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These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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Medical Policies

Coverage for services under Medicare is primarily established through the Social Security Act. Provisions of the Social Security Act are applied to specific services based on various regulations, National Coverage Determinations established by the Centers for Medicare & Medicaid Services (CMS), various CMS guidelines, and Local Coverage Determinations (LCDs) established by CGS.

  • NCDs are developed by CMS to describe the circumstances for Medicare coverage nationwide for an item or service.
  • LCDs are developed by Medicare Administrative Contractors (MACs), including CGS, and indicate whether a particular item or service is covered in accordance with the Social Security Act, section 1862(a)(1)(A). (See list of LCDs below.)
  • NCDs and LCDs only address certain services and items; in other words, not every item or service has a corresponding NCD or LCD. In these cases, the Social Security Act, and in some cases, additional guidance published by CMS, establish the basis for coverage.
  • For more information about NCDs, LCDs, and other coverage provisions, refer to the CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 13External PDF.
  • CAC Compliance Open and Provider Touch Point Meetings

IMPORTANT NOTE: CGS does NOT house LCDs on our website. By following the links below you will be sent directly to the CMS Medicare Coverage Database (MCD). When using the individual links provided below there may be times that you will receive the message "superseded", indicating you are not viewing the most current LCD. This is due to system processes which cause a delay in updating these links. If you get the note "superseded" on a policy, please use the main link listed below for current LCDs to the MCD provided while we complete the process of updating the individual links.

The following CGS Part B Local Coverage Determinations (LCDs) are located on the Centers for Medicare & Medicaid Services (CMS) Medicare Coverage Database (MCD) webpage. CMS also provides the LCD Contractor IndexExternal Website, where providers can browse LCDs by contractor.

ID Title / ID Effective Date Revision Effective Date Last Updated Status HCPC/CPT code Related Policy Article(s)

L32553External Website

Allergy Immunotherapy

10/1/15

11/7/19

10/7/20

Active

95115, 95117, 95144, 95145, 95146, 95147, 95148, 95149, 95165, 95170, 95180, 95199

A56424 – Billing and Coding: Allergy ImmunotherapyExternal Website

L33943External Website B-type Natriuretic Peptide (BNP) Testing 10/1/15 11/28/19 11/25/19 Active 83880 A56425 – Billing and Coding: B-type Natriuretic Peptide (BNP) TestingExternal Website
L36975External Website Bladder/Urothelial Tumor Markers 3/6/17 10/31/19 1/24/20 Active 86294, 86316, 86386, 88120, 88121 A56471 – Billing and Coding: Bladder / Urothelial Tumor MarkersExternal Website

L33944External Website

Blepharoplasty

10/1/15

11/7/19

10/21/20

Active

Group 1: 67909, 67911, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924

Group 2: 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908

A56439 – Billing and Coding: BlepharoplastyExternal Website

L36460External Website Bone Mass Measurement 2/1/16 12/26/19 12/20/19 Active 76977, 77078, 77080, 77081, 77085, 78350, 78351, G0130, 0508T, 0554T, 0555T, 0556T, 0557T, 0558T A57132 – Billing and Coding: Bone Mass MeasurementExternal Website
L33949External Website Botulinum Toxins 10/1/15 11/28/19 11/25/19 Active Group 1: 43201, 43236, 46505, 52287, 64611, 64612, 64615, 64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647, 64650, 64653, 67345

Group 2: C9399, J0585, J0586, J0587, J0588, J3590
A56472 – Billing and Coding: Botulinum ToxinsExternal Website
L33950External Website Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography 10/1/15 11/28/19 11/25/19 Active 77065, 77066, 77067 A56448 – Billing and Coding: Breast Imaging Mammography / Breast Echography (Sonography) / Breast MRI / DuctographyExternal Website

L33946External Website

Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy

10/1/15

11/7/19

10/19/20

Active

66820, 66821

A56493 – Billing and Coding: Capsule Opacification Following Cataract Surgery: Discission and YAG Laser CapsulotomyExternal Website

L33959External Website

Cardiac Catheterization and Coronary Angiography

10/1/15

11/7/19

10/19/20

Active

Group 1: 92978, 92979, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93462, 93463, 93464, 93503, 93505, 93530, 93531, 93532, 93533, 93561, 93562, 93563, 93564, 93565, 93566, 93567, 93568, 93571, 93572, G0269

Group 2: 36140, 36200, 36215, 36216, 36217, 36218, 36221, 36222, 36223, 36224, 36225, 36226, 36227, 36228, 36245, 36246, 36247, 36248, 75625, 75630, 75635, 75705, 75710, 75716

Group 3: G0278

A56500 – Billing and Coding: Cardiac Catheterization and Coronary AngiographyExternal Website

