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CodeMap® CodeMap® Contractor Policy Detail

List of All Medicare MAC Part A and MAC Part B Contractors

Noridian Healthcare Solutions, LLC
American Samoa
MAC B
01212

Currently Active LCDs93
Draft LCDs16
Retired LCDs9
Currently Active Articles321
Retired Articles23

Currently Active LCDs

LCD
Effective
Date
Revision
Effective
Date
Title
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 04/08/2021 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 08/18/2022 Lumbar MRI
L34228 10/01/2015 01/10/2021 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)
L34247 10/01/2015 10/01/2019 Pulmonary Function Testing
L34313 10/01/2015 10/01/2019 Allergy Testing
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
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 09/04/2022 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
L36155 06/16/2016 08/12/2021 MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)
L36180 04/19/2016 06/30/2022 MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease
L36188 04/15/2016 10/14/2021 MolDX: MGMT Promoter Methylation Analysis
L36335 07/05/2016 10/07/2021 MolDX: NRAS Genetic Testing
L36351 10/15/2015 12/24/2020 Lab: Special Histochemical Stains and Immunohistochemical Stains
L36358 06/01/2016 04/22/2021 MolDX: Biomarkers in Cardiovascular Risk Assessment
L36380 05/03/2016 04/22/2021 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 07/08/2021 MolDX: HLA-DQB1*06:02 Testing for Narcolepsy
L36575 09/07/2016 12/01/2019 Total Knee Arthroplasty
L36668 06/28/2016 04/08/2021 Lab: Controlled Substance Monitoring and Drugs of Abuse Testing
L36678 05/16/2017 03/04/2021 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 12/30/2021 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 03/04/2021 GlycoMark® Testing for Glycemic Control
L36886 05/15/2017 12/01/2019 MolDX: Percepta© Bronchial Genomic Classifier
L36941 03/27/2017 11/25/2021 MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)
L37054 09/29/2017 04/28/2022 BDX-XL2
L37066 10/02/2017 02/25/2021 Lab: Coenzyme Q10 (CoQ10)
L37070 09/22/2017 06/30/2022 MolDX: DecisionDx-UM (Uveal Melanoma)
L37086 05/14/2018 12/01/2019 Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder
L37295 01/30/2018 07/11/2021 MolDX: EndoPredict® Breast Cancer Gene Expression Test
L37299 01/30/2018 02/25/2021 MolDX: Prometheus IBD sgi Diagnostic® Policy
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 06/09/2022 Lab: Cystatin C Measurement
L37620 06/03/2019 06/30/2022 MDS FISH
L37628 10/01/2018 02/25/2021 In Vitro Chemosensitivity & Chemoresistance Assays
L37729 04/01/2019 11/01/2019 Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor
L37750 02/10/2019 08/08/2022 MolDX: Melanoma Risk Stratification Molecular Testing
L37822 04/16/2019 10/28/2021 MolDX: Breast Cancer Index® (BCI) Gene Expression Test
L37879 06/03/2019 11/04/2021 MolDX: myPath® Melanoma Assay
L37887 05/27/2019 06/24/2021 MolDX: Envisia™, Veracyte™, Idiopathic Pulmonary Fibrosis Diagnostic Test
L37897 06/03/2019 10/14/2021 MolDX: Inivata™, InVisionFirst®, Liquid Biopsy for Patients with Lung Cancer
L38119 05/17/2020 06/24/2021 MolDX: Next-Generation Sequencing for Solid Tumors
L38123 05/17/2020 07/08/2021 MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies
L38151 06/07/2020 MolDX: Pigmented Lesion Assay
L38299 03/23/2020 10/03/2021 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 01/06/2022 MolDX: Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer
L38331 12/06/2020 05/26/2022 MolDX: Blood Product Molecular Antigen Typing
L38335 08/17/2020 MolDX: Pharmacogenomics Testing
L38339 12/06/2020 02/03/2022 MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease
L38351 08/03/2020 12/30/2021 MolDX: Repeat Germline Testing
L38355 12/06/2020 MolDX: AlloSure® or Equivalent Cell-Free DNA Testing for Kidney and Heart Allografts
L38613 04/26/2021 09/18/2022 Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease
L38629 07/04/2021 MolDX: Molecular Testing for Solid Organ Allograft Rejection
L38643 07/04/2021 06/02/2022 MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells
L38647 07/25/2021 MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer
L38657 11/02/2020 11/02/2020 Implantable Continuous Glucose Monitors (I-CGM)
L38705 12/27/2020 Transurethral Waterjet Ablation of the Prostate
L38709 12/13/2020 Computed Tomography Cerebral Perfusion Analysis (CTP)
L38801 04/25/2021 02/03/2022 Facet Joint Interventions for Pain Management
L38814 01/02/2022 MolDX: Minimal Residual Disease Testing for Cancer
L38824 03/28/2021 12/19/2021 Colon Capsule Endoscopy (CCE)
L38902 11/28/2021 Wound and Ulcer Care
L38972 08/08/2022 MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer
L39001 04/17/2022 06/02/2022 MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
L39005 08/08/2022 MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer
L39058 01/23/2022 01/23/2022 Platelet Rich Plasma Injections for Non-Wound Injections
L39230 12/26/2022 MolDX: Plasma-Based Genomic Profiling in Solid Tumors
L39240 06/19/2022 Epidural Steroid Injections for Pain Management
L39396 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



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