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LCD Title LCD Number Billing and Coding Companion Article CPT / HCPCS Codes Referenced
Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin L39398 A59177 38240
B-type Natriuretic Peptide (BNP) Testing L34038 A57084 83880
BDX-XL2 L37062 A57357 0080U
Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs) L33979* A57162 11200, 11201, 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, 17110, 17111
Blepharoplasty Eyelid Surgery, and Brow Lift L36286 A57191 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909,
Botulinum Toxin Types A and B L35172 A57186 J0585, J0586, J0587, J0588, 31513, 31570, 43201, 43236, 43499, 46505, 52287, 64611, 64612, 64615, 64616, 64617, 64640, 64642, 64643, 64644, 64645, 64646, 64647, 64650, 64653, 64999, 67345, 95873, 95874
Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography L36889 A57184 93015, 93016, 93017, 93018, 93320, 93321, 93325, 93350, 93351, 93352, J0153, J0395, J1245, J1250, J3490
Cataract Surgery in Adults L37027 A57196 66830, 66840, 66850, 66852, 66920, 66940, 66982, 66983, 66984, 66987, 66988
Chest X-Ray Policy L37549 A57498 71045, 71046, 71047, 71048
Colon Capsule Endoscopy L38826 A58438 91113
Computed Tomography Cerebral Perfusion Analysis (CTP) L38700 A58225 0042T
Diagnostic and Therapeutic Colonoscopy L36868 A57343 44388, 44389, 44390, 44391, 44392, 44394, 44401, 44402, 44404, 44405, 44406, 44407, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45388, 45389, 45391, 45392, 45393
Electrocardiograms L37283 A57327 93000, 93005, 93010, 93040, 93041, 93042, 93319, 93593, 93594, 93595, 93596, 93597, 93598
Epidural Steroid Joint Injections for Pain Management L39242 A58995 62320, 62321, 62322, 62323, 64479, 64480, 64483, 64484
Facet Joint Interventions for Pain Management L38803 A58405 64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636, 0213T. 0214T, 0215T, 0216T, 0217T, 0218T, 0219T, 0220T, 0221T, 0222T
Frequency of Hemodialysis L37504 A55676 90999
GlycoMark Testing for Glycemic Control L36866 A57238 84378, 84999
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea L38312 A57949 64582, 64583, 64584
Immune Globulin Intravenous (IVIg) L34074 A57194 J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599
Implantable Continuous Glucose Monitor (I-CGM) L38659 A58138 0446T, 0447T, 0448T
In Vitro Chemosensitivity & Chemoresistance Assays L37630 A56073 84999, 89240, 0564T, 0083U
Injections – Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma L34076 A57201 20526, 20527, 20550, 20551, 20612, 26341, 28899, 64455, 64632
Lab: Bladder/Urothelial Tumor Markers L36680 A55029 86294, 86316, 86386, 88120, 88121
Lab: Coenzyme Q10 (CoQ10) L37068 A55770 82542
Lab: Controlled Substance Monitoring and Drugs of Abuse Testing L36707 A55030 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, 0150U, 0227U, 80305, 80306, 80307, G0480, G0481, G0482, G0483, G0659
Lab: Cystatin C Measurement L37618 A57644 82610
Lab: Flow Cytometry L36094 A57690 88182, 88184, 88185, 88187, 88188, 88189, 86053, 86355, 86356, 86357, 86359, 86360, 86361, 86363, 86367
Lab: Special Histochemical Stains and Immunohistochemical Stains L36353 A57614 88312, 88313, 88341, 88342, 88344, 88360, 88361
Lumbar MRI L37281 A57207 72148, 72149, 72158, A9585, Q9953
Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor L37738 A57513 0398T
MDS FISH L37622 A57662 88271, 88273, 88274, 88275, 88291
Measurement of Salivary Hormones L36857 A57613 84999
Micro-Invasive Glaucoma Surgery (MIGS) L38301 A57864 66989, 66991, 0449T, 0450T, 0474T, 0671T
Mohs Micrographic Surgery L35704 A56515 17311, 17312, 17313, 17314, 17315, 88302, 88304, 88305, 88307, 88309, 88314, 88331, 88332
MolDX: AlloSure® or Equivalent Cell-Free DNA Testing for Kidney and Heart Allografts L38380 A57233 81479
MolDX: Biomarkers in Cardiovascular Risk Assessment L36362 A57055 82172, 82610, 83090, 83695, 83698, 83700, 83701, 83704, 83719, 83721, 86141