L33947External Website Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) 10/1/15 9/19/19 10/30/19 Active 75571, 75572, 75573, 75574 A56451 – Billing and Coding: Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA)External Website
L33952External Website Cardiac Event Detection 10/1/15 9/19/19 11/25/19 Active 93228, 93229, 93268,93270, 93271 , 93272, 93799 A56452 – Billing and Coding: Cardiac Event DetectionExternal Website
L33960External Website Cardiovascular Nuclear Medicine 10/1/15 9/19/19 1/24/20 Active 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78494, 78496, 93015, 93016, 93017, 93018, A9500, A9501, A9502, A9505, A9512, A9538, A9560, J0153, J1245, J1250, J2785, J3490 A56494 – Billing and Coding: Cardiovascular Nuclear MedicineExternal Website
L33954External Website Cataract Extraction 10/1/15 12/16/16 12/20/19 Active 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984 A56453 – Billing and Coding: Cataract ExtractionExternal Website
L33945External Website Cerumen (Earwax) Removal 10/1/15 9/19/19 1/24/20 Active 69209, 69210, G0268 A56454 – Billing and Coding: Cerumen (Earwax) RemovalExternal Website
L37254External Website Chiropractic Services 11/6/17 9/19/19 9/19/19 Active 98940, 98941, 98942 A56455 – Billing and Coding: Chiropractic ServicesExternal Website
L37126External Website Coenzyme Q10 (CoQ10) 7/10/17 9/19/19 12/27/19 Active 82542 A55715 – Billing and Coding: Coenzyme Q10 (CoQ10)External Website
L34005External Website Colonoscopy/Sigmoidoscopy/ Proctosigmoidoscopy 10/1/15 9/19/19 1/24/20 Active 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, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45388, 45389, 45391, 45392, 45399 A56456 – Billing and Coding: Colonoscopy / Sigmoidoscopy / ProctosigmoidoscopyExternal Website
L34008External Website Computerized Corneal Topography 10/1/15 9/19/19 1/28/20 Active 92025 A56816 – Billing and Coding: Computerized Corneal TopographyExternal Website
L36029External Website Controlled Substance Monitoring and Drugs of Abuse Testing 10/5/15 11/21/19 6/19/20 Active 80305, 80306, 80307, G0480, G0481, G0482, G0483, G0659, 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, 0150U A56818 – Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse TestingExternal Website
L33999External Website Corneal Pachymetry 10/1/15 9/19/19 1/28/20 Active 76514 A56457 – Billing and Coding: Billing and Coding for Corneal PachymetryExternal Website
L34032External Website Debridement Services 10/1/15 9/12/19 1/28/20 Active 11000, 11001, 11042, 11043, 11044, 11045, 11046, 11047 A56459 – Billing and Coding: Debridement ServicesExternal Website
L34062External Website Dialysis Access Maintenance 10/1/15 9/19/19 1/28/20 Active 36005, 36010, 36140, 36215, 36216, 36217, 36218, 36245, 36246, 36247, 36593, 36831, 36832, 36833, 36901, 36902, 36903, 36904, 36905, 36906, 36907, 37186, 37211, 37212, 37213, 37214, 37236, 37237, 37246, 37247, 37248, 37249, 75710, 75820, 75822, 75825, 75827, 93990 A56460 – Billing and Coding: Dialysis Access MaintenanceExternal Website
L34081External Website Endoscopy by Capsule 10/1/15 9/19/19 2/28/20 Active Group 1: 91110

Group 2: 91111, 91299
A56461 – Billing and Coding: Endoscopy by CapsuleExternal Website
L34356External Website Erythropoiesis Stimulating Agents (ESA) 10/1/15 10/3/19 2/24/20 Active J0881, J0882, J0885, J0890. Q4081, Q5105, Q5106 A56462 – Billing and Coding: Erythropoiesis Stimulating Agents (ESA)External Website
L34832External Website Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy 10/1/15 12/26/19 12/20/19 Active 64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636 A56463 – Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency NeurotomyExternal Website
L34037External Website Flow Cytometry 10/1/15 10/1/19 2/24/20 Active Group 1: 88182, 88184, 88185, 88187, 88188, 88189

Group 2: 86355, 86356, 86357, 86359, 86360, 86361, 86367 
A56464 – Billing and Coding: Flow CytometryExternal Website
L38378External Website Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH) 4/1/20 6/1/20 3/19/20 Active 0421T A57926 - Billing and Coding: Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH)External Website
L37364External Website Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs) 1/7/19 11/28/19 11/21/19 Active Group 1: 87505, 87506, 0097U

