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Currently Active LCDs

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LCD
Effective
Date
Revision
Effective
Date
Title
CPT Codes Covered in Policy
L34149 10/01/2015 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
L34163 10/01/2015 10/01/2016 Total Hip Arthroplasty 27130 27132 27134 27137 27138
L34194 10/01/2015 10/01/2018 Blepharoplasty, Eyelid Surgery, and Brow Lift 15822 15823 67900 67901 67902 67903 67904 67906 67908 67909
L34203 10/01/2015 10/10/2017 Cataract Surgery in Adults 66830 66840 66850 66852 66920 66940 66982 66983 66984
L34209 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
L34211 10/01/2015 10/01/2018 Trigger Point Injections 20552 20553
L34213 10/01/2015 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
L34215 10/01/2015 10/01/2018 Flow Cytometry 86355 86356 86357 86359 86360 86361 86367 88182 88184 88185 88187 88188 88189
L34218 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
L34220 10/01/2015 10/01/2018 Lumbar MRI 72148 72149 72158 A9585 Q9953
L34228 10/01/2015 10/01/2015 Percutaneous Vertebral Augmentation 0200T 0201T 22510 22511 22512 22513 22514 22515
L34233 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
L34243 10/01/2015 10/01/2017 Treatment of Ulcers & Symptomatic Hyperkeratoses 11042 11043 11044 11045 11046 11047 11055 11056 11057 97597 97598
L34314 10/01/2015 07/01/2018 Immune Globulin Intravenous (IVIg) J1459 J1556 J1557 J1561 J1566 J1568 J1569 J1572 J1599
L34315 10/01/2015 10/01/2018 Electrocardiograms 93000 93005 93010 93040 93041 93042
L34324 10/01/2015 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
L34328 10/01/2015 11/02/2018 Peripheral Nerve Stimulation 61885 64550 64553 64555 64561 64569 64570 64575 64581 64585 64590 64595 64999
L34982 10/01/2015 10/01/2017 Lumbar Epidural Injections 62322 62323 62326 62327 64483 64484
L34993 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
L35136 10/01/2015 10/01/2017 Spinal Cord Stimulators for Chronic Pain 63650 63655 63663 63664 63685
L35160 10/01/2015 06/21/2018 MolDX: Molecular Diagnostic Tests (MDT) 0001M 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 0020U 0021U 0022U 0023U 0024U 0025U 0026U 0027U 0028U 0029U 0030U 0031U 0032U and more.....
L35163 10/01/2015 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.....
L35170 10/01/2015 10/01/2018 Botulinum Toxin Types A and B Policy 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
L35456 10/01/2015 10/01/2017 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 64508 64510 64517 64520 64530 64620 64640 76881 76882 and more.....
L35526 10/01/2015 10/01/2017 B-type Natriuretic Peptide (BNP) Testing 83880
L35702 10/01/2015 10/01/2018 Mohs Micrographic Surgery 17311 17312 17313 17314 17315
L35710 10/01/2015 09/24/2018 MolDX: Circulating Tumor Cell Marker Assays 86152 86153
L36145 04/01/2016 MolDX: HLA-B*15:02 Genetic Testing 81381
L36155 06/16/2016 MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) 81240 81241 81291
L36161 04/15/2016 07/12/2018 MolDX: BRCA1 and BRCA2 Genetic Testing 81162 81211 81212 81213 81214 81215 81216 81217 81432 81445 81455 81479
L36167 04/01/2016 02/01/2017 MolDX: Molecular RBC Phenotyping 0001U 81403
L36180 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
L36188 04/15/2016 01/01/2018 MolDX: MGMT Promoter Methylation Analysis 81287
L36219 10/01/2015 08/24/2018 Non-Covered Services 0042T 0054T 0055T 0071T 0072T 0098T 0100T 0101T 0102T 0106T 0107T 0108T 0109T 0110T 0111T 0126T 0159T 0163T 0165T 0174T 0175T 0190T 0195T 0196T 0198T 0202T 0205T 0206T 0207T 0208T 0209T 0210T 0211T 0212T 0219T 0220T 0221T 0222T 0232T 0234T and more.....