MolDX: Blood Product Molecular Antigen Typing L38333 A57376 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81403, 0001U, 0084U, 0180U, 0181U, 0182U, 0183U, 0814U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0221U, 0222U
MolDX: Breast Cancer Assay: Prosigna L36386 A57364 81520
MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test L37824 A57774 81518
MolDX: Decision Dx-UM (Uveal Melanoma) L37072 A57622 81552
MolDX: EndoPredict® Breast Cancer Gene Expression Test L37311 A57608 81522
MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test L37891 A57420 81554
MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease L36186 A57422 81206, 81207, 81208, 81219, 81270, 81279, 81338, 81339, 81450, 81479, 81599, 0027U, 0040U
MolDX: Genetic Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR L36159 A57424 81240, 81241, 81291
MolDX: HLA-DQB1*06:02 Testing for Narcolepsy L36544 A57465 81383
MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer L37899 A57665 81479
MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer L38974 A58681 81202, 81215, 81217, 81293, 81296, 81299, 81308, 81318, 81322, 81353, 81403, 81404, 81405, 81406, 81432, 81433, 81435, 81436, 81437, 81438, 81479, 0101U, 0102U, 0103U, 0129U, 81163, 81164, 81165, 81166, 81167, 81201, 81203, 81212, 81216, 81292, 81294, 81295, 81297, 81298, 81300, 81307, 81317, 81319, 81321, 81323, 81351
MolDX: Melanoma risk Stratification Molecular Testing L37748 A57290 81529
MolDX: MGMT Promoter Methylation Analysis L36192 A57433 81287
MolDX: Minimal Residual Disease Testing for Cancer L38816 A58456 81445, 81479
MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer L39007 A58724 81313, 81479, 81551, 0340U
MolDX: Molecular Diagnostic Tests (MDT) L36256* A57527 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81120, 81121, 81161, 81162, 81163, 81164, 81165, 81166, 81167, 81170, 81171, 81172, 81173, 81174, 81175, 81176, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81200, 81201, 81202, 81203, 81204, 81205, 81206, 81207, 81208, 81209, 81210, 81212, 81215, 81216, 81217, 81218, 81219, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81232, 81233, 81234, 81235, 81236, 81237, 81238, 81239, 81240, 81241, 81242, 81243, 81244, 81245, 81246, 81247, 81248, 81249, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81258, 81259, 81260, 81261, 81262, 81263, 81264, 81265, 81266, 81267, 81268, 81269, 81270, 81271, 81272, 81273, 81274, 81275, 81276, 81277, 81283, 81284, 81285, 81286, 81287, 81288, 81289, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81305, 81306, 81307, 81308, 81309, 81310, 81311, 81312, 81313, 81314, 81315, 81316, 81317, 81318, 81319, 81320, 81321, 81322, 81323, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81332, 81333, 81334, 81335, 81336, 81337, 81338, 81339, 81343, 81344, 81345, 81346, 81349, 81350, 81355, 81361, 81362, 81363, 81364, 81374, 81377, 81381, 81383, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81419, 81420, 81422, 81425, 81426, 81427, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, 81440, 81441, 81442, 81443, 81445, 81448, 81449, 81450, 81451, 81455, 81456, 81460, 81465, 81470, 81471, 81479, 81493, 81504, 81507, 81518, 81519, 81520, 81521, 81522, 81523, 81525, 81528, 81529, 81540, 81541, 81542, 81546, 81551, 81552, 81554, 81595, 0004M, 0006M, 0007M, 0011M, 0012M, 0013M, 0016M, 0017M, 0001U, 0005U, 0016U, 0017U, 0018U, 0019U, 0022U, 0023U, 0026U, 0027U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0036U, 0037U, 0040U, 0045U, 0046U, 0047U, 0048U, 0049U, 0050U, 0055U, 0060U, 0069U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0078U, 0079U, 0084U, 0087U, 0088U, 0089U, 0090U, 0091U, 0094U, 0101U, 0102U, 0103U, 0111U, 0113U, 0114U, 0118U, 0120U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U, 0153U, 0154U, 0155U, 0156U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U, 0169U, 0170U, 0171U, 0172U, 0173U, 0175U, 0177U, 0179U, 0180U, 0181U, 0182U, 0183U, 0184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0203U, 0204U, 