Group 2: 87507
A56596 – Billing and Coding: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs)External Website
L37575 External Website Frequency of Hemodialysis 4/1/19 10/1/19 1/28/20 Active 90999 A56159 – Billing and Coding: Frequency of HemodialysisExternal Website
L36906External Website GlycoMark Testing for Glycemic Control 3/6/17 10/31/19 3/25/20 Active 84378, 84999 A56465 – Billing and Coding: GlycoMark Testing for Glycemic ControlExternal Website
L34089External Website Human Papillomavirus (HPV) Testing 10/1/15 9/19/19 3/25/20 Active 87623, 87624 A56466 – Billing and Coding: Human Papillomavirus (HPV) TestingExternal Website
L38307External Website Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea 4/1/20 4/1/20 3/6/20 Active 64568, 0466T, 0467T, 0468T A57149 - Billing and Coding: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep ApneaExternal Website
L38268External Website Immune Thrombocytopenia (ITP) Therapy 4/1/20 N/A 2/7/20 Active 38100, 38120, 90283, J1459, J1460, J1556, J1557, J1560, J1561, J1566, J1568, J1569, J1572, J1599, J2788, J2790, J2791, J2792, J2796, J8499, J9312 A57160 - Billing and Coding: Immune Thrombocytopenia (ITP) TherapyExternal Website
L35891External Website Intravenous Immune Globulin 10/1/15 9/19/19 3/25/20 Active J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572 A56779 – Billing and Coding: Intravenous Immune GlobulinExternal Website
L34090External Website Laser Ablation of the Prostate 10/1/15 9/19/19 3/25/20 Active 52647, 52648, 52649 A56467 – Billing and Coding: Laser Ablation of the ProstateExternal Website
L34807External Website Lumbar Epidural Steroid Injections (ESI) 10/1/15 12/26/19 12/20/19 Active 62323, 62327, 64483, 64484 A56469 – Billing and Coding: Lumbar Epidural Steroid Injections (ESI)External Website
L37790External Website Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor 10/1/18 9/19/19 8/25/20 Active 0398T A56470 – Billing and Coding: Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential TremorExternal Website
L37578External Website Micro-Invasive Glaucoma Surgery (MIGS) 3/19/18 12/30/18 3/25/20 Active Group 1: 0191T

Group 2: 0449T

Group 3: 0253T, 0376T, 0450T, 0474T
A56491 – Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS)External Website
L36494External Website Minimally-Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint 2/1/16 12/26/19 12/20/19 Active 27279 A56535 – Billing and Coding: Minimally-Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) JointExternal Website
L34195External Website Mohs Micrographic Surgery 10/1/15 8/8/19 9/13/19 Active 17311, 17312, 17313, 17314, 17315 A56836 – Billing and Coding: Mohs Micrographic SurgeryExternal Website
L36979External Website MolDX: 4Kscore Assay 3/13/17 10/31/19 11/25/19 Active 81539 A56944 – Billing and Coding: MolDX: 4Kscore AssayExternal Website
L37362External Website MolDX: AlloSure® Donor-Derived Cell-Free DNA Test 3/6/18 10/31/19 1/23/20 Active 81479 A57032 – Billing and Coding: MolDX: AlloSure® Donor-Derived Cell-Free DNA TestExternal Website
L36910External Website MolDX: APC and MUTYH Gene Testing 3/13/17 11/28/19 11/21/19 Active Group 1: 81201, 81202, 81203, 81479

Group 2: 81401, 81403, 81406, 81435, 81436

Group 3: 0157U
A56828 – Billing and Coding: MolDX: APC and MUTYH GeneExternal Website
L37134External Website MolDX: BDX-XL2 7/10/17 10/24/19 10/17/19 Active 0080U A56947 – Billing and Coding: MolDX: BDX-XL2External Website
L36139External Website MolDX: Biomarkers in Cardiovascular Risk Assessment 10/5/15 11/14/19 6/19/20 Active 81439, 82172, 82610, 83090, 83695, 83698, 83700, 83701, 83704, 83719, 83721, 86141 A54685 – Billing and Coding: MolDX: Arrhythmogenic Right Ventricular Dysplasia / Cardiomyopathy (ARVD / C) Testing Coding and Billing GuidelinesExternal Website

A57386 – Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk AssessmentExternal Website
L36456External Website MolDX: BRCA1 and BRCA2 Genetic Testing 2/15/16 1/9/20 12/31/19 Active Group 1: 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 81432, 81433, 81479, 0102U, 0103U, 0129U

Group 2: 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U

Group 3: 81162, 81445, 81455
A56971 – Billing and Coding: MolDX: BRCA1 and BRCA2 Genetic TestingExternal Website

A54689 – Billing and Coding: MolDX: Myriad’s BRACAnalysis CDx™External Website
L36425External Website MolDX: Breast Cancer Assay: Prosigna 2/1/16 9/23/19 8/25/20 Active 81520 A56989 – Billing and Coding: MolDX: Breast Cancer Assay: ProsignaExternal Website
L37832External Website MolDX: Breast Cancer™ (BCI) Gene Expression Test 4/1/19 10/31/19 4/30/20 Active 81518 A56884 – Billing and Coding: MolDX: Breast Cancer Index™ (BCI) Gene Expression TestExternal Website
L36006External Website MolDX-CDD: ConfirmMDx Epigenetic Molecular Assay 10/5/15 11/7/19 8/25/20 Active 81551 A57031 – Billing and Coding: MolDX: ConfirmMDx Epigenetic Molecular AssayExternal Website