L36310 10/01/2015 10/01/2018 MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing 81225 81226 81227 81355 81479 81479
L36314 10/01/2015 12/21/2017 MolDX: Breast Cancer Index℠ Genetic Assay 81479
L36323 10/01/2015 03/08/2018 MolDX: GeneSight® Assay for Refractory Depression 81479
L36327 10/01/2015 05/21/2018 MolDX: ConfirmMDx Epigenetic Molecular Assay 81551
L36335 07/05/2016 01/19/2017 MolDX: NRAS Genetic Testing 81311 81479
L36343 10/15/2015 12/21/2017 MolDX: Decipher® Prostate Cancer Classifier Assay 81479
L36348 10/15/2015 01/01/2018 MolDX: Prolaris™ Prostate Cancer Genomic Assay 81541
L36351 10/15/2015 08/31/2017 Special Histochemical Stains and Immunohistochemical Stains 88312 88313 88341 88342 88344 88360 88361
L36358 06/01/2016 10/01/2018 MolDX: Biomarkers in Cardiovascular Risk Assessment 82172 82610 83090 83695 83698 83700 83701 83704 83719 83721 86141
L36364 07/05/2016 07/01/2018 MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay 0047U
L36370 06/01/2016 12/15/2016 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
L36380 05/03/2016 01/01/2018 MolDX: Breast Cancer Assay: Prosigna 0008M 81520
L36524 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
L36538 07/12/2016 10/01/2017 Treatment of Males with Low Testosterone 11980 84410 96372 J1071 J3121 J3145 J3490
L36551 09/15/2016 10/01/2016 MolDX: HLA-DQB1*06:02 Testing for Narcolepsy 81383
L36575 09/07/2016 10/01/2016 Total Knee Arthroplasty 27445 27447 27486 27487
L36668 06/28/2016 10/01/2018 Controlled Substance Monitoring and Drugs of Abuse Testing 80305 80306 80307 G0480 G0481 G0482 G0483 G0659
L36678 05/16/2017 05/16/2017 Bladder/Urothelial Tumor Markers 86294 86316 86386 88120 88121
L36692 02/03/2017 10/01/2018 Vitamin D Assay Testing 82306 82652
L36702 03/13/2017 10/01/2017 Serum Magnesium 83735
L36704 06/01/2017 01/01/2018 MolDX: ProMark Risk Score 81479
L36846 07/21/2017 10/01/2017 Measurement of Salivary Hormones 84999
L36861 06/05/2017 10/01/2017 Polysomnography and Other Sleep Studies 95782 95783 95800 95801 95803 95805 95806 95807 95808 95810 95811 G0398 G0399 G0400
L36864 08/01/2017 12/21/2017 GlycoMark Testing for Glycemic Control 84378
L36882 05/15/2017 05/15/2017 MolDX: APC and MUTYH Gene Testing 81201 81202 81203 81401 81403 81406 81435 81479
L36886 05/15/2017 08/25/2017 MolDX: Percepta© Bronchial Genomic Classifier 81479
L36941 03/27/2017 07/01/2018 MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) 0045U
L37054 09/29/2017 MolDX: Xpresys Lung 81599
L37066 10/02/2017 04/30/2018 Coenzyme Q10 (CoQ10) XX000
L37070 09/22/2017 MolDX: DecisionDx-UM (Uveal Melanoma) 81599
L37080 09/25/2017 01/01/2018 MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease 81541
L37086 05/14/2018 Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder 90867 90868 90869
L37295 01/30/2018 01/30/2018 MolDX: EndoPredict® Breast Cancer Gene Expression Test 81599
L37299 01/30/2018 01/30/2018 MolDX: Prometheus IBD sgi Diagnostic Policy 81479 82397 83520 86140
L37303 12/11/2017 MolDX: AlloSure® Donor-Derived Cell-Free DNA Test 81479
L37305 03/18/2018 08/16/2018 MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer 81479
L37373 10/08/2018 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
L37547 06/22/2018 Chest X-Ray Policy 71045 71046 71047 71048
L37628 10/01/2018 10/08/2018 In Vitro Chemosensitivity & Chemoresistance Assays 84999 89240
L37649 10/20/2018 MolDX: Guardant360® Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC) 81479



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