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Currently Active LCDs95
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CPT Codes Covered in LCD
L34149 10/01/2015 10/01/2019 Respiratory Care (Respiratory Therapy)
L34163 10/01/2015 12/01/2019 Total Hip Arthroplasty
L34194 10/01/2015 10/01/2019 Blepharoplasty, Eyelid Surgery, and Brow Lift
L34203 10/01/2015 10/01/2019 Cataract Surgery in Adults
L34209 10/01/2015 12/01/2019 Treatment of Varicose Veins of the Lower Extremities
L34211 10/01/2015 12/01/2019 Trigger Point Injections
L34213 10/01/2015 10/01/2019 Diagnostic and Therapeutic Colonoscopy
L34215 10/01/2015 12/01/2019 Lab: Flow Cytometry
L34218 10/01/2015 10/01/2019 Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma
L34220 10/01/2015 10/01/2019 Lumbar MRI
L34228 10/01/2015 02/19/2020 Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF)
L34233 10/01/2015 10/01/2019 Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs)
L34243 10/01/2015 10/01/2019 Treatment of Ulcers & Symptomatic Hyperkeratoses
L34314 10/01/2015 02/01/2020 Immune Globulin Intravenous (IVIg)
L34315 10/01/2015 10/01/2019 Electrocardiograms
L34324 10/01/2015 10/01/2019 Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography
L34328 10/01/2015 12/01/2019 Peripheral Nerve Stimulation
L34982 10/01/2015 10/01/2019 Lumbar Epidural Injections
L34993 10/01/2015 12/01/2019 Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
L35136 10/01/2015 12/01/2019 Spinal Cord Stimulators for Chronic Pain
L35160 10/01/2015 11/01/2019 MolDX: Molecular Diagnostic Tests (MDT)
L35163 10/01/2015 10/01/2019 Plastic Surgery
L35170 10/01/2015 10/01/2019 Botulinum Toxin Types A and B Policy
L35456 10/01/2015 12/01/2019 Nerve Blockade for Treatment of Chronic Pain and Neuropathy
L35526 10/01/2015 10/01/2019 B-type Natriuretic Peptide (BNP) Testing
L35702 10/01/2015 12/01/2019 Mohs Micrographic Surgery
L35710 10/01/2015 12/01/2019 MolDX: Circulating Tumor Cell Marker Assays
L36145 04/01/2016 11/01/2019 MolDX: HLA-B*15:02 Genetic Testing
L36155 06/16/2016 11/01/2019 MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)
L36161 04/15/2016 12/04/2019 MolDX: BRCA1 and BRCA2 Genetic Testing
L36167 04/01/2016 11/01/2019 MolDX: Molecular RBC Phenotyping
L36180 04/19/2016 11/01/2019 MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease
L36188 04/15/2016 11/01/2019 MolDX: MGMT Promoter Methylation Analysis
L36327 10/01/2015 11/01/2019 MolDX: ConfirmMDx Epigenetic Molecular Assay
L36335 07/05/2016 12/01/2019 MolDX: NRAS Genetic Testing
L36343 10/15/2015 12/01/2019 MolDX: Decipher® Prostate Cancer Classifier Assay
L36348 10/15/2015 12/01/2019 MolDX: Prolaris™ Prostate Cancer Genomic Assay
L36351 10/15/2015 12/01/2019 Lab: Special Histochemical Stains and Immunohistochemical Stains
L36358 06/01/2016 10/01/2019 MolDX: Biomarkers in Cardiovascular Risk Assessment
L36364 07/05/2016 11/01/2019 MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay
L36370 06/01/2016 11/01/2019 MolDX: Genetic Testing for Lynch Syndrome
L36380 05/03/2016 11/01/2019 MolDX: Breast Cancer Assay: Prosigna
L36524 06/01/2016 12/01/2019 Nerve Conduction Studies and Electromyography
L36538 07/12/2016 11/01/2019 Treatment of Males with Low Testosterone
L36551 09/15/2016 11/01/2019 MolDX: HLA-DQB1*06:02 Testing for Narcolepsy
L36575 09/07/2016 12/01/2019 Total Knee Arthroplasty
L36668 06/28/2016 10/01/2019 Lab:Controlled Substance Monitoring and Drugs of Abuse Testing