L36675External Website

MolDX - CDD: ProMark Risk Score

10/10/16

11/28/19

11/21/20

Active

81479

A57034 – Billing and Coding: MolDX - CDD: ProMark Risk ScoreExternal Website

L36973External Website MolDX: Circulating Tumor Cell Marker Assays 3/6/17 11/7/19 3/25/20 Active 86152, 86153 A57288 – Billing and Coding: MolDX: Circulating Tumor Cell Marker AssaysExternal Website
L37787External Website MolDX: Corus® CAD Assay 11/12/18 9/19/19 11/25/19 Active 81493 A56950 – Billing and Coding: MolDX: Corus® CAD AssayExternal Website
L37598External Website MolDX: Cystatin C Measurement 12/17/18 11/28/19 12/27/19 Active 82610 A56988 – Billing and Coding: MolDX: Cystatin C MeasurementExternal Website
L38077External Website MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Intermediate Risk Disease 4/6/20 N/A 2/13/20 Active 81542 A57796 - Billing and Coding: MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Intermediate Risk DiseaseExternal Website
L37834External Website MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease 4/29/19 1/9/20 3/25/20 Active 81542 A56984 – Billing and Coding: MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk DiseaseExternal Website
L36656External Website MolDX: Decipher® Prostate Cancer Classifier Assay 10/10/16 11/14/19 11/25/19 Active 81542 A56992 – Billing and Coding: MolDX: Decipher® Prostate Cancer Classifier AssayExternal Website
L38016External Website MolDX: DecisionDx-Melanoma 6/24/19 10/3/19 9/26/19 Active 81599 A56990 – Billing and Coding: MolDX: DecisionDx-MelanomaExternal Website
L37130External Website MolDX: DecisionDx-UM (Uveal Melanoma) 7/10/17 10/31/19 12/27/19 Active 81552 A56981 – Billing and Coding: MolDX: DecisionDx-UM (Uveal Melanoma)External Website
L37356External Website MolDX: EndoPredict Breast Cancer Gene Expression Test 3/6/18 11/14/19 11/8/19 Active 81522 A56997 – Billing and Coding: MolDX: EndoPredict Breast Cancer Gene Expression TestExternal Website
L37905External Website MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test 5/20/19 11/7/19 2/28/20 Active 81479 A56985 – Billing and Coding: MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic TestExternal Website
L35443External Website MolDX: GeneSight Assay for Refractory Depression 10/1/15 11/28/19 11/21/19 Active 81479 A56936 – Billing and Coding: MolDX: GeneSight® Assay for Refractory DepressionExternal Website
L36117External Website MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease 10/5/15 12/19/19 6/30/20 Active Group 1: 81206, 81207, 81208, 81219, 81270, 81402, 81479, 0040U

Group 2: 81403, 81445, 81450, 81455
A54686 – Billing and Coding: MolDX: BCR-ABLExternal Website

A56999 – Billing and Coding: MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative DiseaseExternal Website
L35984External Website MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) 10/1/15 10/31/15 6/30/20 Active 81240, 81241, 81291 A56980 – Billing and Coding: MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)External Website
L35349External Website MolDX: Genetic Testing for Lynch Syndrome 10/1/15 12/5/19 12/31/19 Active Group 1: 81210, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, 81479, 88341,88342, 0101U

Group 2: 81445, 81455, 0130U, 0134U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U

Group 3: 81301, 81403, 81435, 81436
A56882 – Billing and Coding: MolDX: Genetic Testing for Lynch SyndromeExternal Website

A56106 – Billing and Coding: MolDX: Microsatellite Instability-High (MSI-H) and Mismatch Repair Deficient (dMMR) Biomarker for Patients with Unresectable or Metastatic Solid TumorsExternal Website
L36206External Website MolDX: Genomic Health® Oncotype DX® Prostate Cancer Assay 10/5/15 11/14/19 11/4/19 Active 0047U A56976 – Billing and Coding: MolDX: Genomic Health™ Oncotype DX® Prostate Cancer AssayExternal Website
L36048External Website MolDX: HLA-B*15:02 Genetic Testing 10/5/15 11/7/19 10/28/19 Active 81381 A56979 – Billing and Coding: MolDX: HLA-B*15:02 Genetic TestingExternal Website
L36485External Website MolDX: HLA-DQB1*06:02 Testing for Narcolepsy 2/15/16 12/26/19 12/20/19 Active 81383 A56881 – Billing and Coding: MolDX: HLA-DQB1*06:02 Testing for NarcolepsyExternal Website
L37903External Website MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer 5/13/19 3/5/20 3/25/20 Active 81479 A56982 – Billing and Coding: MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung CancerExternal Website
L37608External Website MolDX: MDS FISH 5/6/19 11/7/19 3/25/20 Active 88271, 88273, 88274, 88275, 88291 A56926 – Billing and Coding: MolDX: MDS FISHExternal Website
L36113External Website MolDX: MGMT Promoter Methylation Analysis 10/5/15 11/21/19 12/27/19 Active 81287 A56983 – Billing and Coding: MolDX: MGMT Promoter Methylation AnalysisExternal Website
L36011External Website MolDX: Molecular RBC Phenotyping 10/5/15 11/7/19 6/30/20 Active 0001U A56986 – Billing and Coding: MolDX: Molecular RBC PhenotypingExternal Website
L37348External Website MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels 12/3/18 11/28/19 11/21/19 Active Group 1: 87631, 0098U, 0099U, 0100U, 0115U

