This Local Coverage Determination (LCD) has been revised under contractor numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, and NMI), and 01312 (NV).

Medicare Coverage Database (MCD) Number: L34203

Effective Date: October 01, 2019

Summary of Changes: Updated #1 under Sources of Information to remove broken link.

Visit the Active LCDs webpage to view the Active LCD or access it via the CMS MCD.