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All LCDs Laboratory LCDs Radiology LCDs
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 03/21/2019 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 05/09/2019 Cardiac Radionuclide Imaging XX000
L33459 10/01/2015 05/16/2019 Computerized Axial Tomography (CT), Thorax XX000
L33467 10/01/2015 03/15/2018 Ophthalmology: Extended Ophthalmoscopy and Fundus Photography 92225 92226 92227 92228 92250
L34410 10/01/2015 04/11/2019 B-type Natriuretic Peptide (BNP) Testing 83880
L34411 10/01/2015 04/18/2019 Blepharoplasty, Eyelid Surgery, and Brow Lift XX000
L34413 10/01/2015 02/26/2018 Cataract Surgery 66830 66840 66850 66852 66920 66940 66982 66983 66984
L34415 10/01/2015 03/28/2019 CT of the Abdomen and Pelvis XX000
L34417 10/01/2015 10/01/2018 CT of the Head 70450 70460 70470
L34419 10/01/2015 04/11/2019 Homocysteine Level, Serum 83090
L34422 10/01/2015 05/09/2019 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 05/09/2019 Upper Gastrointestinal Endoscopy and Visualization XX000
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 04/11/2019 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 05/09/2019 Ambulance Services XX000
L34551 10/01/2015 05/24/2018 One Day Stays for Chest Pain XX000
L34552 10/01/2015 04/11/2019 Outpatient Observation Bed/Room Services 99217 99218 99219 99220 99234 99235 99236 G0378 G0379
L34553 10/01/2015 04/25/2019 Stretta Procedure 43257
L34554 10/01/2015 09/10/2018 In Vitro Chemosensitivity & Chemoresistance Assays 84999 89240
L34555 10/01/2015 05/05/2019 Non-Covered Category III CPT Codes XX000
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 05/09/2019 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
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 04/11/2019 Infliximab XX000
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 05/09/2019 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 05/05/2019 Noncovered Services other than CPT® Category III Noncovered Services XX000
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 03/21/2019 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 03/28/2019 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 05/16/2019 Health and Behavior Assessment/Intervention XX000
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 04/11/2019 Intraoperative Radiation Therapy 19294 77424 77425 77469 C9726
L37785 04/01/2019 05/09/2019 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
L37826 05/06/2019 Lumbar Artificial Disc Replacement XX000
L37848 05/06/2019 05/06/2019 Lumbar Spinal Fusion XX000
L37857 04/01/2019 MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test 81479
L37859 04/29/2019 MolDX: myPath Melanoma Assay 81479
L37863 05/06/2019 05/06/2019 Voretigene Neparvovec-rzyl (Luxturna™) XX000
L37870 04/08/2019 04/08/2019 MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer 81479
L37873 05/06/2019 05/06/2019 Topical Oxygen Therapy XX000



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