Group 2: 87632, 87633
A56974 – Billing and Coding: MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral PanelsExternal Website
L37907External Website MolDX: myPath Melanoma Assay 6/3/19 10/31/19 3/25/20 Active 81479, 0090U A56878 – Billing and Coding: MolDX: myPath Melanoma AssayExternal Website
L38067External Website MolDX: Next-Generation Sequencing for Solid Tumors 2/10/20 3/5/20 3/12/20 Active 81445, 81479 A57870 - Billing and Coding: MolDX: Next-Generation Sequencing for Solid TumorsExternal Website
L38070External Website MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies 2/10/20 3/5/20 3/12/20 Active 81450, 81479 A57873 - Billing and Coding: MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid MalignanciesExternal Website
L35442External Website MolDX: NRAS Genetic Testing 10/1/15 11/28/19 11/21/19 Active 81311, 81479 A56998 – Billing and Coding: MolDX: NRAS Genetic TestingExternal Website
L37836External Website MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC) 3/25/19 11/21/19 1/23/20 Active 81479 A57003 – Billing and Coding: MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC)External Website

L36951External Website

MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health®)

3/6/17

11/28/19

11/21/20

Active

0045U

A56887 – Billing and Coding: MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)External Website

L37354External Website MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer 3/6/18 11/14/19 3/25/20 Active 0047U A56976 – Billing and Coding: MolDX: Genomic Health™ Oncotype DX® Prostate Cancer AssayExternal Website
L36908External Website MolDX: Percepta® Bronchial Genomic Classifier 3/13/17 11/28/19 11/21/19 Active 81479 A56972 – Billing and Coding: MolDX: Percepta® Bronchial Genomic ClassifierExternal Website
L36002External Website MolDX: Prolaris® Prostate Cancer Genomic Assay 10/5/15 11/7/19 7/13/20 Active 81541 A57303 – Billing and Coding: MolDX: Prolaris™ Prostate Cancer Genomic Assay External Website
L37142External Website MolDX: Prolaris® Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease 7/10/17 10/31/19 10/24/19 Active 81541 A56925 – Billing and Coding: MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk DiseaseExternal Website
L37352External Website MolDX: Prometheus IBD sgi Diagnostic Policy 11/6/17 11/14/19 8/25/20 Active 81479, 82397, 83520, 86140 A56940 – Billing and Coding: MolDX: Prometheus IBD sgi Diagnostic PolicyExternal Website
L38059External Website MolDX: Prospera 3/10/20 N/A 1/16/20 Active 81479 A57859 - Billing and Coding: MolDX: Prospera™External Website
L38053External Website MolDX: TruGraf Blood Gene Expression Test 12/30/19 N/A 11/5/19 Active 81479 A57446 - Billing and Coding: MolDX: TruGraf Blood Gene Expression TestExternal Website
L36021External Website Molecular Diagnostic Tests (MDT) 10/1/15 12/19/19 12/11/19 Active Group 1: 81105, 81106, 8110,7 81108, 81109, 81110, 81111, 81112, 81120, 81121, 81161 - 81364 81400, 81402, 81404, 81405, 81408, 81410, 81411, 81413 - 81595 81599, 84999, 85999, 86152, 86153, 86849, 87999, 0004M, 0006M, 0007M, 0011M, 0012M, 0013M, 0001U, 0003U, 0005U, 0009U, 0012U, 0013U, 0014U, 0016U, 0017U, 0018U, 0019U, 0021U, 0022U, 0023U, 0024U, 0026U, 0027U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0036U, 0037U, 0039U, 0040U, 0045U - 0050U 0053U - 0060U 0062U, 0067U, 0068U, 0070U - 0076U, 0078U - 0080U 0083U, 0084U, 0087U - 0092U 0094U, 0101U - 0103U 0105U, 0107U, 0108U, 0111U, 0113U, 0114U, 0118U, 0120U, 0129U - 0132U, 0134U - 0138U, 0153U - 0162U

Group 2: 81401, 81403, 80406, 81407, 81412
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A54243 – Billing and Coding: MolDX: CHD7 Gene Analysis GuidelinesExternal Website

A54241 – Billing and Coding: MolDX: 4q25-AF Risk Genotype GuidelinesExternal Website

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A54185 – Billing and Coding: MolDX: Afirma™ Assay by Veracyte UpdateExternal Website

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A54253 – Billing and Coding: MolDX: Aspartoacyclase 2 Deficiency(ASPA) TestingExternal Website

A54254 – Billing and Coding: MolDX: ATP7B Gene TestsExternal Website

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A54256 – Billing and Coding: MolDX: BLM Gene AnalysisExternal Website

