CodeMap® CodeMap® Contractor Policy Detail

LCD	Effective Date	Revision Effective Date	Title	CPT Codes Covered in LCD
L33252	10/01/2015	07/01/2020	Psychiatric Diagnostic Evaluation and Psychotherapy Services
L33261	10/01/2015	07/11/2021	Allergy Testing
L33267	10/01/2015	01/08/2019	B-Type Natriuretic Peptide (BNP)
L33274	10/01/2015	03/21/2021	Botulinum Toxins
L33405	10/01/2015	07/01/2020	Polysomnography and Sleep Testing
L33411	10/01/2015	10/01/2019	Surgical Management of Morbid Obesity
L33583	10/01/2015	10/01/2019	Diagnostic and Therapeutic Esophagogastroduodenoscopy
L33609	10/01/2015	01/07/2021	Autonomic Function Tests
L33618	10/01/2015	01/08/2019	Major Joint Replacement (Hip and Knee)
L33667	10/01/2015	10/01/2019	Duplex Scan Of Lower Extremity Arteries
L33671	10/01/2015	03/21/2021	Diagnostic Colonoscopy
L33674	10/01/2015	01/08/2019	Duplex Scanning
L33689	10/01/2015	01/08/2019	Mohs Micrographic Surgery (MMS)
L33693	10/01/2015	01/28/2024	Peripheral Venous Ultrasound
L33695	10/01/2015	01/08/2019	Non-invasive Extracranial Arterial Studies
L33751	10/01/2015	11/28/2019	Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
L33756	10/01/2015	10/01/2019	Transesophageal Echocardiogram
L33766	10/01/2015	01/08/2019	Visual Field Examination
L33771	10/01/2015	10/29/2020	Vitamin D; 25 hydroxy, includes fraction(s), if performed
L33774	10/01/2015	07/11/2019	Wireless Capsule Endoscopy
L33813	10/01/2015	01/08/2019	Destruction of Malignant Skin Lesions
L33818	10/01/2015	01/08/2019	Excision of Malignant Skin Lesions
L33833	10/01/2015	01/30/2022	Surgical Treatment of Nails
L33906	10/01/2015	12/12/2021	Epidural Steroid Injections for Pain Management
L33907	10/01/2015	09/07/2021	Hepatic (Liver) Function Panel
L33908	10/01/2015	01/08/2019	High Sensitivity C-Reactive Protein (hsCRP)
L33912	10/01/2015	10/01/2019	Injection of Trigger Points
L33922	10/01/2015	11/28/2019	Nail Debridement
L33923	10/01/2015	10/01/2019	Noninvasive Ear or Pulse Oximetry For Oxygen Saturation
L33930	10/01/2015	08/11/2024	Facet Joint Interventions for Pain Management
L33933	10/01/2015	01/08/2019	Peripheral Nerve Blocks
L33937	10/01/2015	12/16/2019	Proton Beam Radiotherapy
L33941	10/01/2015	10/01/2019	Routine Foot Care
L33958	10/01/2015	01/08/2019	Somatosensory Testing
L33966	10/01/2015	10/01/2019	Vestibular Function Tests
L33967	10/01/2015	01/01/2021	Vitamin B₁₂ Injections
L33977	10/01/2015	10/29/2019	Transcranial Doppler Studies
L34007	10/01/2015	02/05/2023	Immune Globulin
L34011	10/01/2015	10/01/2019	Ionized Calcium
L34018	10/01/2015	09/07/2021	Parathormone (Parathyroid Hormone)
L34021	10/01/2015	01/08/2019	Sedimentation Rate, Erythrocyte
L34027	10/01/2015	01/08/2019	Ultrasound, Soft Tissues of Head and Neck
L34028	10/01/2015	03/21/2021	Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow
L34372	10/01/2015	07/01/2020	Magnetic Resonance Angiography (MRA)
L34519	10/01/2015	12/12/2021	Molecular Pathology Procedures
L34520	10/01/2015	07/01/2020	Psychological and Neuropsychological Tests
L34521	10/01/2015	01/08/2019	Special EEG Tests
L34522	10/01/2015	12/11/2022	Transcranial Magnetic Stimulation (TMS) in the Treatment of Adults with Major Depressive Disorder
L34859	10/01/2015	12/10/2023	Nerve Conduction Studies and Electromyography
L34912	10/01/2015	10/01/2019	Genetic Testing for Lynch Syndrome
L34976	10/01/2015	07/11/2021	Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
L36377	10/01/2015	01/08/2019	Application of Skin Substitute Grafts for Treatment of DFU and VLU of Lower Extremities
L36393	10/11/2015	10/01/2019	Controlled Substance Monitoring and Drugs of Abuse Testing
L36499	04/11/2016	12/10/2020	BRCA1 and BRCA2 Genetic Testing
L36767	10/31/2016	10/01/2019	Aortography and peripheral angiography
L36773	11/07/2016	07/31/2019	Intensity Modulated Radiation Therapy (IMRT)
L37166	12/07/2017	07/23/2020	Wound Care
L37398	02/02/2018	11/28/2019	Electroretinography (ERG)
L37561	02/02/2018	11/28/2019	Cystatin C Measurement
L37564	03/01/2019	07/01/2019	Frequency of Hemodialysis
L37798	03/18/2019	01/06/2020	4Kscore Test Algorithm
L37800	10/18/2018	03/31/2024	Allergen Immunotherapy
L38227	12/30/2019	10/26/2023	Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs)
L38231	12/30/2019	12/27/2020	Endovenous Stenting
L38233	12/30/2019		Micro-Invasive Glaucoma Surgery (MIGS)
L38396	03/15/2020	04/25/2021	Cardiology Non-emergent Outpatient Stress Testing
L38398	03/15/2020		Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
L38506	07/12/2020		Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor
L38664	10/11/2020	08/11/2024	Implantable Continuous Glucose Monitors (I-CGM)
L38720	12/27/2020		Treatment of Chronic Venous Insufficiency of the Lower Extremities
L38726	12/27/2020		Transurethral Waterjet Ablation of the Prostate
L38805	03/28/2021		Colon Capsule Endoscopy (CCE)
L38914	07/11/2021	07/11/2021	Cosmetic and Reconstructive Surgery
L38918	07/11/2021		Respiratory Pathogen Panel Testing
L38926	07/11/2021	07/11/2021	Cataract Extraction (including Complex Cataract Surgery)
L39071	12/12/2021	12/12/2021	Platelet Rich Plasma
L39073	12/12/2021		Pharmacogenomics Testing
L39084	01/30/2022	01/30/2022	Genetic Testing for Cardiovascular Disease
L39367	07/17/2023		Genetic Testing for Oncology
L39492	06/11/2023		Ambulatory Electrocardiograph (AECG) Monitoring

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