CodeMap® CodeMap® Contractor Policy Detail

LCD	Effective Date	Revision Effective Date	Title	CPT Codes Covered in LCD
L33420	10/01/2015	01/17/2019	Lab: Bladder/Urothelial Tumor Markers	86294 86316 86386 88120 88121
L33423	10/01/2015	08/09/2018	Cardiac Computed Tomography & Angiography (CCTA)	0501T 0502T 0503T 0504T 75571 75572 75573 75574
L33428	10/01/2015	10/01/2018	Cosmetic and Reconstructive Surgery	15730 15733 15780 15781 15782 15783 15830 15847 19316 19318 19318 19324 19325 19328 19330 19340 19342 19350 19355 19357 19361 19364 19366 19367 19368 19369 19370 19371 19380 19396 21076 21077 21079 21080 21081 21082 21083 21084 21086 21087 and more.....
L33445	10/01/2015	01/01/2019	Removal of Benign and Malignant Skin Lesions	XX000
L33456	10/01/2015	10/26/2018	Total Joint Arthroplasty	27130 27132 27132 27134 27137 27138 27445 27447 27486 27487
L33457	10/01/2015	11/08/2018	Cardiac Radionuclide Imaging	78451 78452 78453 78454 78472 78473 78481 78483 78491 78492 78494 78496 A4641 A9500 A9501 A9502 A9505 A9526 A9555 J0153 J0280 J0461 J1245 J1250
L33459	10/01/2015	10/01/2018	Computerized Axial Tomography (CT), Thorax	71250 71260 71270
L33467	10/01/2015	03/15/2018	Ophthalmology: Extended Ophthalmoscopy and Fundus Photography	92225 92226 92227 92228 92250
L34410	10/01/2015	10/01/2018	B-type Natriuretic Peptide (BNP) Testing	83880
L34411	10/01/2015	03/14/2019	Blepharoplasty, Eyelid Surgery, and Brow Lift	15820 15821 15822 15823 67900 67901 67902 67903 67904 67906 67908 67909 67911 67912 67914 67915 67916 67917 67921 67922 67923 67924
L34412	10/01/2015	02/04/2019	Cardiac Rehabilitation	93797 93798 G0422 G0423
L34413	10/01/2015	02/26/2018	Cataract Surgery	66830 66840 66850 66852 66920 66940 66982 66983 66984
L34415	10/01/2015	10/01/2018	CT of the Abdomen and Pelvis	72192 72193 72194 74150 74160 74170 74176 74177 74178
L34417	10/01/2015	10/01/2018	CT of the Head	70450 70460 70470
L34419	10/01/2015	10/01/2018	Homocysteine Level, Serum	83090
L34422	10/01/2015	02/08/2018	Infrared Coagulation (IRC) of Hemorrhoids	46930
L34424	10/01/2015	10/01/2018	Magnetic Resonance Angiography	70544 70545 70546 70547 70548 70549 C8900 C8901 C8902 C8909 C8910 C8911 C8912 C8913 C8914 C8918 C8919 C8920 C8934 C8935 C8936
L34425	10/01/2015	10/01/2018	Magnetic Resonance Imaging of the Orbit, Face, and/or Neck	70540 70542 70543
L34426	10/01/2015	07/05/2018	Ophthalmic Angiography (Fluorescein and Indocyanine Green)	92235 92240 92242
L34427	10/01/2015	01/01/2019	Outpatient Occupational Therapy	29065 29075 29085 29086 29105 29125 29126 29130 29131 29200 29240 29260 29280 29345 29365 29405 29505 29515 29520 29530 29540 29550 29799 90901 90911 92526 92548 92610 95831 95832 95833 95834 95851 95852 96112 96113 96125 97010 97012 97016 and more.....
L34428	10/01/2015	01/01/2019	Outpatient Physical Therapy	29065 29075 29085 29105 29125 29126 29130 29131 29200 29240 29260 29280 29345 29365 29405 29445 29505 29515 29520 29530 29540 29550 29580 29799 90901 90911 92548 95831 95832 95833 95834 95851 95852 95992 97010 97012 97016 97018 97022 97024 and more.....
