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Noridian Healthcare Solutions, LLC
American Samoa
MAC B
01212

Currently Active LCDs98
Draft LCDs21
Retired LCDs18
Currently Active Articles327
Retired Articles33

Currently Active LCDs

All LCDs Laboratory LCDs Radiology 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 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 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)
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
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
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
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 12/10/2020 MolDX: ConfirmMDx Epigenetic Molecular Assay
L36335 07/05/2016 12/01/2019 MolDX: NRAS Genetic Testing
L36348 10/15/2015 12/01/2019 MolDX: Prolaris™ Prostate Cancer Genomic Assay
L36351 10/15/2015 12/24/2020 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 01/07/2021 MolDX: Genetic Testing for Lynch Syndrome
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 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 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 12/01/2019 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 03/04/2021 GlycoMark® Testing for Glycemic Control
L36882 05/15/2017 04/01/2021 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 02/25/2021 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 02/25/2021 MolDX: Prometheus IBD sgi Diagnostic® Policy
L37301 05/13/2019 10/01/2019 MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels
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 12/10/2020 MolDX: Cystatin C Measurement
L37620 06/03/2019 11/01/2019 MolDX: MDS FISH
L37628 10/01/2018 02/25/2021 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 12/06/2020 MolDX: Androgen Receptor Variant (AR-V7) Protein Test
L37750 02/10/2019 12/06/2020 MolDX: Melanoma Risk Stratification Molecular Testing
L37822 04/16/2019 05/10/2021 MolDX: Breast Cancer Index® (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
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
L38331 12/06/2020 12/06/2020 MolDX: Blood Product Molecular Antigen Typing
L38335 08/17/2020 MolDX: Pharmacogenomics Testing
L38339 12/06/2020 MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease
L38351 08/03/2020 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 Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic Heart Disease
L38657 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 Facet Joint Interventions for Pain Management
L38824 03/28/2021 Colon Capsule Endoscopy (CCE)



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