A54257 – Billing and Coding: MolDX: BluePrint® TestExternal Website

A54258 – Billing and Coding: MolDX: CFTR Gene AnalysisExternal Website

A54189 – Billing and Coding: MolDX: cobas® EGFR Mutation Test GuidelinesExternal Website

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A54262 – Billing and Coding: MolDX: ENG and ACVRL1 Gene TestsExternal Website

A54263 – Billing and Coding: MolDX: FANCC Genetic TestingExternal Website

A54191 – Billing and Coding: MolDX: FDA-Approved BRAF TestsExternal Website

A54192 – Billing and Coding: MolDX: FDA-Approved EGFR TestsExternal Website

A54264 – Billing and Coding: MolDX: Fragile XExternal Website

A54265 – Billing and Coding: MolDX: GBA Genetic TestingExternal Website

A54266 – Billing and Coding: MolDX: HAX1 Gene SequencingExternal Website

A54267 – Billing and Coding: MolDX: HBB Gene TestsExternal Website

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A54269 – Billing and Coding: MolDX: HTTLPR Gene TestingExternal Website

A54270 – Billing and Coding: MolDX: IKBKAP Genetic TestingExternal Website

A54271 – Billing and Coding: MolDX: Immunohistochemistry (IHC) Indications for Breast PathologyExternal Website

A54272 – Billing and Coding: MolDX: KIF6 GenotypeExternal Website

A54273 – Billing and Coding: MolDX: know error®External Website

A54274 – Billing and Coding: MolDX: L1CAM Gene Sequencing GuidelinesExternal Website

A54275 – Billing and Coding: MolDX: LPA-Aspirin GenotypeExternal Website

A54276 – Billing and Coding: MolDX: LPA-Intron 25 GenotypeExternal Website

A54194 – Billing and Coding: MolDX: MammaPrintExternal Website

A54277 – Billing and Coding: MolDX: MCOLN1 Genetic Testing GuidelinesExternal Website

A54278 – Billing and Coding: MolDX: MECP2 Genetic TestingExternal Website

A54288 – Billing and Coding: MolDX: Mitochondrial Nuclear Gene Tests GuidelinesExternal Website

A54209 – Billing and Coding: MolDX: MMACHC TestExternal Website

A56973 – Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT)External Website

A54290 – Billing and Coding: MolDX: myPap™External Website

A54291 – Billing and Coding: MolDX: NSD1 Gene TestsExternal Website

A54292 – Billing and Coding: MolDX: OncoCee™External Website

A54195 – Billing and Coding: MolDX: Oncotype DX® Breast Cancer AssayExternal Website

A54196 – Billing and Coding: MolDX: Oncotype DX® Colon Cancer GuidelinesExternal Website

A54293 – Billing and Coding: MolDX: PAX6 Gene Sequencing GuidelinesExternal Website

A54295 – Billing and Coding: MolDX: PIK3CA Gene TestsExternal Website

A54296 – Billing and Coding: MolDX: PreDx®External Website

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A54297 – Billing and Coding: MolDX: PTCH1 Gene TestingExternal Website

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A54299 – Billing and Coding: MolDX: RPS19 Gene TestsExternal Website

A54300 – Billing and Coding: MolDx: SEPT9 Gene TestExternal Website

A54286 – Billing and Coding: MolDX: SLCO1B1 GenotypeExternal Website

A54285 – Billing and Coding: MolDX: SMPD1 Genetic TestingExternal Website

A54284 – Billing and Coding: MolDX: STAT3 Gene TestingExternal Website

A54283 – Billing and Coding: MolDX: SULT4A1 Genetic TestingExternal Website

A54282 – Billing and Coding: MolDX: TERC Gene TestsExternal Website

A54199 – Billing and Coding: MolDX: Therascreen® EGFR RGQ PCR Kit GuidelinesExternal Website

A54200 – Billing and Coding: MolDX: therascreen® KRAS PCR Kit GuidelinesExternal Website

A54281 – Billing and Coding: MolDX: TP53 Gene TestExternal Website

A54280 – Billing and Coding: MolDX: UGT1A1 Gene AnalysisExternal Website

A54201 – Billing and Coding: MolDX: Vectra™ DAExternal Website

A54279 – Billing and Coding: MolDx: VEGFR2 TestsExternal Website

A54830 – Billing and Coding: Short Tandem Repeat (STR) Markers and Chimerism (CPT® codes 81265-81268)External Website
L34171External Website Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation 10/1/15 9/26/19 9/19/19 Active 68801, 68810, 68811, 68815, 68816, 68840 A57284 – Billing and Coding: Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without IrrigationExternal Website
L35249External Website Nerve Blocks for Peripheral Neuropathy 10/1/15 10/31/19 4/30/20 Active Group 1: 64450

Group 2: 76881, 76882, 76942, 76999, 97032, 97139, G0282, G0283
A57663 – Billing and Coding: Nerve Blocks for Peripheral NeuropathyExternal Website
L35897External Website Nerve Conduction Studies and Electromyography 10/1/15 10/24/19 10/15/194/30/20 Active 51785, 92265, 95860, 95861, 95863, 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95872, 95873, 95874, 95885, 95886, 95887, 95905, 95907, 95908, 95909, 95910, 95911, 95912, 95913, 95933, 95937, 95999, G0255 A57307 – Billing and Coding: Nerve Conduction Studies and ElectromyographyExternal Website