L34429	10/01/2015	01/01/2019	Outpatient Speech Language Pathology	31579 92507 92508 92511 92512 92520 92521 92522 92523 92524 92526 92597 92605 92606 92607 92608 92609 92610 92611 92612 92613 92614 92615 92616 92617 92618 92626 92627 92630 92633 95857 96105 96112 96113 96116 96121 96125 97150 97533 97535 and more.....
L34430	10/01/2015	10/01/2018	Respiratory Therapy (Respiratory Care)	31500 31502 31720 92950 94002 94003 94004 94010 94011 94012 94013 94060 94070 94150 94200 94250 94375 94400 94450 94621 94640 94642 94660 94662 94664 94667 94668 94669 94726 94727 94728 94729 94750 94772 G0237 G0238 G0239
L34431	10/01/2015	05/16/2018	Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)	92132 92133 92134
L34433	10/01/2015	04/12/2018	Somatosensory Testing	95925 95926 95927
L34434	10/01/2015	10/01/2018	Upper Gastrointestinal Endoscopy and Visualization	43191 43192 43193 43194 43195 43196 43197 43198 43200 43201 43202 43204 43205 43206 43210 43211 43212 43213 43214 43215 43216 43217 43220 43226 43227 43229 43231 43232 43233 43235 43236 43237 43238 43239 43240 43241 43242 43243 43244 43245 and more.....
L34454	10/01/2015	03/14/2019	Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy	44388 44389 44390 44391 44392 44394 44401 44402 45300 45303 45305 45307 45308 45309 45315 45317 45320 45321 45327 45330 45331 45332 45333 45334 45335 45337 45338 45340 45341 45342 45346 45347 45349 45378 45379 45380 45381 45382 45384 45385 and more.....
L34512	10/01/2015	02/26/2018	Corneal Pachymetry	76514
L34513	10/01/2015	01/17/2019	Lab: Flow Cytometry	86355 86356 86357 86359 86360 86361 86367 88182 88184 88185 88187 88188 88189
L34549	10/01/2015	05/31/2018	Ambulance Services	A0425 A0426 A0427 A0428 A0429 A0430 A0431 A0432 A0433 A0434 A0435 A0436
L34551	10/01/2015	05/24/2018	One Day Stays for Chest Pain	XX000
L34552	10/01/2015	06/28/2018	Outpatient Observation Bed/Room Services	99217 99218 99219 99220 99234 99235 99236 G0378 G0379
L34553	10/01/2015	01/29/2018	Stretta Procedure	43257
L34554	10/01/2015	09/10/2018	In Vitro Chemosensitivity & Chemoresistance Assays	84999 89240
L34555	10/01/2015	01/01/2019	Non-Covered Category III CPT Codes	0042T 0058T 0071T 0072T 0095T 0098T 0101T 0102T 0106T 0107T 0108T 0109T 0110T 0111T 0126T 0163T 0165T 0174T 0175T 0184T 0198T 0200T 0201T 0202T 0205T 0206T 0207T 0208T 0209T 0210T 0211T 0212T 0213T 0214T 0215T 0216T 0217T 0218T 0219T 0220T and more.....
L34570	10/01/2015	10/01/2018	Psychiatric Inpatient Hospitalization	XX000
L34573	10/01/2015	03/07/2019	Cardiac Event Detection	93228 93229 93268 93270 93271 93272 93799
L34574	10/01/2015	02/08/2018	Dental Services	41820 41821 41822 41823 41828 41830 41850 41870 41872 41874 41899
L34575	10/01/2015	03/01/2019	Frequency of Hemodialysis	90999
L34576	10/01/2015	10/01/2018	Laparoscopic Sleeve Gastrectomy for Severe Obesity	43775
L34577	10/01/2015	10/01/2018	Retroperitoneal Ultrasound	76770 76775 76776
L34578	10/01/2015	03/15/2018	Surface Electrical Stimulation in the Treatment of Dysphagia	XX000
L34580	10/01/2015	07/26/2018	Intravenous Immunoglobulin (IVIG)	J1459 J1556 J1557 J1561 J1566 J1568 J1569 J1572 J1599 J2791 J2792
L35024	10/01/2015	09/03/2018	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
L35025	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.....
