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Date
Revision
Effective
Date
Title
CPT Codes Covered in Policy
L33252 10/01/2015 10/01/2018 Psychiatric Diagnostic Evaluation and Psychotherapy Services 90785 90791 90792 90832 90833 90834 90836 90837 90838 90839 90840 90845 90846 90847 90853
L33256 10/01/2015 10/01/2018 3D Interpretation and Reporting of Imaging Studies 76376 76377
L33257 10/01/2015 01/02/2018 Abatacept J0129
L33261 10/01/2015 01/01/2018 Allergy Testing 83516 84600 86001 86003 86005 86008 86140 86160 86161 86162 86332 86485 86628 88341 88342 88344 88346 95004 95017 95018 95024 95027 95028 95044 95052 95056 95060 95065
L33263 10/01/2015 10/01/2016 Anorectal Manometry and EMG of the Urinary and Anal Sphincters 51784 51785 91122
L33266 10/01/2015 10/01/2015 Azacitidine (Vidaza®) J9025
L33267 10/01/2015 10/01/2017 B-Type Natriuretic Peptide (BNP) 83880
L33268 10/01/2015 10/01/2017 Bendamustine hydrochloride (Treanda®, Bendeka™) J9033 J9034
L33270 10/01/2015 07/19/2018 Bisphosphonates (Intravenous [IV]) and Monoclonal Antibodies in the Treatment of Osteoporosis and Their Other Indications J0897 J1740 J2430 J3489
L33271 10/01/2015 10/01/2017 Biventricular Pacing/ Cardiac Resynchronization Therapy 33202 33203 33206 33207 33208 33212 33213 33214 33217 33221 33224 33225 33226 33230 33231 33240 33249
L33272 10/01/2015 Bone and/or Joint Imaging 78300 78305 78306 78315 78320
L33273 10/01/2015 02/08/2018 Bortezomib (Velcade®) J9041
L33274 10/01/2015 11/15/2018 Botulinum Toxins J0585 J0586 J0587 J0588
L33275 10/01/2015 10/01/2018 Carboplatin (Paraplatin®, Paraplatin-AQ®) J9045
L33278 10/01/2015 10/01/2018 Cetuximab (Erbitux®) J9055
L33282 10/01/2015 01/02/2018 Computed Tomographic Angiography of the Chest, Heart and Coronary Arteries 71275 75571 75572 75573 75574
L33283 10/01/2015 10/01/2017 Computed Tomographic Colonography 74261 74262
L33284 10/01/2015 10/01/2015 Computed Tomography of the Abdomen and Pelvis 72192 72193 72194 74150 74160 74170 74176 74177 74178
L33285 10/01/2015 10/01/2015 Computed Tomography of the Thorax 71250 71260 71270
L33296 10/01/2015 01/25/2018 Noncovered Procedures - Endoscopic Treatment of Gastroesophageal Reflux Disease (GERD) 43201 43236 43241 43257 43499
L33380 10/01/2015 10/24/2017 Long-Term Wearable Electrocardiographic Monitoring (WEM) 0295T 0296T 0297T 0298T 93224 93225 93226 93227 93228 93229 93268 93270 93271 93272
L33382 10/01/2015 10/23/2018 Lumbar Spinal Fusion for Instability and Degenerative Disc Conditions 22533 22534 22558 22585 22612 22614 22630 22632 22633 22634 22800 22802 22804 22808 22810 22812 22853 22854 22859
L33405 10/01/2015 03/15/2018 Polysomnography and Sleep Testing 95782 95783 95800 95801 95803 95805 95806 95807 95808 95810 95811 G0398 G0399 G0400
L33406 10/01/2015 10/01/2016 Posterior Tibial Nerve Stimulation (PTNS) 64566
L33410 10/01/2015 10/01/2018 Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) 77371 77372 77373 G0339 G0340
L33411 10/01/2015 11/06/2018 Surgical Management of Morbid Obesity 43644 43645 43770 43771 43772 43773 43774 43775 43842 43843 43845 43846 43847 43848 43886 43887 43888 43999
L33412 10/01/2015 10/01/2015 Testosterone pellets (Testopel®) XX000
L33413 10/01/2015 04/24/2018 Therapy and Rehabilitation Services 92507 92508 92521 92522 92523 92524 92607 92608 92609 92626 92627 92630 92633 96105 96111 96116 96125 96125 97012 97016 97018 97022 97024 97028 97032 97033 97034 97035 97036 97110 97112 97113 97116 97124 97140 97150 97161 97162 97163 97164 and more.....
