| 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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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
|
|
|
L34106
|
10/01/2015
|
01/10/2021
|
Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF)
|
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|
L35172
|
10/01/2015
|
10/01/2019
|
Botulinum Toxin Types A and B
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L35175
|
10/01/2015
|
10/01/2019
|
MRI and CT Scans of the Head and Neck
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|
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L35457
|
10/01/2015
|
09/04/2022
|
Nerve Blockade for Treatment of Chronic Pain and Neuropathy
|
|
|
L35704
|
10/01/2015
|
12/01/2019
|
Mohs Micrographic Surgery
|
|
|
L36094
|
10/01/2015
|
04/08/2021
|
Lab: Flow Cytometry
|
|
|
L36159
|
06/16/2016
|
08/12/2021
|
MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)
|
|
|
L36186
|
04/19/2016
|
06/30/2022
|
MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease
|
|
|
L36192
|
04/15/2016
|
10/14/2021
|
MolDX: MGMT Promoter Methylation Analysis
|
|
|
L36204
|
06/01/2016
|
12/01/2019
|
Spinal Cord Stimulators for Chronic Pain
|
|
|
L36256
|
10/01/2015
|
05/04/2023
|
MolDX: Molecular Diagnostic Tests (MDT)
|
|
|
L36286
|
10/01/2015
|
10/01/2019
|
Blepharoplasty, Eyelid Surgery, and Brow Lift
|
|
|
L36339
|
07/05/2016
|
10/07/2021
|
MolDX: NRAS Genetic Testing
|
|
|
L36353
|
10/15/2015
|
12/24/2020
|
Lab: Special Histochemical Stains and Immunohistochemical Stains
|
|
|
L36362
|
06/01/2016
|
04/22/2021
|
MolDX: Biomarkers in Cardiovascular Risk Assessment
|
|
|
L36386
|
05/03/2016
|
04/22/2021
|
MolDX: Breast Cancer Assay: Prosigna®
|
|
|
L36526
|
06/01/2016
|
12/01/2019
|
Nerve Conduction Studies and Electromyography
|
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|
L36544
|
09/15/2016
|
07/08/2021
|
MolDX: HLA-DQB1*06:02 Testing for Narcolepsy
|
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L36569
|
07/12/2016
|
11/01/2019
|
Treatment of Males with Low Testosterone
|
|
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L36573
|
09/07/2016
|
12/01/2019
|
Total Hip Arthroplasty
|
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L36577
|
09/07/2016
|
12/01/2019
|
Total Knee Arthroplasty
|
|
|
L36680
|
05/16/2017
|
03/04/2021
|
Lab: Bladder/Urothelial Tumor Markers
|
|
|
L36700
|
03/13/2017
|
10/01/2019
|
Serum Magnesium
|
|
|
L36706
|
06/01/2017
|
12/30/2021
|
ProMark® Risk Score
|
|
|
L36707
|
06/28/2016
|
04/08/2021
|
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
|
03/04/2021
|
GlycoMark® Testing for Glycemic Control
|
|
|
L36868
|
07/17/2017
|
10/01/2019
|
Diagnostic and Therapeutic Colonoscopy
|
|
|
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
|
11/25/2021
|
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
|
04/28/2022
|
BDX-XL2
|
|
|
L37068
|
10/02/2017
|
02/25/2021
|
Lab: Coenzyme Q10 (CoQ10)
|
|
|
L37072
|
09/22/2017
|
06/30/2022
|
MolDX: DecisionDx-UM (Uveal Melanoma)
|
|
|
L37088
|
05/14/2018
|
12/01/2019
|
Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder
|
|
|
L37281
|
08/27/2018
|
08/18/2022
|
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
|
07/11/2021
|
MolDX: EndoPredict® Breast Cancer Gene Expression Test
|
|
|
L37313
|
01/30/2018
|
02/25/2021
|
MolDX: Prometheus IBD sgi Diagnostic® Policy
|
|
|
L37360
|
08/27/2018
|
12/01/2019
|
Peripheral Nerve Stimulation
|
|
|