L35026	10/01/2015	03/14/2019	Rituximab (Rituxan®)	XX000
L35048	10/01/2015	10/01/2018	Nerve Conduction Studies and Electromyography	51785 92265 95860 95861 95863 95864 95865 95866 95867 95868 95869 95870 95872 95885 95886 95887 95905 95907 95908 95909 95910 95911 95912 95913 95933 95937 95999 G0255
L35071	10/01/2015	09/24/2018	MolDX: Circulating Tumor Cell Marker Assays	86152 86153
L35072	10/01/2015	10/01/2018	MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing	0070U 81225 81226 81227 81355 81479
L35073	10/01/2015	02/26/2018	MolDX: NRAS Genetic Testing	81311 81479
L35631	10/01/2015	01/01/2019	MolDX: Breast Cancer Index℠ Genetic Assay	81518
L35632	10/01/2015	09/03/2018	MolDX: ConfirmMDx Epigenetic Molecular Assay	81551
L35633	10/01/2015	07/30/2018	MolDX: GeneSight® Assay for Refractory Depression	81479
L35677	10/01/2015	02/07/2019	Infliximab	J1745 Q5103 Q5104 Q5109
L35724	10/01/2015	12/27/2018	Lab: Controlled Substance Monitoring and Drugs of Abuse Testing	80305 80306 80307 G0480 G0481 G0482 G0483 G0659
L35868	10/01/2015	09/10/2018	MolDX: Decipher® Prostate Cancer Classifier Assay	81479
L35869	10/01/2015	10/15/2018	MolDX: Prolaris™ Prostate Cancer Genomic Assay	81541
L35922	10/01/2015	01/17/2019	Lab: Special Histochemical Stains and Immunohistochemical Stains	88312 88313 88341 88342 88344 88360 88361
L35974	10/01/2015	02/26/2018	MolDX: MGMT Promoter Methylation Analysis	81287
L36033	10/05/2015	12/06/2018	MolDX: HLA-B*15:02 Genetic Testing	81381
L36044	10/05/2015	08/16/2018	MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease	81206 81207 81208 81219 81270 81402 81403 81445 81450 81455 81479
L36074	10/01/2015	02/26/2018	MolDX: Molecular RBC Phenotyping	0001U
L36082	10/05/2015	01/01/2019	MolDX: BRCA1 and BRCA2 Genetic Testing	81162 81163 81164 81165 81166 81167 81212 81215 81216 81217 81432 81445 81455 81479
L36089	10/01/2015	05/17/2018	MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)	81240 81241 81291
L36109	10/01/2015	07/26/2018	Minimally Invasive Treatment for Benign Prostatic Hyperplasia Involving Prostatic Urethral Lift (Urolift®)	52441 52442 C9739 C9740 L8699
L36125	10/01/2015	02/26/2018	MolDX: Breast Cancer Assay: Prosigna	81520
L36129	10/05/2015	01/31/2019	MolDX: Biomarkers in Cardiovascular Risk Assessment	82172 82610 83090 83695 83698 83700 83701 83704 83719 83721 86141
L36153	10/01/2015	10/01/2018	MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay	0047U
L36427	01/25/2016	04/19/2018	Wireless Capsule Endoscopy	91110 91111
L36464	02/15/2016	02/27/2018	MolDX: HLA-DQB1*06:02 Testing for Narcolepsy	81383
L36471	02/15/2016	02/26/2018	Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy	64490 64491 64492 64493 64494 64495 64633 64634 64635 64636
L36593	06/13/2016	01/01/2019	Polysomnography	95782 95783 95800 95801 95803 95805 95806 95807 95808 95810 95811 G0398 G0399 G0400
L36665	10/10/2016	10/08/2018	MolDX: ProMark Risk Score	81479
L36761	10/17/2016	09/24/2018	GlycoMark Testing for Glycemic Control	84378 84999
L36763	11/21/2016	02/26/2018	MolDX: 4Kscore Assay	81539
L36827	03/13/2017	03/08/2018	MolDX: APC and MUTYH Gene Testing	81201 81202 81203 81401 81403 81406 81435 81479
L36854	03/13/2017	02/26/2018	MolDX: Percepta© Bronchial Genomic Classifier	81479
L36912	03/06/2017	10/01/2018	MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)	0045U
L36954	06/05/2017	01/01/2019	Noncovered Services other than CPT® Category III Noncovered Services	01990 15824 15825 15826 15828 15829 15876 15877 15878 15879 17380 19105 20985 21073 21811 22586 22857 22858 22861 22862 22865 28035 28446 28890 29868 32998 41530 43257 46707 53860 58321 58322 58323 58670 58671 58970 58974 58976 59012 62263 and more.....