L33583 10/01/2015 10/01/2017 Diagnostic and Therapeutic Esophagogastroduodenoscopy 43233 43235 43236 43237 43238 43239 43241 43243 43244 43245 43246 43247 43248 43249 43250 43251 43253 43254 43255 43266 43270
L33586 10/01/2015 01/01/2018 Gene Expression Profiling Panel for use in the Management of Breast Cancer Treatment 81519 81520 81521
L33594 10/01/2015 01/01/2017 Manipulation Under Anesthesia (MUA) 22505 23700 24300 27570
L33595 10/01/2015 01/09/2018 Monitored Anesthesia Care (MAC) for Certain Interventional Pain Management Services 01991 01992
L33600 10/01/2015 10/01/2015 Sinus X-ray(s) 70210 70220
L33609 10/01/2015 10/01/2017 Autonomic Function Tests 95921 95922 95923 95924
L33615 10/01/2015 04/03/2018 Biofeedback 90901 90911
L33618 10/01/2015 10/01/2018 Major Joint Replacement (Hip and Knee) 27130 27132 27134 27137 27138 27445 27447 27486 27487
L33661 10/01/2015 02/08/2018 Flow Cytometry 88182 88184 88185 88187 88188 88189
L33667 10/01/2015 09/18/2018 Duplex Scan Of Lower Extremity Arteries 93925 93926
L33669 10/01/2015 10/01/2018 Electrocardiography 93000 93005 93010
L33670 10/01/2015 03/01/2018 Fundus Photography 92250
L33671 10/01/2015 05/17/2018 Diagnostic Colonoscopy 44388 44388 44389 44389 44390 44390 44391 44391 44392 44392 44394 44394 44401 44401 44402 44402 44403 44403 44404 44404 44405 44405 44406 44406 44407 44407 44408 44408 45378 45378 45379 45379 45380 45380 45381 45381 45382 45382 45384 45384 and more.....
L33674 10/01/2015 10/01/2016 Duplex Scanning 93975 93976 93978 93979
L33684 10/01/2015 01/01/2018 Hemophilia Clotting Factors J7179 J7182 J7183 J7186 J7187 J7188 J7189 J7190 J7191 J7192 J7193 J7194 J7195 J7198 J7200 J7201 J7202 J7205 J7207 J7209 J7210 J7211
L33685 10/01/2015 03/15/2018 Luteinizing Hormone-Releasing Hormone (LHRH) Analogs 11981 11982 11983 J1950 J3315 J9202 J9217 J9218 J9219 J9225
L33689 10/01/2015 10/01/2018 Mohs Micrographic Surgery (MMS) 17311 17312 17313 17314 17315
L33693 10/01/2015 10/01/2017 Non-Invasive Evaluation of Extremity Veins 93970 93971
L33695 10/01/2015 10/01/2018 Non-invasive Extracranial Arterial Studies 93880 93882
L33696 10/01/2015 01/09/2018 Noninvasive Physiologic Studies of Upper or Lower Extremity Arteries 93922 93923 93924
L33704 10/01/2015 04/01/2018 Infliximab (Remicade TM ) J1745 Q5103 Q5104
L33707 10/01/2015 11/13/2018 Pulmonary Diagnostic Services 94010 94010 94060 94060 94070 94070 94150 94200 94200 94250 94250 94375 94375 94617 94617 94618 94618 94621 94621 94726 94726 94727 94727 94728 94728 94729 94729 94750 94750