L36678 05/16/2017 10/01/2019 Lab: Bladder/Urothelial Tumor Markers
L36692 02/03/2017 12/01/2019 Vitamin D Assay Testing
L36702 03/13/2017 10/01/2019 Serum Magnesium
L36704 06/01/2017 12/01/2019 MolDX: ProMark Risk Score
L36846 07/21/2017 11/01/2019 Measurement of Salivary Hormones
L36861 06/05/2017 12/01/2019 Polysomnography and Other Sleep Studies
L36864 08/01/2017 10/01/2019 GlycoMark Testing for Glycemic Control
L36882 05/15/2017 11/01/2019 MolDX: APC and MUTYH Gene Testing
L36886 05/15/2017 12/01/2019 MolDX: Percepta© Bronchial Genomic Classifier
L36941 03/27/2017 12/01/2019 MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)
L37054 09/29/2017 11/01/2019 MolDX: BDX-XL2
L37066 10/02/2017 01/01/2020 Lab: Coenzyme Q10 (CoQ10)
L37070 09/22/2017 12/01/2019 MolDX: DecisionDx-UM (Uveal Melanoma)
L37080 09/25/2017 12/01/2019 MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease
L37086 05/14/2018 12/01/2019 Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder
L37120 01/13/2019 11/01/2019 MolDX: 4Kscore Assay
L37295 01/30/2018 11/01/2019 MolDX: EndoPredict® Breast Cancer Gene Expression Test
L37299 01/30/2018 12/01/2019 MolDX: Prometheus IBD sgi Diagnostic Policy
L37301 05/13/2019 10/01/2019 MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels
L37303 12/11/2017 11/01/2019 MolDX: AlloSure® Donor-Derived Cell-Free DNA Test
L37305 03/18/2018 11/01/2019 MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer
L37350 02/11/2019 10/01/2019 Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs)
L37373 10/08/2018 10/01/2019 MRI and CT Scans of the Head and Neck
L37502 02/18/2019 10/01/2019 Frequency of Hemodialysis
L37547 06/22/2018 11/01/2019 Chest X-Ray Policy
L37616 02/11/2019 11/01/2019 MolDX: Cystatin C Measurement
L37620 06/03/2019 11/01/2019 MolDX: MDS FISH
L37628 10/01/2018 12/01/2019 In Vitro Chemosensitivity & Chemoresistance Assays
L37673 02/10/2019 11/01/2019 MolDX: Corus® CAD Assay
L37729 04/01/2019 11/01/2019 Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor
L37746 03/02/2019 12/01/2019 MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC)
L37750 02/10/2019 11/01/2019 MolDX: DecisionDx-Melanoma
L37818 05/27/2019 11/01/2019 MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease
L37822 04/16/2019 01/01/2020 MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test
L37879 06/03/2019 11/01/2019 MolDX: myPath Melanoma Assay
L37887 05/27/2019 11/01/2019 MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test
L37897 06/03/2019 11/01/2019 MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer
L38119 05/17/2020 MolDX: Next-Generation Sequencing for Solid Tumors
L38123 05/17/2020 MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies
L38135 01/05/2020 01/05/2020 MolDX: TruGraf Blood Gene Expression Test
L38147 05/04/2020 MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Intermediate Risk Disease
L38151 06/07/2020 MolDX: Pigmented Lesion Assay
L38299 03/23/2020 03/23/2020 Micro-Invasive Glaucoma Surgery (MIGS)
L38310 03/15/2020 03/15/2020 Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
L38327 08/24/2020 MolDX: Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer
L38335 08/17/2020 MolDX: Pharmacogenomics Testing
L38351 08/03/2020 MolDX: Repeat Germline Testing
L38657 11/02/2020 Implantable Continuous Glucose Monitors (I-CGM)

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