L34045External Website

Non-Invasive Vascular Studies

10/1/15

11/28/19

11/21/20

Active

Group 1: 93880, 93882,

Group 2: 93886, 93888, 93890, 93892, 93893

Group 3: 93922, 93923, 93924, 93925, 93926, 93930, 93931

Group 4: 93970, 93971

Group 5: 93975, 93976, 93979

Group 6: 93985, 93986, 93990

Group 7: 93930, 93931, 93970, 93971

Group 8: 93970, 93971

A56697 – Billing and Coding: Non-Invasive Vascular StudiesExternal Website

L34393External Website Ocular Photography - External 10/1/15 10/31/19 10/24/19 Active 92285 A57068 – Billing and Coding: Ocular Photography – ExternalExternal Website
L34175External Website Ophthalmic Angiography (Fluorescein and Indocyanine Green) 10/1/15 10/31/19 10/24/19 Active 92235, 92240 A57069 – Billing and Coding: Ophthalmic Angiography (Fluorescein and Indocyanine Green)External Website
L34181External Website Ophthalmic Biometry for Intraocular Lens Power Calculation 10/1/15 12/5/19 11/26/19 Active 76519, 92136 A57070 – Billing and Coding: Ophthalmic Biometry for Intraocular Lens Power CalculationExternal Website
L34399External Website Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) 10/1/15 12/5/19 11/27/19 Active 92201, 92202, 92227, 92228, 92250 A57071 – Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)External Website
L34049External Website Outpatient Physical and Occupational Therapy Services 10/1/15 11/14/19 11/6/19 Active 29065, 29075, 29085, 29086, 29105, 29125, 29126, 29130, 29131, 29200, 29240, 29260, 29280, 29345, 29355, 29365, 29405, 29425, 29445, 29505, 29515, 29520, 29530, 29540, 29550, 29580, 29799, 90901, 90912, 90913, 95851, 95852, 96125, 97010, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97129, 97130, 97139, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97533, 97535, 97537, 97542, 97597, 97598, 97602, 97605, 97606, 97607, 97608, 97750, 97755, 97760, 97761, 97763, 97799, G0281, G0283, G0329 A57067 – Billing and Coding: Outpatient Physical and Occupational Therapy ServicesExternal Website
L34353External Website Outpatient Psychiatry and Psychology Services 10/1/15 11/7/19 10/29/19 Active 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90863, 90865, 90870, 90880, 90885, 90887, 90889, 90899, 96105, 96110, 96112, 96113, 96116, 96130, 96131, 96136, 96137, 96138, 96139, 96146 A57065 – Billing and Coding: Outpatient Psychiatry and Psychology ServicesExternal Website
L38201External Website Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) 11/18/19 N/A 9/26/19 Active 22510, 22511, 22512, 22513, 22514, 22515 A57282 - Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF)External Website
L34064External Website Panretinal (Scatter) Laser Photocoagulation 10/1/15 10/3/19 2/24/20 Active 61882 A56594 – Billing and Coding: Panretinal (Scatter) Laser PhotocoagulationExternal Website
L36902External Website Polysomnography and Other Sleep Studies 3/6/17 9/26/19 9/20/19 Active Group 1: 95782, 95783, 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400

