| LCD |
Effective
Date |
Revision
Effective
Date |
Title |
CPT Codes Covered in LCD |
|
L33420
|
10/01/2015
|
03/04/2021
|
Lab: Bladder/Urothelial Tumor Markers
|
|
|
L33423
|
10/01/2015
|
10/24/2019
|
Cardiac Computed Tomography & Angiography (CCTA)
|
|
|
L33428
|
10/01/2015
|
10/24/2019
|
Cosmetic and Reconstructive Surgery
|
|
|
L33445
|
10/01/2015
|
10/24/2019
|
Removal of Benign and Malignant Skin Lesions
|
|
|
L33456
|
10/01/2015
|
10/24/2019
|
Total Joint Arthroplasty
|
|
|
L33457
|
10/01/2015
|
10/10/2019
|
Cardiac Radionuclide Imaging
|
|
|
L33459
|
10/01/2015
|
10/10/2019
|
Computerized Axial Tomography (CT), Thorax
|
|
|
L33467
|
10/01/2015
|
01/01/2021
|
Ophthalmology: Extended Ophthalmoscopy and Fundus Photography
|
|
|
L34410
|
10/01/2015
|
01/14/2021
|
B-type Natriuretic Peptide (BNP) Testing
|
|
|
L34411
|
10/01/2015
|
10/10/2019
|
Blepharoplasty, Eyelid Surgery, and Brow Lift
|
|
|
L34413
|
10/01/2015
|
10/10/2019
|
Cataract Surgery
|
|
|
L34415
|
10/01/2015
|
10/10/2019
|
CT of the Abdomen and Pelvis
|
|
|
L34417
|
10/01/2015
|
10/10/2019
|
CT of the Head
|
|
|
L34419
|
10/01/2015
|
10/24/2019
|
Homocysteine Level, Serum
|
|
|
L34422
|
10/01/2015
|
10/24/2019
|
Infrared Coagulation (IRC) of Hemorrhoids
|
|
|
L34424
|
10/01/2015
|
10/24/2019
|
Magnetic Resonance Angiography
|
|
|
L34425
|
10/01/2015
|
11/05/2020
|
Magnetic Resonance Imaging of the Orbit, Face, and/or Neck
|
|
|
L34426
|
10/01/2015
|
10/24/2019
|
Ophthalmic Angiography (Fluorescein and Indocyanine Green)
|
|
|
L34427
|
10/01/2015
|
03/25/2021
|
Outpatient Occupational Therapy
|
|
|
L34428
|
10/01/2015
|
03/25/2021
|
Outpatient Physical Therapy
|
|
|
L34429
|
10/01/2015
|
06/25/2020
|
Outpatient Speech Language Pathology
|
|
|
L34430
|
10/01/2015
|
10/24/2019
|
Respiratory Therapy (Respiratory Care)
|
|
|
L34431
|
10/01/2015
|
10/24/2019
|
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
|
|
|
L34433
|
10/01/2015
|
10/24/2019
|
Somatosensory Testing
|
|
|
L34434
|
10/01/2015
|
10/24/2019
|
Upper Gastrointestinal Endoscopy and Visualization
|
|
|
L34454
|
10/01/2015
|
10/10/2019
|
Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
|
|
|
L34512
|
10/01/2015
|
06/18/2020
|
Corneal Pachymetry
|
|
|
L34513
|
10/01/2015
|
04/08/2021
|
Lab: Flow Cytometry
|
|
|
L34549
|
10/01/2015
|
10/10/2019
|
Ambulance Services
|
|
|
L34551
|
10/01/2015
|
02/20/2020
|
One Day Stays for Chest Pain
|
|
|
L34552
|
10/01/2015
|
10/31/2019
|
Outpatient Observation Bed/Room Services
|
|
|
L34553
|
10/01/2015
|
12/27/2020
|
Stretta Procedure
|
|
|
L34554
|
10/01/2015
|
02/25/2021
|
In Vitro Chemosensitivity & Chemoresistance Assays
|
|
|
L34570
|
10/01/2015
|
10/31/2019
|
Psychiatric Inpatient Hospitalization
|
|
|
L34573
|
10/01/2015
|
10/10/2019
|
Cardiac Event Detection
|
|
|
L34574
|
10/01/2015
|
10/10/2019
|
Dental Services
|
|
|
L34575
|
10/01/2015
|
12/10/2020
|
Frequency of Hemodialysis
|
|
|
L34576
|
10/01/2015
|
12/10/2020
|
Laparoscopic Sleeve Gastrectomy for Severe Obesity
|
|
|
L34577
|
10/01/2015
|
11/07/2019
|
Retroperitoneal Ultrasound
|
|
|
L34578
|
10/01/2015
|
11/21/2019
|
Surface Electrical Stimulation in the Treatment of Dysphagia
|
|
|
L34580
|
10/01/2015
|
10/04/2020
|
Intravenous Immunoglobulin (IVIG)
|
|
|
L35024
|
10/01/2015
|
01/07/2021
|
MolDX: Genetic Testing for Lynch Syndrome
|
|
|
L35025
|
10/01/2015
|
12/12/2019
|
MolDX: Molecular Diagnostic Tests (MDT)
|
|
|
L35026
|
10/01/2015
|
11/28/2019
|
Rituximab
|
|
|
L35048
|