0205U, 0209U, 0211U, 0212U, 0213U, 0214U, 0215U, 0216U, 0217U, 0218U, 0221U, 0222U, 0228U, 0229U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 0239U, 0242U, 0244U, 0245U, 0246U, 0250U, 0258U, 0260U, 0262U, 0264U, 0265U, 0266U, 0267U, 0268U, 0269U, 0270U, 0271U, 0272U, 0273U, 0274U, 0276U, 0277U, 0278U, 0282U, 0285U, 0286U, 0287U, 0288U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 0296U, 0297U, 0298U, 0299U, 0300U, 0306U, 0307U, 0313U, 0314U, 0315U, 0318U, 0319U, 0320U, 0323U, 0326U, 0327U, 0329U, 0330U, 0331U, 0332U, 0333U, 0335U, 0336U, 0339U, 0340U, 0341U, 0347U, 0348U, 0349U, 0350U, 0355U, 0356U, 0362U, 0363U
MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing L39003 A58726 87631, 87636, 87637,87801,0240U, 0241U, 87505, 87483, 87154, 8151381514, 87800, 87999, 0352U, 0353U, 87632, 87633, 0115U, 0202U, 0223U, 0225U, 87506, 87507, 87468, 87469, 87471, 87472, 87475, 87476, 87478, 87480, 87481, 87482, 87484, 87485, 87486, 87487, 87490, 87491, 87492, 87493, 87495, 87496, 87497, 87498, 87501, 87502, 87503, 87510, 87511, 87512, 87516, 87517, 87520, 87521, 87522, 87525, 87526, 87527, 87528, 87529, 87530, 87531, 87532, 87533, 87534, 87535, 87536, 87537, 87538, 87539, 87540, 87541, 87542, 87550, 87551, 87552, 87555, 87556, 87557, 87560, 87561, 87562, 87563, 87580, 87581, 87582, 87590, 87591, 87592, 87593, 87623, 87624, 87625, 87634, 87635, 87640, 87641, 87650, 87651, 87652, 87653, 87660, 87661, 87662, 87797, 87798, 87799, U0001, U0002, U0003, U0004, U0005
MolDX: Molecular Testing for Solid Organ Allograft Rejection L38671 A58170 81479, 81595, 81599, 0118U
MolDX: myPath Melanoma Assay L37881 A57627 81479, 0090U
MolDX: Next-Generation Sequencing for Solid Tumors L38121 A57905 81445, 81449, 81479, 0244U, 0250U, 0329U, 0334U
MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies L38125 A57892 81450, 81451, 81479
MolDX: NRAS Genetic Testing L36339 A57487 81311, 81479
MolDX: Oncotype DX® Breast Cancer for (DCIS) Genomic Health™ L36947 A57620 0045U
MolDX: Percepta© Bronchial Genomic Classifier L36891 A57504 81479
MolDX: Pharmacogenomics Testing L38337 A57385 81220, 81225, 81226, 81227, 81231, 81232, 81247, 81283, 81306, 81328, 81335, 81350, 81355, 81374, 81377, 81381, 81383, 81418, 81479, 81406, 0029U, 0030U, 0034U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0286U, 0345U
MolDX: Phenotypic Biomarker Detection in Circulating Tumor Cells L38645 A58185 81479
MolDX: Pigmented Lesion Assay L38153 A58053 0089U
MolDX: Plasma-Based Genomic Profiling in Solid Tumors L39232 A58975 81445, 81479, 0326U, 0179U
MolDX: Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer L38329 A57330 81479, 0288U
MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer L38649 A58187 81401, 81403, 81404, 81445, 81479, 0016M
MolDX: Prometheus IBD sgi Diagnostic Policy L37313 A57517 81479, 82397, 83520, 86140
MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease L38341 A57236 81541, 81542, 0047U
MolDX: Repeat Germline Testing L38353 A57332 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81161, 81162, 81163, 81164, 81165, 81166, 81167, 81168, 81171, 81172, 81173, 81174, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81191, 81192, 81193, 81194, 81200, 81201, 81202, 81203, 81204, 81205, 81209, 81212, 81215, 81216, 81217, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81232, 81233, 81234, 81238, 81239, 81240, 81241, 81242, 81243, 81244, 81247, 81248, 81249, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81258, 81259, 81260, 81269, 81271, 81274, 81278, 81279, 81283, 81284, 81285, 81286, 81288, 81289, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81306, 81307, 81309, 81312, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81328, 81329, 81330, 81331, 81332, 81333, 81335, 81336, 81337, 81340, 81341, 81342, 81343, 81344, 81345, 81346, 81347, 81348, 81350, 81351, 81352, 81353, 81355, 81357, 81360, 81361, 81362, 81363, 81364, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81419, 81420, 81422, 