Group 2: 95803
A57049 – Billing and Coding: Polysomnography and Other Sleep StudiesExternal Website
L34085External Website Post-Void Residual Urine and/or Bladder Capacity by Ultrasound 10/1/15 10/1/16 9/20/19 Active 51798 A57050 – Billing and Coding: Post-Void Residual Urine and / or Bladder Capacity by UltrasoundExternal Website
L36658External Website Proton Beam Therapy 10/24/16 9/26/19 8/25/20 Active 77520, 77522, 77523, 77525 A55315 – Billing and Coding: Proton Beam TherapyExternal Website
L34183External Website Psychiatric Inpatient Hospitalization 10/1/15 9/26/19 2/24/20 Active NA A57052 – Billing and Coding: Psychiatric Inpatient HospitalizationExternal Website
L34196External Website Psychiatric Partial Hospitalization Programs 10/1/15 11/7/19 2/24/20 Active 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90899, 96116, 96130, 96131, 96136, 96137, 96138, 96139, 96146, G0129, G0176, G0177, G0410, G0411 A57053 – Billing and Coding: Psychiatric Partial Hospitalization ProgramsExternal Website
L34539External Website Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians 10/1/15 11/28/19 2/24/20 Active 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90846, 90847, 90849, 90853, 90863, 90880, 90899  A57054 – Billing and Coding: Psychological Services Coverage under the Incident to Provision for Physicians and Non-physiciansExternal Website
L34063External Website RAST Type Tests 10/1/15 12/5/19 7/31/20 Active 86001, 86003, 86005 A57043 – Billing and Coding: RAST Type TestsExternal Website
L34200External Website Removal of Benign Skin Lesions 10/1/15 9/26/19 7/13/20 Active 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, 17000, 17003, 17004, 17106, 17107, 17108, 17110, 17111, 17340 A57044 – Billing and Coding: Removal of Benign Skin LesionsExternal Website
L36469External Website Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder 2/8/16 12/26/19 12/19/19 Active 90867, 90868, 90869 A57047 – Billing and Coding: Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive DisorderExternal Website
L34246External Website Routine Foot Care and Debridement of Nails 10/1/15 11/28/19 11/20/19 Active 11055, 11056, 11057, 11719, 11720, 11721, G0127 A57193 – Billing and Coding: Routine Foot Care and Debridement of NailsExternal Website
L34061External Website Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) 10/1/15 10/3/19 9/23/19 Active 92133, 92134 A56692 – Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)External Website
L35906External Website Somatosensory Testing 10/1/15 9/26/19 3/25/20 Active 95925, 95926, 95927, 95928 A57041 – Billing and Coding: Somatosensory TestingExternal Website
L35986External Website Special Histochemical Stains and Immunohistochemical Stains 10/1/15 10/31/19 6/30/20 Active 88312, 88313, 88341, 88342, 88344, 88360, 88361 A56536 – Billing and Coding: Special Histochemical Stains and Immunohistochemical StainsExternal Website
L34046External Website Speech-Language Pathology 10/1/15 9/26/19 9/20/19 Active 31579, 92507, 92508, 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92609, 92626, 92627, 96105, 96110, 96112, 96113, 96125, 97129, 97130, 97533 A57040 – Billing and Coding: Speech-Language PathologyExternal Website
L34540External Website Stretta Procedure 10/1/15 9/26/19 8/25/20 Active 43257 A57039 – Billing and Coding: Stretta ProcedureExternal Website
L34087External Website Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs): Office, Hospital, Web, or Non-Web Based 10/1/15 9/26/19 8/25/20 Active 93282, 93283, 93284, 93287, 93289, 93292, 93295, 93296 A57038 – Billing and Coding: Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs): Office, Hospital, Web, or Non-Web BasedExternal Website
L34084External Website Transcatheter Infusion Therapy 10/1/15 12/5/19 8/25/20 Active 61650, 61651 A56811 – Billing and Coding: Transcatheter Infusion TherapyExternal Website
L34337External Website Transesophageal Echocardiography (TEE) 10/1/15 9/26/19 8/25/20 Active 76376, 76377, 93312, 93313, 93314, 93315, 93316, 93317, 93318, 93320, 93321, 93325, C8925, C8926, C8927 A56809 – Billing and Coding: Transesophageal Echocardiography (TEE)External Website
L34541External Website Transtelephonic Spirometry 10/1/15 9/26/19 9/15/20 Active 94014, 94015, 94016 A56808 – Billing and Coding: Transtelephonic SpirometryExternal Website
L34338External Website Transthoracic Echocardiography (TTE) 10/1/15 9/26/19 9/15/20 Active Group 1: 76376, 76377, 93303, 93304, 93306, 93307, 93308, 93320, 93321, 93325, 93350, 93351, 93352, A9700, C8921, C8922, C8923, C8924, C8928, C8929, C8930, Q9955, Q9956, Q9957

Group 2: C9399, J0153, J0280, J0461, J1245, J1250, J2785, J3490
A57306 – Billing and Coding: Transthoracic Echocardiography (TTE)External Website
L34056External Website Urodynamics 10/1/15 9/26/19 9/15/20 Active 51725, 51726, 51727, 51728, 51729, 51736, 51741, 51792, 51797 A56802 – Billing and Coding: UrodynamicsExternal Website
L34082External Website Varicose Veins of the Lower Extremity, Treatment of 10/1/15 9/26/19 9/15/20 Active 36465, 36466, 36468, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37799, 76942, 93970, 93971 A57305 – Billing and Coding: Varicose Veins of the Lower Extremity, Treatment ofExternal Website
L34055External Website Virtual Colonoscopy (CT Colonography) 10/1/15 9/26/19 9/15/20 Active Group 1: 74261, 74262

Group 2: 74263
A56800 – Billing and Coding: Virtual Colonoscopy (CT Colonography)External Website
L34394External Website Visual Fields Testing 10/1/15 9/26/19 9/15/20 Active 92081, 92082, 92083 A56799 – Billing and Coding: Billing and Coding for Visual Fields TestingExternal Website
L33996External Website Vitamin D Assay Testing 10/1/15 11/28/19 9/15/20 Active 82306 A56798 – Billing and Coding: Vitamin D Assay TestingExternal Website
L36690External Website Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities 10/10/16 10/31/19 8/25/20 Active 15002, 15003, 15004, 15005, 15040, 15050, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278 A56696 – Billing and Coding: Wound Application of Cellular and / or Tissue Based Products (CTPs), Lower ExtremitiesExternal Website

Updated: 11.02.20

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