Corporate

September 30, 2015 - Updated 10.08.19

MolDX LCDs

ID Title Effective Date Revision Effective Date Last Updated Status HCPCS/CPT Code
L36979screenshot MolDX: 4Kscore Assay 3/13/2017 9/13/2019 9/13/2019 Active N/A
L37362screenshot MolDX: AlloSure® Donor-Derived Cell-Free DNA Test 3/6/2018 9/12/2019 9/20/2019 Active N/A
L36910screenshot MolDX: APC and MUTYH Gene Testing 3/13/2017 9/19/2019 9/13/2019 Active N/A
L37134screenshot MolDX: BDX-XL2 7/10/2017 9/19/2019 9/13/2019 Active N/A
L36139screenshot MolDX: Biomarkers in Cardiovascular Risk Assessment 10/5/2015 10/3/2019 9/26/2019 Active N/A
L36456screenshot MolDX: BRCA1 and BRCA2 Genetic Testing 2/15/2016 9/19/2019 9/13/2019 Active N/A
L36425screenshot MolDX: Breast Cancer Assay: Prosigna 2/1/2016 9/23/2019 9/23/2019 Active N/A
L37832screenshot MolDX: Breast CancerTM (BCI) Gene Expression Test 4/1/2019 9/19/2019 9/13/2019 Active N/A
L36006screenshot MolDX-CDD: ConfirmMDx Epigenetic Molecular Assay 10/5/2015 9/19/2019 9/23/2019 Active N/A
L36675screenshot MolDX-CDD: ProMark Risk Score 10/10/2016 9/19/2019 9/13/2019 Active N/A
L36973screenshot MolDX: Circulating Tumor Cell Marker Assays 3/6/2017 9/26/2019 9/19/2019 Active N/A
L37787screenshot MolDX: Corus® CAD Assay 11/12/2018 9/19/2019 9/13/2019 Active N/A
L35332screenshot MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing 10/1/2015 9/19/2019 9/13/2019 Active N/A
L37598screenshot MolDX: Cystatin C Measurement 12/17/2018 9/19/2019 9/13/2019 Active N/A
L37834screenshot MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease 4/29/2019 9/19/2019 9/13/2019 Active N/A
L36656screenshot MolDX: Decipher® Prostate Cancer Classifier Assay 10/10/2016 9/19/2019 9/13/2019 Active N/A
L38016screenshot MolDX: DecisionDx-Melanoma 6/24/2019 10/3/2019 9/26/2019 Active N/A
L37130screenshot MolDX: DecisionDx-UM (Uveal Melanoma) 7/10/2017 9/19/2019 9/13/2019 Active N/A
L37356screenshot MolDX: EndoPredict Breast Cancer Gene Expression Test 3/6/2018 9/19/2019 9/13/2019 Active N/A
L37905screenshot MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test 5/20/2019 9/19/2019 9/13/2019 Future N/A
L37364screenshot MolDX: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs) 1/7/2019 9/19/2019 9/13/2019 Active N/A
L35443screenshot MolDX: GeneSight Assay for Refractory Depression 10/1/2015 9/19/2019 9/13/2019 Active N/A
L36117screenshot MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease 10/5/2015 9/19/2019 9/13/2019 Active N/A
L35984screenshot MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) 10/1/2015 9/19/2019 9/13/2019 Active N/A
L35349screenshot MolDX: Genetic Testing for Lynch Syndrome 10/1/2015 9/19/2019 9/13/2019 Active N/A
L36206screenshot MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay 10/5/2015 9/19/2019 9/13/2019 Active N/A
L37366screenshot MolDX: Guardant360® Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC) 11/19/2018 9/19/2019 9/12/2019 Active N/A
L36048screenshot MolDX: HLA-B*15:02 Genetic Testing 10/5/2015 9/19/2019 9/13/2019 Active N/A
L36485screenshot MolDX: HLA-DQB1*06:02 Testing for Narcolepsy 2/15/2016 9/19/2019 9/13/2019 Active N/A
L37903screenshot MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer 5/13/2019 9/19/2019 9/13/2019 Future N/A
L37608screenshot MolDX: MDS FISH 5/6/2019 9/19/2019 9/13/2019 Active N/A
L36113screenshot MolDX: MGMT Promoter Methylation Analysis 10/5/2015 9/19/2019 9/13/2019 Active N/A
L36011screenshot MolDX: Molecular RBC Phenotyping 10/5/2015 9/19/2019 9/13/2019 Active N/A
L37348screenshot MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels 12/3/2018 9/19/2019 9/13/2019 Active N/A
L37907screenshot MolDX: myPath Melanoma Assay 6/30/2019 9/19/2019 9/13/2019 Active N/A
L35442screenshot MolDX: NRAS Genetic Testing 10/1/2015 9/19/2019 9/12/2019 Active N/A
L37836screenshot MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC) 3/25/2019 9/19/2019 9/13/2019 Future N/A
L36951screenshot MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) 3/6/2017 9/19/2019 9/13/2019 Active N/A
L37354screenshot MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer 3/6/2018 9/19/2019 9/13/2019 Active N/A
L36908screenshot MolDX: Percepta® Bronchial Genomic Classifier 3/13/2017 9/19/2019 9/13/2019 Active N/A
L36002screenshot MolDX: Prolaris™ Prostate Cancer Genomic Assay 10/5/2015 9/26/2019 9/19/2019 Active N/A
L37142screenshot MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease 7/10/2017 9/19/2019 9/13/2019 Active N/A
L37352screenshot MolDX: Prometheus IBD sgi Diagnostic Policy 11/6/2017 9/23/2019 9/23/2019 Active N/A
L36021screenshot Molecular Diagnostic Tests (MDT) 10/1/2015 9/19/2019 9/13/2019 Active N/A

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