81425, 81426, 81427, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, 81440, 81442, 81443, 81448, 81460, 81465, 81470, 81471, 81479, 81493, 81554, 004M, 0001U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0078U, 0079U, 0084U, 0094U, 0101U, 0102U, 0103U, 01129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U, 0156U, 0157U, 0158U, 0159U, 0160U, 0160U, 0161U, 0162U, 0169U, 0170U, 0173U, 0175U, 0180U, 0181U, 0182U, 0183U, 0184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0203U, 0205U, 0209U, 0212U, 0213U, 0214U, 0215U, 0216U, 0217U, 0218U, 0221U, 0222U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 0246U, 0258U, 0260U, 0264U, 0265U, 0266U, 0267U, 0268U, 0269U, 0270U, 0271U, 0272U, 0273U, 02744U, 0276U, 0277U, 0278U, 0282U, 0286U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 0318U, 0345U, 0347U, 0348U, 0349U, 0350U, 0355U
MRI and CT Scans of the Head and Neck L35175 A57215 70336, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70540, 70542, 70543, 70551, 70552, 70553, 70557, 70558, 70559, 72125, 72126, 72127, 72141, 72142, 72156
Nerve Blockade for Treatment of Chronic Pain and Neuropathy L35457 A52725 62281, 62324, 62325, 64405, 64408, 64415, 64417, 64418, 64420, 64421, 64425, 64430, 64435, 64445, 64446, 64447, 64448, 64449, 64450, 64451, 64461, 64462, 64463, 64505, 64510, 64517, 64520, 64530, 64620, 64640, 64999, 64450, 76881, 76882, 76942, 76999, 97032, 97139, G0282, G0283
Nerve Conduction Studies and Electromyography L36526 A54992 95873, 95905, 95907, 95908, 95909, 95910, 95911, 95912, 95913, 95933, 95937, 95999, G0255, 51785, 92265, 95860, 95861, 95863, 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95872, 95874, 95885, 95886, 95887
Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic Heart Disease L38615 A58097 0501T, 0502T, 0503T, 0504T
Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) L34106 A56573 22510, 22511, 22512, 22513, 22514, 22515
Peripheral Nerve Stimulation L37360 A55531 61885, 64553, 64555, 64561, 64569, 64570, 64575, 64581, 64585, 64590, 64595, 64999
Plastic Surgery L37020 A57222 15780, 15781, 15782, 15783, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396, 30400, 30410, 30420, 30430, 30435, 30450
Platelet Rich Plasma Injections for Non-Wound Injections L39060 A58790 86965, G0460, G0465, M0076, P9020, 0232T
Polysomnography and Other Sleep Studies L34040 A57698 G0398, G0399, G0400, 95782, 95783, 95800, 95801, 95803, 95805, 95806, 95807, 95808, 95810, 95811
ProMark Risk Score L36706 A57609 81479
Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder L37088 A57693 90867, 90868, 90869
Respiratory Care (Respiratory Therapy) L37293 A57225 G0237, G0238, G0239, 31502, 31720, 94002, 94003, 94004, 94010, 94011, 94012, 94013, 94060, 94070, 94150, 94200, 94375, 94450, 94617, 94618, 94619, 94621, 94640, 94642, 94660, 94662, 94664, 94667, 94668, 94669, 94726, 94727, 94728, 94729, 94772
Sacroiliac Joint Injections and Procedures L39464 A59246 27096, 64451, 64625, 77002, 77012, G0260
Serum Magnesium L36700 A57198 83735
Spinal Cord Stimulators for Chronic Pain L36204 A57792 63650, 63655, 63663, 63664, 63685
Total Hip Arthroplasty L36573 A57684 27130, 27132, 27134, 27137, 27138
Total Knee Arthroplasty L36577 A57686 27445, 27447, 27486, 27487
Transurethral Waterjet Ablation of the Prostate L38707 A58229 C2596, 0421T
Treatment of Males with Low Testosterone L36569 A57616 11980, 84410, 96372, J1071, J3121, J3145, J3490
Treatment of Varicose Veins of the Lower Extremities L34010 A57707 36299, 36465, 36466, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799, 93970, 93971
Trigger Point Injections L36859 A57702 20552, 20553
Vitamin D Assay Testing L34051 A57719 82306, 82652
Wound and Ulcer Care L38904 A58567 11000, 11001, 11004, 11005, 11006, 11008, 11010, 11011, 11012, 11042, 11043, 11044, 11045, 11046, 11047, 11055, 11056, 11057, 29445, 29580, 29581, 97597, 97598, 97602, 97605, 97606, 97607, 97608, 97610

 

Last Updated Tue, 21 Feb 2023 18:15:11 +0000