This Local Coverage Determination (LCD) has been revised under contractor numbers: 02102 (AK), 02202 (ID), 02302 (OR), 02402 (WA), 03102 (AZ), 03202 (MT), 03302 (ND), 03402 (SD), 03502 (UT), and 03602 (WY).

Medicare Coverage Database (MCD) Number: L37027

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.