| 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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04/08/2021
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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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08/18/2022
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Lumbar MRI
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L34228
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10/01/2015
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01/10/2021
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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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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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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
|
05/04/2023
|
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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09/04/2022
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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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L36155
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06/16/2016
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08/12/2021
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MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)
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L36180
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04/19/2016
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06/30/2022
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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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10/14/2021
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MolDX: MGMT Promoter Methylation Analysis
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L36335
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07/05/2016
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10/07/2021
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MolDX: NRAS Genetic Testing
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L36351
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10/15/2015
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12/24/2020
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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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04/22/2021
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MolDX: Biomarkers in Cardiovascular Risk Assessment
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L36380
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05/03/2016
|
04/22/2021
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MolDX: Breast Cancer Assay: Prosigna®
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L36524
|
06/01/2016
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12/01/2019
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Nerve Conduction Studies and Electromyography
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L36538
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07/12/2016
|
11/01/2019
|
Treatment of Males with Low Testosterone
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L36551
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09/15/2016
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07/08/2021
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MolDX: HLA-DQB1*06:02 Testing for Narcolepsy
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L36575
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09/07/2016
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12/01/2019
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Total Knee Arthroplasty
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L36668
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06/28/2016
|
04/08/2021
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Lab: Controlled Substance Monitoring and Drugs of Abuse Testing
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L36678
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05/16/2017
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03/04/2021
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Lab: Bladder/Urothelial Tumor Markers
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L36692
|
02/03/2017
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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
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Serum Magnesium
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L36704
|
06/01/2017
|
12/30/2021
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ProMark® Risk Score
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L36846
|
07/21/2017
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11/01/2019
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Measurement of Salivary Hormones
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L36861
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06/05/2017
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12/01/2019
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Polysomnography and Other Sleep Studies
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L36864
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08/01/2017
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03/04/2021
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GlycoMark® Testing for Glycemic Control
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L36886
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05/15/2017
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12/01/2019
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MolDX: Percepta© Bronchial Genomic Classifier
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L36941
|
03/27/2017
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11/25/2021
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MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)
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L37054
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09/29/2017
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04/28/2022
|
BDX-XL2
|
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L37066
|
10/02/2017
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02/25/2021
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Lab: Coenzyme Q10 (CoQ10)
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L37070
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09/22/2017
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06/30/2022
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MolDX: DecisionDx-UM (Uveal Melanoma)
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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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L37295
|
01/30/2018
|
07/11/2021
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MolDX: EndoPredict® Breast Cancer Gene Expression Test
|
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L37299
|
01/30/2018
|
02/25/2021
|
MolDX: Prometheus IBD sgi Diagnostic® Policy
|
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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
|
06/09/2022
|
Lab: Cystatin C Measurement
|
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L37620
|
06/03/2019
|
06/30/2022
|
MDS FISH
|
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L37628
|
10/01/2018
|
02/25/2021
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In Vitro Chemosensitivity & Chemoresistance Assays
|
|
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L37729
|
04/01/2019
|
11/01/2019
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Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor
|
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|
L37750
|
02/10/2019
|
08/08/2022
|
MolDX: Melanoma Risk Stratification Molecular Testing
|
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L37822
|
04/16/2019
|
10/28/2021
|
MolDX: Breast Cancer Index® (BCI) Gene Expression Test
|
|
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L37879
|
06/03/2019
|
11/04/2021
|
MolDX: myPath® Melanoma Assay
|
|
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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
|
|
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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
|
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MolDX: Pharmacogenomics Testing
|
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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
|
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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
|
|
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L38629
|
07/04/2021
|
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MolDX: Molecular Testing for Solid Organ Allograft Rejection
|
|
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L38643
|
07/04/2021
|
06/02/2022
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MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells
|
|
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L38647
|
07/25/2021
|
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MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer
|
|
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L38657
|
11/02/2020
|
11/02/2020
|
Implantable Continuous Glucose Monitors (I-CGM)
|
|
|
L38705
|
12/27/2020
|
|
Transurethral Waterjet Ablation of the Prostate
|
|
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L38709
|
12/13/2020
|
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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
|
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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
|
|
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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
|
|
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L39240
|
06/19/2022
|
|
Epidural Steroid Injections for Pain Management
|
|
|
L39262
|
05/28/2023
|
|
MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia
|
|
|
L39396
|
03/05/2023
|
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Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin
|
|
|
L39462
|
03/19/2023
|
|
Sacroiliac Joint Injections and Procedures
|
|
