| 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
|
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L34209
|
10/01/2015
|
12/01/2019
|
Treatment of Varicose Veins of the Lower Extremities
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L34211
|
10/01/2015
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12/01/2019
|
Trigger Point Injections
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L34213
|
10/01/2015
|
10/01/2019
|
Diagnostic and Therapeutic Colonoscopy
|
|
|
L34215
|
10/01/2015
|
12/01/2019
|
Lab: Flow Cytometry
|
|
|
L34217
|
10/01/2015
|
10/01/2019
|
Intensity Modulated Radiation Therapy (IMRT)
|
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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
|
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|
L34223
|
10/01/2015
|
12/01/2019
|
Stereotactic Radiosurgery
|
|
|
L34224
|
10/01/2015
|
12/01/2019
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Stereotactic Body Radiation Therapy
|
|
|
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
|
|
|
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
|
|
|
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
|
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|
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
|
|
|
L36219
|
10/01/2015
|
12/01/2019
|
Non-Covered Services
|
|
|
L36310
|
10/01/2015
|
11/01/2019
|
MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing
|
|
|
L36323
|
10/01/2015
|
11/01/2019
|
MolDX: GeneSight® Assay for Refractory Depression
|
|
|
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
|
|
|
L37624
|
05/27/2019
|
10/01/2019
|
Helicobacter Pylori Infection Testing
|
|
|
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
|
|
|
L38335
|
08/17/2020
|
|
MolDX: Pharmacogenomics Testing
|
|
|
L38351
|
08/03/2020
|
|
MolDX: Repeat Germline Testing
|
|