L33721 10/01/2015 10/01/2015 Computed Tomography Scans of the Head or Brain 70450 70460 70470
L33722 10/01/2015 10/01/2016 Doxorubicin, Liposomal (Doxil/Lipodox) Q2049 Q2050
L33723 10/01/2015 10/01/2018 Etoposide (Etopophos®, Toposar®, Vepesid®, VP-16) J9181
L33726 10/01/2015 06/14/2018 Gemcitabine (Gemzar) J9201
L33727 10/01/2015 01/01/2017 Irinotecan J9205 J9206
L33729 10/01/2015 Oxaliplatin (Eloxatin®) J9263
L33730 10/01/2015 10/01/2018 Paclitaxel (Taxol®) J9267
L33745 10/01/2015 10/01/2016 Respiratory Therapeutic Services G0237 G0238 G0239
L33746 10/01/2015 10/01/2017 Rituximab (Rituxan®) J9310
L33747 10/01/2015 10/01/2018 Pegfilgrastim (Neulasta®) J2505 Q5108
L33748 10/01/2015 Romiplostim (Nplate®) J2796
L33751 10/01/2015 05/31/2018 Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) 92132 92133 92134
L33752 10/01/2015 10/01/2015 Topotecan Hydrochloride (Hycamtin®) J9351
L33754 10/01/2015 05/12/2017 Syphilis Test 86592 86593 86780
L33755 10/01/2015 10/01/2017 Susceptibility Studies 87181 87184 87185 87186 87187 87188 87190
L33756 10/01/2015 01/01/2018 Transesophageal Echocardiogram 93312 93312 93313 93313 93314 93314 93315 93315 93316 93316 93317 93317 93318 93318 93355 93355 C8925 C8926 C8927
L33762 10/01/2015 07/10/2018 Treatment of varicose veins of the lower extremity 36465 36466 36470 36471 36473 36474 36475 36476 36478 36479 36482 36483 37500 37700 37718 37722 37735 37765 37766 37780 37785 37799 93970 93971
L33763 10/01/2015 10/01/2015 Vascular Stenting of Lower Extremity Arteries 37221 37223 37226 37227 37230 37231 37234 37235
L33766 10/01/2015 10/01/2018 Visual Field Examination 92081 92082 92083
L33767 10/01/2015 02/08/2018 Viscosupplementation Therapy For Knee 20610 20610 J7320 J7320 J7321 J7321 J7322 J7322 J7323 J7323 J7324 J7324 J7325 J7325 J7326 J7326 J7327 J7327 J7328 J7328
L33768 10/01/2015 10/01/2018 Transthoracic Echocardiography (TTE) 93303 93303 93304 93304 93306 93306 93307 93307 93308 93308 93320 93320 93321 93321 93325 93325 C8921 C8922 C8923 C8924
L33771 10/01/2015 10/01/2018 Vitamin D; 25 hydroxy, includes fraction(s), if performed 82306
L33774 10/01/2015 02/08/2018 Wireless Capsule Endoscopy 91110 91111
L33777 10/01/2015 10/25/2018 Noncovered Services 0042T 0054T 0055T 0058T 0095T 0098T 0101T 0102T 0106T 0107T 0108T 0109T 0110T 0111T 0126T 0159T 0163T 0164T 0165T 0174T 0175T 0184T 0190T 0195T 0196T 0198T 01990 01999 0202T 0205T 0206T 0207T 0208T 0209T 0210T 0211T 0212T 0213T 0214T 0215T and more.....
