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LCD
Effective
Date
Revision
Effective
Date
Title
CPT Codes Covered in Policy
L33420 10/01/2015 08/30/2018 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 11/26/2018 Removal of Benign and Malignant Skin Lesions 11300 11301 11302 11303 11305 11306 11307 11308 11310 11311 11312 11313 11400 11401 11402 11403 11404 11406 11420 11421 11422 11423 11424 11426 11440 11441 11442 11443 11444 11446 11600 11601 11602 11603 11604 11606 11620 11621 11622 11623 and more.....
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 10/01/2018 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 03/08/2018 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 10/01/2018 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 64550 90901 90911 92526 92548 92610 95831 95832 95833 95834 95851 95852 96111 96125 97010 97012 97016 and more.....
L34428 10/01/2015 10/01/2018 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 64550 90901 90911 92548 95831 95832 95833 95834 95851 95852 95992 97010 97012 97016 97018 97022 and more.....
L34429 10/01/2015 10/01/2018 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 96111 96116 96125 97150 97533 97535 G0515
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 10/01/2018 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 10/01/2018 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 09/27/2018 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 0188T 0189T 0190T 0198T 0200T 0201T 0202T 0205T 0206T 0207T 0208T 0209T 0210T 0211T 0212T 0213T 0214T 0215T 0216T 0217T and more.....
L34570 10/01/2015 10/01/2018 Psychiatric Inpatient Hospitalization XX000
L34573 10/01/2015 10/01/2018 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 01/29/2018 Frequency of Dialysis 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 10/01/2018 MolDX: Molecular Diagnostic Tests (MDT) 0001M 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 and more.....
L35026 10/01/2015 06/13/2018 Rituximab (Rituxan®) C9467 J9310
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 81225 81226 81227 81355 81479
L35073 10/01/2015 02/26/2018 MolDX: NRAS Genetic Testing 81311 81479
L35631 10/01/2015 09/10/2018 MolDX: Breast Cancer Index℠ Genetic Assay 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 08/06/2018 Infliximab J1745 Q5103 Q5104
L35724 10/01/2015 10/01/2018 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 02/26/2018 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 04/12/2018 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 08/23/2018 MolDX: BRCA1 and BRCA2 Genetic Testing 81162 81211 81212 81213 81214 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 10/01/2018 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
L36466 05/17/2016 03/29/2018 Application of Skin Substitutes 15002 15003 15004 15005 15040 15050 15271 15272 15273 15274 15275 15276 15277 15278 C5271 C5272 C5273 C5274 C5275 C5276 C5277 C5278
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 04/26/2018 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 05/07/2018 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 04/12/2018 Coenzyme Q10 (CoQ10) XX000
L37031 07/10/2017 11/08/2018 MolDX: BDX-XL2 81599
L37033 07/10/2017 02/26/2018 MolDX: DecisionDx-UM (Uveal Melanoma) 81599
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 10/18/2018 White Cell Colony Stimulating Factors J1442 J1447 J2505 J2820 Q5101 Q5108 Q5110
L37260 09/26/2017 08/09/2018 MolDX: Prometheus IBD sgi Diagnostic Policy 81479 82397 83520 86140
L37262 10/02/2017 08/16/2018 MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer 81479
L37264 10/02/2017 08/16/2018 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 10/01/2018 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
L37612 11/05/2018 MolDX: Corus® CAD Assay 81493
L37632 01/29/2018 02/26/2018 Spinal Cord Stimulators for Chronic Pain 63650 63655 63661 63662 63663 63664 63685 63688 95970 95971 95972 L8680
L37633 01/29/2018 10/18/2018 Partial Hospitalization Programs 90785 90791 90792 90832 90833 90834 90836 90837 90838 90846 90847 90875 90876 90899 96101 96102 96103 96116 96118 96119 96120 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 02/26/2018 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 02/26/2018 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 MolDX: 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 Supervised Exercise Therapy for the Treatment of Peripheral Arterial Disease with Symptomatic Lower Extremity Intermittent Claudication 93668
L37779 09/24/2018 09/24/2018 Intraoperative Radiation Therapy 19294 77424 77425 77469 C9726



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