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
|
06/09/2022
|
Lab: Cystatin C Measurement
|
|
|
L37622
|
06/03/2019
|
06/30/2022
|
MDS FISH
|
|
|
L37630
|
10/01/2018
|
02/25/2020
|
In Vitro Chemosensitivity & Chemoresistance Assays
|
|
|
L37738
|
04/01/2019
|
11/01/2019
|
Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor
|
|
|
L37748
|
02/10/2019
|
08/08/2022
|
MolDX: Melanoma Risk Stratification Molecular Testing
|
|
|
L37824
|
04/16/2019
|
10/28/2021
|
MolDX: Breast Cancer Index® (BCI) Gene Expression Test
|
|
|
L37881
|
06/03/2019
|
11/04/2021
|
MolDX: myPath® Melanoma Assay
|
|
|
L37891
|
05/27/2019
|
06/24/2021
|
MolDX: Envisia™, Veracyte™, Idiopathic Pulmonary Fibrosis Diagnostic Test
|
|
|
L37899
|
06/03/2019
|
10/14/2021
|
MolDX: Inivata™, InvisionFirst®, Liquid Biopsy for Patients with Lung Cancer
|
|
|
L38121
|
05/17/2020
|
06/24/2021
|
MolDX: Next-Generation Sequencing for Solid Tumors
|
|
|
L38125
|
05/17/2020
|
07/08/2021
|
MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies
|
|
|
L38153
|
06/07/2020
|
|
MolDX: Pigmented Lesion Assay
|
|
|
L38301
|
03/23/2020
|
10/03/2021
|
Micro-Invasive Glaucoma Surgery (MIGS)
|
|
|
L38312
|
03/15/2020
|
|
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
|
|
|
L38329
|
08/24/2020
|
01/06/2022
|
MolDX: Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer
|
|
|
L38333
|
12/06/2020
|
05/26/2022
|
MolDX: Blood Product Molecular Antigen Typing
|
|
|
L38337
|
08/17/2020
|
|
MolDX: Pharmacogenomics Testing
|
|
|
L38341
|
12/06/2020
|
02/03/2022
|
MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease
|
|
|
L38353
|
08/03/2020
|
12/30/2021
|
MolDX: Repeat Germline Testing
|
|
|
L38380
|
12/06/2020
|
|
MolDX: AlloSure® or Equivalent Cell-Free DNA Testing for Kidney and Heart Allografts
|
|
|
L38615
|
04/26/2021
|
09/18/2022
|
Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease
|
|
|
L38645
|
07/04/2021
|
06/02/2022
|
MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells
|
|
|
L38649
|
07/25/2021
|
|
MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer
|
|
|
L38659
|
11/02/2020
|
11/02/2020
|
Implantable Continuous Glucose Monitors (I-CGM)
|
|
|
L38671
|
07/04/2021
|
|
MolDX: Molecular Testing for Solid Organ Allograft Rejection
|
|
|
L38700
|
12/13/2020
|
|
Computed Tomography Cerebral Perfusion Analysis (CTP)
|
|
|
L38707
|
12/27/2020
|
|
Transurethral Waterjet Ablation of the Prostate
|
|
|
L38803
|
04/25/2021
|
02/03/2022
|
Facet Joint Interventions for Pain Management
|
|
|
L38816
|
01/02/2022
|
|
MolDX: Minimal Residual Disease Testing for Cancer
|
|
|
L38826
|
03/28/2021
|
12/19/2021
|
Colon Capsule Endoscopy (CCE)
|
|
|
L38904
|
11/28/2021
|
|
Wound and Ulcer Care
|
|
|
L38974
|
08/08/2022
|
|
MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer
|
|
|
L39003
|
04/17/2022
|
06/02/2022
|
MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
|
|
|
L39007
|
08/08/2022
|
|
MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer
|
|
|
L39060
|
01/23/2022
|
01/23/2022
|
Platelet Rich Plasma Injections for Non-Wound Injections
|
|
|
L39232
|
12/26/2022
|
|
MolDX: Plasma-Based Genomic Profiling in Solid Tumors
|
|
|
L39242
|
06/19/2022
|
|
Epidural Steroid Injections for Pain Management
|
|
|
L39264
|
05/28/2023
|
|
MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia
|
|
|
L39398
|
03/05/2023
|
|
Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin
|
|
|
L39464
|
03/19/2023
|
|
Sacroiliac Joint Injections and Procedures
|
|
