolDX: EndoPredict® Breast Cancer Gene Expression Test 81599
L37313 01/30/2018 01/30/2018 MolDX: Prometheus IBD sgi Diagnostic Policy 81479 82397 83520 86140
L37315 05/13/2019 MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels 87631 87632 87633
L37321 03/18/2018 08/16/2018 MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer 81479
L37358 12/11/2017 MolDX: AlloSure® Donor-Derived Cell-Free DNA Test 81479
L37360 08/27/2018 01/01/2019 Peripheral Nerve Stimulation 61885 64553 64555 64561 64569 64570 64575 64581 64585 64590 64595 64999
L37368 02/11/2019 02/11/2019 MolDX: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs) 87505 87506 87507
L37504 02/18/2019 03/01/2019 Frequency of Hemodialysis 90999
L37549 06/22/2018 Chest X-Ray Policy 71045 71046 71047 71048
L37618 02/11/2019 MolDX: Cystatin C Measurement 82610
L37630 10/01/2018 10/08/2018 In Vitro Chemosensitivity & Chemoresistance Assays 84999 89240
L37651 10/20/2018 MolDX: Guardant360® Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC) 81479
L37675 02/10/2019 MolDX: Corus® CAD Assay 81493
L37738 04/01/2019 Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor 0398T
L37744 03/02/2019 MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC) 81479
L37748 02/10/2019 MolDX: DecisionDx-Melanoma 81599
L37824 04/16/2019 MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test 81518



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