10/01/2015
|
10/10/2019
|
Nerve Conduction Studies and Electromyography
|
|
|
L35071
|
10/01/2015
|
10/31/2019
|
MolDX: Circulating Tumor Cell Marker Assays
|
|
|
L35073
|
10/01/2015
|
11/07/2019
|
MolDX: NRAS Genetic Testing
|
|
|
L35632
|
10/01/2015
|
12/17/2020
|
MolDX: ConfirmMDx Epigenetic Molecular Assay
|
|
|
L35677
|
10/01/2015
|
10/31/2019
|
Infliximab
|
|
|
L35724
|
10/01/2015
|
04/08/2021
|
Lab: Controlled Substance Monitoring and Drugs of Abuse Testing
|
|
|
L35869
|
10/01/2015
|
10/31/2019
|
MolDX: Prolaris™ Prostate Cancer Genomic Assay
|
|
|
L35922
|
10/01/2015
|
12/24/2020
|
Lab: Special Histochemical Stains and Immunohistochemical Stains
|
|
|
L35974
|
10/01/2015
|
11/21/2019
|
MolDX: MGMT Promoter Methylation Analysis
|
|
|
L36044
|
10/05/2015
|
11/07/2019
|
MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease
|
|
|
L36082
|
10/05/2015
|
12/04/2019
|
MolDX: BRCA1 and BRCA2 Genetic Testing
|
|
|
L36089
|
10/01/2015
|
10/31/2019
|
MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)
|
|
|
L36125
|
10/01/2015
|
11/21/2019
|
MolDX: Breast Cancer Assay: Prosigna
|
|
|
L36129
|
10/05/2015
|
11/07/2019
|
MolDX: Biomarkers in Cardiovascular Risk Assessment
|
|
|
L36427
|
01/25/2016
|
10/24/2019
|
Wireless Capsule Endoscopy
|
|
|
L36464
|
02/15/2016
|
10/31/2019
|
MolDX: HLA-DQB1*06:02 Testing for Narcolepsy
|
|
|
L36471
|
02/15/2016
|
10/10/2019
|
Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
|
|
|
L36593
|
06/13/2016
|
12/03/2020
|
Polysomnography
|
|
|
L36665
|
10/10/2016
|
11/07/2019
|
MolDX: ProMark Risk Score
|
|
|
L36761
|
10/17/2016
|
03/04/2021
|
GlycoMark® Testing for Glycemic Control
|
|
|
L36763
|
11/21/2016
|
04/01/2021
|
MolDX: 4Kscore® Assay
|
|
|
L36827
|
03/13/2017
|
04/01/2021
|
MolDX: APC and MUTYH Gene Testing
|
|
|
L36854
|
03/13/2017
|
10/31/2019
|
MolDX: Percepta® Bronchial Genomic Classifier
|
|
|
L36912
|
03/06/2017
|
10/31/2019
|
MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)
|
|
|
L37022
|
07/10/2017
|
02/25/2021
|
Lab: Coenzyme Q10 (CoQ10)
|
|
|
L37031
|
07/10/2017
|
11/19/2020
|
MolDX: BDX-XL2
|
|
|
L37033
|
07/10/2017
|
10/31/2019
|
MolDX: DecisionDx-UM (Uveal Melanoma)
|
|
|
L37043
|
07/10/2017
|
10/31/2019
|
MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease
|
|
|
L37176
|
06/12/2017
|
10/10/2019
|
White Cell Colony Stimulating Factors
|
|
|
L37260
|
09/26/2017
|
02/25/2021
|
MolDX: Prometheus IBD sgi Diagnostic® Policy
|
|
|
L37264
|
10/02/2017
|
11/07/2019
|
MolDX: EndoPredict Breast Cancer Gene Expression Test
|
|
|
L37379
|
09/18/2017
|
10/10/2019
|
Echocardiography
|
|
|
L37531
|
12/24/2018
|
02/10/2020
|
Micro-Invasive Glaucoma Surgery (MIGS)
|
|
|
L37581
|
12/03/2018
|
12/10/2020
|
MolDX: Cystatin C Measurement
|
|
|
L37602
|
04/08/2019
|
10/31/2019
|
MolDX: MDS FISH
|
|
|
L37612
|
11/05/2018
|
11/21/2019
|
MolDX: Corus® CAD Assay
|
|
|
L37632
|
01/29/2018
|
12/10/2020
|
Spinal Cord Stimulators for Chronic Pain
|
|
|
L37633
|
01/29/2018
|
08/06/2020
|
Partial Hospitalization Programs
|
|
|
L37638
|
01/29/2018
|
10/10/2019
|
Health and Behavior Assessment/Intervention
|
|
|
L37641
|
01/29/2018
|
10/10/2019
|
Continuous Peripheral Nerve Blocks (CPNB)
|
|
|
L37642
|
01/29/2018
|
10/10/2019
|
Nerve Blocks and Electrostimulation for Peripheral Neuropathy
|
|
|
L37643
|
01/29/2018
|
12/05/2019
|
Routine Foot Care
|
|
|
L37644
|
01/29/2018
|
05/28/2020
|
YAG Capsulotomy
|
|
|
L37701
|
12/10/2018
|
11/01/2020
|
MolDX: Androgen Receptor Variant (AR-V7) Protein Test
