CodeMap® CodeMap® Contractor Policy Detail

LCD	Effective Date	Revision Effective Date	Title	CPT Codes Covered in LCD
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	Lab: Flow Cytometry	86355 86356 86357 86359 86360 86361 86367 88182 88184 88185 88187 88188 88189
L34217	10/01/2015	10/01/2018	Intensity Modulated Radiation Therapy (IMRT)	49411 77301 77338 G6015 G6016
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
L34219	10/01/2015	10/01/2017	Noninvasive Peripheral Arterial Studies	93922 93923 93924 93925 93926 93930 93931 93990
L34220	10/01/2015	10/01/2018	Lumbar MRI	72148 72149 72158 A9585 Q9953
L34221	10/01/2015	10/01/2018	Noninvasive Cerebrovascular Studies	93880 93882 93886 93888
L34223	10/01/2015	10/01/2018	Stereotactic Radiosurgery	61796 61797 61798 61799 61800 63620 63621 77371 77372 77373 77432 77435 G0339 G0340
L34224	10/01/2015	10/01/2015	Stereotactic Body Radiation Therapy	77373 77435 G0339 G0340 G6017
L34228	10/01/2015	10/01/2015	Percutaneous Vertebral Augmentation	0200T 0201T 22510 22511 22512 22513 22514 22515
L34229	10/01/2015	10/01/2018	Noninvasive Peripheral Venous Studies	93970 93971
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
L34242	10/01/2015	10/01/2018	Chiropractic Services	98940 98941 98942 98943
L34243	10/01/2015	10/01/2017	Treatment of Ulcers & Symptomatic Hyperkeratoses	11042 11043 11044 11045 11046 11047 11055 11056 11057 97597 97598
L34247	10/01/2015	10/01/2018	Pulmonary Function Testing	94010 94011 94012 94013 94060 94070 94150 94200 94250 94375 94400 94450 94617 94618 94621 94640 94664 94680 94681 94690 94726 94727 94728 94729 94750
L34313	10/01/2015	10/01/2015	Allergy Testing	86003 86005 95004 95017 95018 95024 95027 95028 95044 95052 95056 95060 95065 95070 95071 95076 95079
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	01/01/2019	Peripheral Nerve Stimulation	61885 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	01/01/2019	MolDX: Molecular Diagnostic Tests (MDT)	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 0021U 0022U 0023U 0024U 0025U 0026U 0027U 0029U 0030U 0031U 0032U 0033U 0034U 0035U 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	01/01/2019	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 64510 64517 64520 64530 64620 64640 76881 76882 76942 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	01/01/2019	MolDX: BRCA1 and BRCA2 Genetic Testing	81162 81163 81164 81165 81166 81167 81212 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	01/01/2019	Non-Covered Services	0042T 0054T 0055T 0071T 0072T 0098T 0100T 0101T 0102T 0106T 0107T 0108T 0109T 0110T 0111T 0126T 0163T 0165T 0174T 0175T 0198T 0202T 0205T 0206T 0207T 0208T 0209T 0210T 0211T 0212T 0219T 0220T 0221T 0222T 0232T 0234T 0235T 0236T 0237T 0238T and more.....
L36310	10/01/2015	01/01/2019	MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing	0070U 81225 81226 81227 81355 81479
L36314	10/01/2015	01/01/2019	MolDX: Breast Cancer Index℠ Genetic Assay	81518
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	Lab: Special Histochemical Stains and Immunohistochemical Stains	88312 88313 88341 88342 88344 88360 88361
L36358	06/01/2016	01/31/2019	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	04/16/2019	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	12/27/2018	Lab:Controlled Substance Monitoring and Drugs of Abuse Testing	80305 80306 80307 G0480 G0481 G0482 G0483 G0659
L36678	05/16/2017	05/16/2017	Lab: 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	Lab: Coenzyme Q10 (CoQ10)	XX000
L37070	09/22/2017	02/21/2019	MolDX: DecisionDx-UM (Uveal Melanoma)	0081U
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
L37120	01/13/2019		MolDX: 4Kscore Assay	81539
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
L37301	05/13/2019		MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels	87631 87632 87633
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
L37350	02/11/2019	02/11/2019	MolDX: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs)	87505 87506 87507
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
L37502	02/18/2019	03/01/2019	Frequency of Hemodialysis	90999
L37547	06/22/2018		Chest X-Ray Policy	71045 71046 71047 71048
L37616	02/11/2019		MolDX: Cystatin C Measurement	82610
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
L37673	02/10/2019		MolDX: Corus® CAD Assay	81493
L37729	04/01/2019		Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor	0398T
L37746	03/02/2019		MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC)	81479
L37750	02/10/2019		MolDX: DecisionDx-Melanoma	81599
L37822	04/16/2019		MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test	81518

CodeMap® is a Registered Trademark of Wheaton Partners, LLC.