L37022	07/10/2017	01/10/2019	Lab: Coenzyme Q10 (CoQ10)	XX000
L37031	07/10/2017	01/01/2019	MolDX: BDX-XL2	0080U
L37033	07/10/2017	02/21/2019	MolDX: DecisionDx-UM (Uveal Melanoma)	0081U
L37043	07/10/2017	02/27/2018	MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease	81541
L37176	06/12/2017	01/01/2019	White Cell Colony Stimulating Factors	J1442 J1447 J2505 J2820 Q5101 Q5108 Q5110 Q5111
L37260	09/26/2017	08/09/2018	MolDX: Prometheus IBD sgi Diagnostic Policy	81479 82397 83520 86140
L37262	10/02/2017	01/01/2019	MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer	0047U
L37264	10/02/2017	01/10/2019	MolDX: EndoPredict Breast Cancer Gene Expression Test	81599
L37266	10/02/2017	02/26/2018	MolDX: AlloSure® Donor-Derived Cell-Free DNA Test	81479
L37379	09/18/2017	01/01/2019	Echocardiography	93303 93304 93306 93307 93308 93312 93313 93314 93315 93316 93317 93318 93320 93321 93325 93350 93351 93352 93355 A9700 J0153 J0280 J0461 J1245 J1250
L37531	12/24/2018		Micro-Invasive Glaucoma Surgery (MIGS)	0191T 0376T 0449T 0450T
L37581	12/03/2018		MolDX: Cystatin C Measurement	82610
L37602	04/08/2019		MolDX: MDS FISH	88271 88273 88274 88275 88291
L37612	11/05/2018		MolDX: Corus® CAD Assay	81493
L37632	01/29/2018	01/01/2019	Spinal Cord Stimulators for Chronic Pain	63650 63655 63661 63662 63663 63664 63685 63688 95970 95971 95972 L8680
L37633	01/29/2018	01/01/2019	Partial Hospitalization Programs	90785 90791 90792 90832 90833 90834 90836 90837 90838 90846 90847 90875 90876 90899 96116 96130 96131 96132 96133 96136 96137 96138 96139 G0129 G0176 G0177 G0410 G0411
L37638	01/29/2018	09/13/2018	Health and Behavior Assessment/Intervention	96150 96151 96152 96153 96154 96155
L37641	01/29/2018	03/14/2019	Continuous Peripheral Nerve Blocks (CPNB)	64416 64446 64448 64449
L37642	01/29/2018	02/26/2018	Nerve Blocks and Electrostimulation for Peripheral Neuropathy	64450 97032 97139 G0282 G0283
L37643	01/29/2018	12/13/2018	Routine Foot Care	11055 11056 11057 11719 11720 11721 G0127
L37644	01/29/2018	02/26/2018	YAG Capsulotomy	66821
L37699	08/27/2018	08/30/2018	MolDX: Guardant360® Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC)	81479
L37701	12/10/2018		MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC)	81479
L37709	12/10/2018	12/27/2018	Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs)	87505 87506 87507
L37713	11/12/2018		MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels	87631 87632 87633
L37725	12/03/2018		MolDX: DecisionDx-Melanoma	81599
L37761	09/24/2018		Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor	0398T
L37774	11/19/2018	03/14/2019	Supervised Exercise Therapy for the Treatment of Peripheral Arterial Disease with Symptomatic Lower Extremity Intermittent Claudication	XX000
L37779	09/24/2018	09/24/2018	Intraoperative Radiation Therapy	19294 77424 77425 77469 C9726
L37785	04/01/2019		MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease	81479
L37794	03/11/2019	03/11/2019	MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test	81518
L37857	04/01/2019		MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test	81479
L37859	04/29/2019		MolDX: myPath Melanoma Assay	81479
L37870	04/08/2019		MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer	81479

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