|
|
|
L37709
|
12/10/2018
|
03/04/2021
|
Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs)
|
|
|
L37713
|
11/12/2018
|
11/02/2019
|
MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels
|
|
|
L37725
|
12/03/2018
|
12/10/2020
|
MolDX: Melanoma Risk Stratification Molecular Testing
|
|
|
L37761
|
09/24/2018
|
08/13/2020
|
Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor
|
|
|
L37774
|
11/19/2018
|
10/24/2019
|
Supervised Exercise Therapy for the Treatment of Peripheral Arterial Disease with Symptomatic Lower Extremity Intermittent Claudication
|
|
|
L37779
|
09/24/2018
|
10/10/2019
|
Intraoperative Radiation Therapy
|
|
|
L37794
|
03/11/2019
|
05/02/2021
|
MolDX: Breast Cancer Index® (BCI) Gene Expression Test
|
|
|
L37826
|
05/06/2019
|
10/24/2019
|
Lumbar Artificial Disc Replacement
|
|
|
L37848
|
05/06/2019
|
07/30/2020
|
Lumbar Spinal Fusion
|
|
|
L37857
|
04/01/2019
|
10/24/2019
|
MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test
|
|
|
L37859
|
04/29/2019
|
10/31/2019
|
MolDX: myPath Melanoma Assay
|
|
|
L37863
|
05/06/2019
|
05/28/2020
|
Voretigene Neparvovec-rzyl (Luxturna®)
|
|
|
L37870
|
04/08/2019
|
03/05/2020
|
MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer
|
|
|
L37873
|
05/06/2019
|
04/08/2021
|
Topical Oxygen Therapy
|
|
|
L38026
|
10/21/2019
|
02/13/2020
|
Corneal Hysteresis
|
|
|
L38033
|
10/28/2019
|
10/28/2019
|
Cervical Disc Replacement
|
|
|
L38039
|
11/25/2019
|
|
MolDX: TruGraf Blood Gene Expression Test
|
|
|
L38041
|
02/03/2020
|
12/10/2020
|
MolDX: Prospera™
|
|
|
L38043
|
02/03/2020
|
03/05/2020
|
MolDX: Plasma-Based Genomic Profiling in Solid Tumors
|
|
|
L38045
|
02/10/2020
|
03/05/2020
|
MolDX: Next-Generation Sequencing for Solid Tumors
|
|
|
L38047
|
02/10/2020
|
03/05/2020
|
MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies
|
|
|
L38051
|
02/10/2020
|
|
MolDX: Pigmented Lesion Assay
|
|
|
L38238
|
06/14/2020
|
|
MolDX: Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer
|
|
|
L38240
|
10/25/2020
|
12/10/2020
|
MolDX: Blood Product Molecular Antigen Typing
|
|
|
L38255
|
11/15/2020
|
|
MolDX: AlloSure® or Equivalent Cell-Free DNA Testing for Kidney and Heart Allografts
|
|
|
L38274
|
05/31/2020
|
|
MolDX: Repeat Germline Testing
|
|
|
L38276
|
06/21/2020
|
|
Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
|
|
|
L38278
|
11/22/2020
|
|
Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic Heart Disease
|
|
|
L38290
|
10/18/2020
|
|
MolDX: Minimal Residual Disease Testing for Colorectal Cancer
|
|
|
L38292
|
11/08/2020
|
|
MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease
|
|
|
L38294
|
07/26/2020
|
|
MolDX: Pharmacogenomics Testing
|
|
|
L38549
|
12/27/2020
|
|
Transurethral Waterjet Ablation of the Prostate
|
|
|
L38551
|
10/11/2020
|
|
Transanal Endoscopic Surgery (TES)
|
|
|
L38743
|
04/18/2021
|
|
Implantable Continuous Glucose Monitors (I-CGM)
|
|
|
L38745
|
02/07/2021
|
|
Platelet Rich Plasma
|
|
|
L38747
|
02/28/2021
|
|
Peroral Endoscopic Myotomy (POEM)
|
|
|
L38755
|
04/12/2021
|
|
Colon Capsule Endoscopy (CCE)
|
|
|
L38765
|
04/25/2021
|
|
Facet Joint Interventions for Pain Management
|
|
|
L38769
|
02/07/2021
|
|
Computed Tomography Cerebral Perfusion Analysis (CTP)
|
|
|
L38775
|
02/14/2021
|
|
Extracorporeal Shock Wave Therapy (ESWT)
|
|
|
L38786
|
02/07/2021
|
|
Echocardiography for Myocardial Perfusion
|
|
|
L38792
|
02/07/2021
|
|
Dexamethasone Intracanalicular Ophthalmic Insert (Dextenza®)
|
|
