| LCD |
Effective
Date |
Revision
Effective
Date |
Title |
CPT Codes Covered in LCD |
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L34149
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10/01/2015
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10/01/2019
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Respiratory Care (Respiratory Therapy)
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L34163
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10/01/2015
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12/01/2019
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Total Hip Arthroplasty
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L34194
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10/01/2015
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10/01/2019
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Blepharoplasty, Eyelid Surgery, and Brow Lift
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L34203
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10/01/2015
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10/01/2019
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Cataract Surgery in Adults
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L34209
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10/01/2015
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12/01/2019
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Treatment of Varicose Veins of the Lower Extremities
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L34211
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10/01/2015
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12/01/2019
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Trigger Point Injections
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L34213
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10/01/2015
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10/01/2019
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Diagnostic and Therapeutic Colonoscopy
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L34215
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10/01/2015
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12/01/2019
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Lab: Flow Cytometry
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L34218
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10/01/2015
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10/01/2019
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Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma
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L34220
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10/01/2015
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10/01/2019
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Lumbar MRI
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L34223
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10/01/2015
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12/01/2019
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Stereotactic Radiosurgery
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L34224
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10/01/2015
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12/01/2019
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Stereotactic Body Radiation Therapy
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L34228
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10/01/2015
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02/19/2020
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Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF)
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L34233
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10/01/2015
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10/01/2019
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Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs)
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L34243
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10/01/2015
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10/01/2019
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Treatment of Ulcers & Symptomatic Hyperkeratoses
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L34247
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10/01/2015
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10/01/2019
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Pulmonary Function Testing
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L34313
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10/01/2015
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10/01/2019
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Allergy Testing
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L34314
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10/01/2015
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02/01/2020
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Immune Globulin Intravenous (IVIg)
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L34315
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10/01/2015
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10/01/2019
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Electrocardiograms
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L34324
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10/01/2015
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10/01/2019
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Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography
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L34328
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10/01/2015
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12/01/2019
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Peripheral Nerve Stimulation
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L34982
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10/01/2015
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10/01/2019
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Lumbar Epidural Injections
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L34993
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10/01/2015
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12/01/2019
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Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
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L35136
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10/01/2015
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12/01/2019
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Spinal Cord Stimulators for Chronic Pain
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L35160
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10/01/2015
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11/01/2019
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MolDX: Molecular Diagnostic Tests (MDT)
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L35163
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10/01/2015
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10/01/2019
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Plastic Surgery
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L35170
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10/01/2015
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10/01/2019
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Botulinum Toxin Types A and B Policy
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L35456
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10/01/2015
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12/01/2019
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Nerve Blockade for Treatment of Chronic Pain and Neuropathy
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L35526
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10/01/2015
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10/01/2019
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B-type Natriuretic Peptide (BNP) Testing
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L35702
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10/01/2015
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12/01/2019
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Mohs Micrographic Surgery
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L35710
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10/01/2015
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12/01/2019
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MolDX: Circulating Tumor Cell Marker Assays
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L36145
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04/01/2016
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11/01/2019
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MolDX: HLA-B*15:02 Genetic Testing
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L36155
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06/16/2016
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11/01/2019
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MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)
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L36161
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04/15/2016
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12/04/2019
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MolDX: BRCA1 and BRCA2 Genetic Testing
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L36167
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04/01/2016
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11/01/2019
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MolDX: Molecular RBC Phenotyping
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L36180
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04/19/2016
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11/01/2019
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MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease
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L36188
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04/15/2016
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11/01/2019
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MolDX: MGMT Promoter Methylation Analysis