L33969 10/01/2015 10/01/2017 Diagnostic Aerosol or Vapor Inhalation 94640
L33970 10/01/2015 10/01/2017 Frequency of Hemodialysis Services 90999
L33972 10/01/2015 10/01/2018 Psychiatric Partial Hospitalization Program 90785 90791 90792 90832 90833 90834 90836 90837 90838 90846 90847 96101 96116 96118 97533 G0129 G0176 G0177 G0410 G0411 G0515
L33974 10/01/2015 10/01/2017 Troponin 84484 84512
L33975 10/01/2015 08/15/2016 Psychiatric Inpatient Hospitalization XX000
L33978 10/01/2015 08/18/2016 Pemetrexed J9305
L33989 10/01/2015 10/01/2018 Docetaxel (Taxotere®) J9171
L33997 10/01/2015 10/01/2017 Fluorescein Angiography 92235
L33998 10/01/2015 06/14/2018 Fulvestrant (Faslodex®) J9395
L34002 10/01/2015 10/01/2018 G-CSF (Neupogen®, Granix™,Zarxio™, Nivestym™) J1442 J1447 Q5101 Q5110
L34003 10/01/2015 10/01/2018 Hepatitis B Surface Antibody and Surface Antigen 86706 87340
L34006 10/01/2015 10/01/2017 Interspinous Process Decompression 22867 22867 22868 22868 22869 22869 22870 22870 C1821
L34007 10/01/2015 04/12/2018 Intravenous Immune Globulin J1459 J1555 J1556 J1557 J1561 J1566 J1568 J1569 J1572 J1575
L34011 10/01/2015 05/12/2017 Ionized Calcium 82330
L34014 10/01/2015 10/01/2017 Magnesium 83735
L34017 10/01/2015 10/01/2017 Ophthalmoscopy 92225 92226
L34018 10/01/2015 05/12/2017 Parathormone (Parathyroid Hormone) 83970
L34021 10/01/2015 10/01/2018 Sedimentation Rate, Erythrocyte 85651 85652
L34022 10/01/2015 10/01/2018 Serum Phosphorus 84100
L34023 10/01/2015 10/01/2017 Strapping 29540 29550 29580
L34025 10/01/2015 10/01/2016 Surgical Decompression for Peripheral Polyneuropathy 01470 28035 64702 64704 64708 64712 64714 64722 64726 64727
L34026 10/01/2015 07/14/2017 Trastuzumab (Herceptin®) J9355
L34027 10/01/2015 10/01/2016 Ultrasound, Soft Tissues of Head and Neck 76536
L34028 10/01/2015 10/01/2017 Upper Eyelid and Brow Surgical Procedures 15822 15823 67900 67901 67902 67903 67904 67906 67908
L34031 10/01/2015 10/01/2018 Total Calcium 82310
L34043 10/01/2015 10/01/2015 Dysphagia/Swallowing Diagnosis and Therapy 70370 70371 74230 76536 92511 92526 92610 92611
L34372 10/01/2015 04/12/2018 Magnetic Resonance Angiography (MRA) 70544 70544 70545 70545 70546 70546 70547 70547 70548 70548 70549 70549 71555 72159 72198 73225 73725 74185 C8900 C8900 C8901 C8901 C8902 C8902 C8909 C8909 C8910 C8910 C8911 C8911 C8912 C8912 C8913 C8913 C8914 C8914 C8918 C8918 C8919 C8919 and more.....
L34374 10/01/2015 10/01/2015 Magnetic Resonance Imaging of the Brain 70551 70552 70553 70557 70558 70559
L34375 10/01/2015 10/01/2015 Magnetic Resonance Imaging of the Orbit, Face, and/or Neck 70540 70542 70543
L34376 10/01/2015 10/01/2015 Magnetic Resonance Imaging of the Spine 72141 72142 72146 72147 72148 72149 72156 72157 72158
L34377 10/01/2015 10/01/2015 Magnetic Resonance Imaging of Upper Extremity 73218 73219 73220 73221 73222 73223
L34518 10/01/2015 05/22/2018 Molecular Pathology Procedures for Human Leukocyte Antigen (HLA) Typing 81370 81371 81372 81373 81374 81375 81376 81377 81378 81379 81380 81381 81382 81383
L34519 10/01/2015 01/01/2018 Molecular Pathology Procedures 81105 81106 81107 81108 81109 81110 81111 81112 81120 81121 81162 81170 81175 81176 81200 81201 81202 81203 81205 81206 81207 81208 81209 81210 81211 81212 81213 81214 81215 81216 81217 81218 81219 81220 81221 81222 81223 81224 81225 81226 and more.....
