CodeMap® LCD-L37539

Contractor Information

Contractor Name: Wisconsin Physicians Service Insurance Corporation - Full list of policies of this Medicare Contractor

Contractor Number: 05201
Contractor Type: MAC A

LCD Information

LCD ID Number: L37539 Status: A-Approved
LCD Title: MolDX: Prometheus® IBD sgi Diagnostic® Policy
Geographic Jurisdiction: Kansas Other Jurisdictions
Original Determination Effective Date: 03/19/2018
Original Determination Ending Date:
Revision Effective Date: 02/28/2025
Revision End Date:
CMS National Coverage Policy:
Title XVIII of the Social Security Act, §1862(a)(1)(a) allows coverage and payment for only those services that are considered to be reasonable and necessary.

42 Code of Federal Regulations (CFR) §410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions

CMS Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.0 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests, §80.1.1 Certification Changes

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06/30/2025 05:33:14 216.73.216.44

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