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L36327
|
10/01/2015
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11/01/2019
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MolDX: ConfirmMDx Epigenetic Molecular Assay
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L36335
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07/05/2016
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12/01/2019
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MolDX: NRAS Genetic Testing
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L36343
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10/15/2015
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12/01/2019
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MolDX: Decipher® Prostate Cancer Classifier Assay
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L36348
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10/15/2015
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12/01/2019
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MolDX: Prolaris™ Prostate Cancer Genomic Assay
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L36351
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10/15/2015
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12/01/2019
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Lab: Special Histochemical Stains and Immunohistochemical Stains
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L36358
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06/01/2016
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10/01/2019
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MolDX: Biomarkers in Cardiovascular Risk Assessment
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L36364
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07/05/2016
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11/01/2019
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MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay
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L36370
|
06/01/2016
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11/01/2019
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MolDX: Genetic Testing for Lynch Syndrome
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L36380
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05/03/2016
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11/01/2019
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MolDX: Breast Cancer Assay: Prosigna
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L36524
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06/01/2016
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12/01/2019
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Nerve Conduction Studies and Electromyography
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L36538
|
07/12/2016
|
11/01/2019
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Treatment of Males with Low Testosterone
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L36551
|
09/15/2016
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11/01/2019
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MolDX: HLA-DQB1*06:02 Testing for Narcolepsy
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L36575
|
09/07/2016
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12/01/2019
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Total Knee Arthroplasty
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L36668
|
06/28/2016
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10/01/2019
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Lab:Controlled Substance Monitoring and Drugs of Abuse Testing
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L36678
|
05/16/2017
|
10/01/2019
|
Lab: Bladder/Urothelial Tumor Markers
|
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L36692
|
02/03/2017
|
12/01/2019
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Vitamin D Assay Testing
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L36702
|
03/13/2017
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10/01/2019
|
Serum Magnesium
|
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L36704
|
06/01/2017
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12/01/2019
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MolDX: ProMark Risk Score
|
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L36846
|
07/21/2017
|
11/01/2019
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Measurement of Salivary Hormones
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L36861
|
06/05/2017
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12/01/2019
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Polysomnography and Other Sleep Studies
|
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L36864
|
08/01/2017
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10/01/2019
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GlycoMark Testing for Glycemic Control
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L36882
|
05/15/2017
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11/01/2019
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MolDX: APC and MUTYH Gene Testing
|
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L36886
|
05/15/2017
|
12/01/2019
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MolDX: Percepta© Bronchial Genomic Classifier
|
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L36941
|
03/27/2017
|
12/01/2019
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MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)
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L37054
|
09/29/2017
|
11/01/2019
|
MolDX: BDX-XL2
|
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L37066
|
10/02/2017
|
01/01/2020
|
Lab: Coenzyme Q10 (CoQ10)
|
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L37070
|
09/22/2017
|
12/01/2019
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MolDX: DecisionDx-UM (Uveal Melanoma)
|
|
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L37080
|
09/25/2017
|
12/01/2019
|
MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease
|
|
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L37086
|
05/14/2018
|
12/01/2019
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Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder
|
|
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L37120
|
01/13/2019
|
11/01/2019
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MolDX: 4Kscore Assay
|
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L37295
|
01/30/2018
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11/01/2019
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MolDX: EndoPredict® Breast Cancer Gene Expression Test
|
|
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L37299
|
01/30/2018
|
12/01/2019
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MolDX: Prometheus IBD sgi Diagnostic Policy
|
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L37301
|
05/13/2019
|
10/01/2019
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MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels
|
|
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L37303
|
12/11/2017
|
11/01/2019
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MolDX: AlloSure® Donor-Derived Cell-Free DNA Test
|
|
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L37305
|
03/18/2018
|
11/01/2019
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MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer
|
|
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L37350
|
02/11/2019
|
10/01/2019
|
Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs)
|
|
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L37373
|
10/08/2018
|
10/01/2019
|
MRI and CT Scans of the Head and Neck
|
|
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L37502
|
02/18/2019
|
10/01/2019
|
Frequency of Hemodialysis
|
|
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L37547
|
06/22/2018
|
11/01/2019
|
Chest X-Ray Policy
|
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L37616
|
02/11/2019
|
11/01/2019
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MolDX: Cystatin C Measurement
|
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L37620
|
06/03/2019
|
11/01/2019
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MolDX: MDS FISH
|
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L37628
|
10/01/2018
|
12/01/2019
|
In Vitro Chemosensitivity & Chemoresistance Assays
|
|
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L37673
|
02/10/2019
|
11/01/2019
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MolDX: Corus® CAD Assay
|
|
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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)
|
|
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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
|
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MolDX: Next-Generation Sequencing for Solid Tumors
|
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L38123
|
05/17/2020
|
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MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies
|
|
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L38135
|
01/05/2020
|
01/05/2020
|
MolDX: TruGraf Blood Gene Expression Test
|
|
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L38147
|
05/04/2020
|
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MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Intermediate Risk Disease
|
|
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L38151
|
06/07/2020
|
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MolDX: Pigmented Lesion Assay
|
|
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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
|
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MolDX: Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer
|
|
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L38335
|
08/17/2020
|
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MolDX: Pharmacogenomics Testing
|
|
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L38351
|
08/03/2020
|
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MolDX: Repeat Germline Testing
|
|
|
L38657
|
11/02/2020
|
|
Implantable Continuous Glucose Monitors (I-CGM)
|
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