L34520 10/01/2015 10/01/2018 Psychological and Neuropsychological Tests 96101 96102 96103 96105 96111 96116 96118 96119 96120 G0451
L34521 10/01/2015 Special EEG Tests 95950 95951 95953 95956 95957
L34522 10/01/2015 06/26/2018 Transcranial Magnetic Stimulation for Major Depressive Disorder 90867 90868 90869
L34859 10/01/2015 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
L34912 10/01/2015 02/08/2018 Genetic Testing for Lynch Syndrome 81210 81288 81292 81293 81294 81295 81296 81297 81298 81299 81300 81301 81317 81318 81319 81403 81435 81479 88341 88342 88344
L34976 10/01/2015 04/17/2018 Vertebroplasty, Vertebral Augmentation; Percutaneous 22510 22511 22512 22513 22514 22515
L35698 10/01/2015 04/02/2018 CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing 0028U 81225 81226 81227 81355
L36035 10/01/2015 02/08/2018 Spinal Cord Stimulation for Chronic Pain 63650 63655 63661 63662 63663 63664 63685 63688 95970 95971 95972
L36209 10/01/2015 09/13/2018 Cardiology – non-emergent outpatient testing: exercise stress test, stress echo, MPI SPECT, and cardiac PET 78451 78452 78453 78454 78459 78491 78492 93015 93016 93017 93018 93350 93351 93352 A9526 A9552 A9555
L36230 11/15/2015 01/17/2017 Evaluation and Management Services in a Nursing Facility 99304 99305 99306 99307 99308 99309 99310 99315 99316 99318 G9685
L36232 11/22/2015 11/22/2015 Diagnostic Evaluation and Medical Management of Moderate-Severe Dry Eye Disease (DED) 0330T 68760 68761 83516 83861
L36234 12/06/2015 03/08/2016 Special Histochemical Stains & Immunohistochemical Stains 88312 88313 88341 88342 88344 88360 88361
L36237 10/01/2015 10/13/2016 Amniotic Membrane- Sutureless Placement on the Ocular Surface 65778
L36238 10/01/2015 08/23/2018 Humanitarian Use Device (HUD) and Humanitarian Device Exemption (HDE) process XX000
L36276 10/01/2015 10/01/2018 Erythropoiesis Stimulating Agents J0881 J0881 J0882 J0882 J0885 J0885 J0887 J0887 J0888 J0888 Q4081 Q5105 Q5105 Q5106 Q5106
L36342 10/01/2015 10/01/2018 Screening and Diagnostic Mammography 77063 77065 77066 77067 G0279
L36355 10/01/2015 01/01/2018 Colorectal Cancer Screening 81528 82270 G0104 G0105 G0106 G0120 G0121 G0122 G0328
L36356 10/01/2015 05/01/2018 Bone Mineral Density Studies 76977 77078 77080 77081 77085 G0130
L36377 10/01/2015 Application of Skin Substitute Grafts for Treatment of DFU and VLU of Lower Extremities 15271 15272 15273 15274 15275 15276 15277 15278 C5271 C5272 C5273 C5274 C5275 C5276 C5277 C5278
L36393 10/11/2015 10/01/2018 Controlled Substance Monitoring and Drugs of Abuse Testing 80305 80306 80307 83789 G0480 G0481 G0482 G0483 G0659
L36499 04/11/2016 01/01/2018 BRCA1 and BRCA2 Genetic Testing 81162 81211 81212 81213 81214 81215 81216 81217 81432 81445 81455 81479
L36504 04/11/2016 05/31/2018 Hyperbaric Oxygen (HBO) Therapy 99183 G0277
L36617 09/12/2016 09/12/2016 Chiropractic Services 98940 98941 98942
L36767 10/31/2016 10/01/2018 Aortography and peripheral angiography 36140 36200 36200 36215 36216 36217 36218 36221 36222 36223 36224 36225 36226 36227 36228 36245 36246 36247 36248 36251 36252 36253 36254 75600 75605 75625 75630 75710 75716 75726 G0278
L36773 11/07/2016 10/01/2018 Intensity Modulated Radiation Therapy (IMRT) 77301 77338 77385 77386 G6015 G6016
L36775 10/31/2016 10/30/2018 Prostatic Urethral Lift (PUL) 52441 52442 C9739 C9740
L36962 07/24/2017 10/02/2017 Vascular Endothelial Growth Factor Inhibitors for the Treatment of Ophthalmological Diseases C9257 J0178 J2503 J2778 J3490 J7999
L37166 12/07/2017 12/07/2017 Wound Care 11000 11001 11004 11005 11006 11008 11010 11011 11012 11042 11043 11044 11045 11046 11047 29580 29581 97597 97598 97602 97605 97606 97607 97608 97610
L37398 02/02/2018 08/07/2018 Electroretinography (ERG) 92275
L37561 02/02/2018 02/22/2018 Cystatin C Measurement 82610
L37697 06/28/2018 09/19/2018 Emergency and Non-Emergency Ground Ambulance Services A0425 A0426 A0427 A0428 A0429 A0433 A0434 A0999



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