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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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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 13.
CAC, Compliance and Open Public Meeting

IMPORTANT NOTE: CGS does NOT house LCDs on our website. By following the links below you will be sent directly to the CMS LCD database.

The following CGS Part A 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 Index, where providers can browse LCDs by contractor.

ID	Title	Effective Date	Revision Effective Date	Last Updated	Status	HCPC/CPT code
L32553	Allergy Immunotherapy	10/1/2015	10/1/2015	10/30/2017	Active	95115, 95117, 95144, 95145, 95146, 95147, 95148, 95149, 95165, 95170, 95180, 95199
L33943	B-type Natriuretic Peptide (BNP) Testing	10/1/2015	10/1/2015	11/28/2017	Active	83880
L33944	Blepharoplasty	10/1/2015	10/1/2015	10/30/2017	Active	67909, 67911, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924, Group 2 Codes: 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908
L33945	Cerumen (Earwax) Removal	10/1/2015	1/1/2016	1/30/2018	Active	69209, 69210, G0268
L33946	Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy	10/1/2015	10/1/2015	10/30/2017	Active	66820, 66821
L33947	Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA)	10/1/2015	10/1/2016	10/30/2017	Active	75571, 75572, 75573, 75574
L33949	Botulinum Toxins	10/1/2015	10/1/2015	11/28/2017	Active	Group 1 Codes: 43201, 43236, 46505, 52287, 64611, 64612, 64615, 64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647, 64650, 64653, 67345, Group 2 Codes: C9399, J0585, J0586, J0587, J0588, J3590
L33950	Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography	10/1/2015	1/1/2018	12/14/2017	Active	19030, 76641, 76642, 77053, 77054, 77058, 77059, 77063, 77065, 77066, 77067, C8903, C8904, C8905, C8906, C8907, C8908, G0279
L33952	Cardiac Event Detection	10/1/2015	10/1/2015	10/30/2017	Active	93228, 93229, 93268, 93270, 93271, 93272, 93799
L33954	Cataract Extraction	10/1/2015	10/1/2016	12/21/2017	Active	66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984
L33959	Cardiac Catheterization and Coronary Angiography	10/1/2015	1/1/2018	12/18/2017	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 Codes: 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 Codes: G0278
L33960	Cardiovascular Nuclear Medicine	10/1/2015	10/1/2015	1/30/2018	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
L33996	Vitamin D Assay Testing	10/1/2015	5/1/2017	7/5/2017	Active	82306
L33999	Corneal Pachymetry	10/1/2015	10/1/2016	1/30/2018	Active	76514
L34005	Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy	10/1/2015	10/1/2017	1/30/2018	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
L34008	Computerized Corneal Topography	10/1/2015	5/1/2018	5/9/2018	Active	92025
L34032	Debridement Services	10/1/2015	10/1/2017	1/30/2018	Active	11000, 11001, 11042, 11043, 11044, 11045, 11046, 11047
L34037	Flow Cytometry	10/1/2015	10/1/2017	2/26/2018	Active	86355, 86356, 86357, 86359, 86360, 86361, 86367, 88182, 88184, 88185, 88187, 88188, 88189
L34045	Non-Invasive Vascular Studies	10/1/2015	3/1/2018	3/2/2018	Active	Group 1 Codes: 93880 93882 93886 93888 93890 93892 93893 Group 2 Codes: 93922 93923 93924 93925 93926 93930 93931 Group 3 Codes: 93970 93971 Group 4 Codes: 93975 93976 93978 93979 Group 5 Codes: 93990 G0365
L34046	Speech-Language Pathology	10/1/2015	1/1/2018	07/30/2018	Active	31579, 92507, 92508, 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92609, 92626, 92627, 96105, 96110, 96111, 96125, 97533, G0515
L34048	Vertebroplasty and Vertebral Augmentation (Percutaneous)	10/1/2015	10/1/2015	9/29/2016	Active	22510, 22511, 22512, 22513, 22514, 22515,76380
L34049	Outpatient Physical and Occupational Therapy Services	10/1/2015	1/1/2018	5/31/2018	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 90911 95831 95832 95833 95834 95851 95852 96125 97010 97012 97016 97018 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039 97110 97112 97113 97116 97124 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 G0515
L34055	Virtual Colonoscopy (CT Colonography)	10/1/2015	10/1/2017	9/14/2017	Active	74261, 74262
L34056	Urodynamics	10/1/2015	10/1/2016	9/29/2016	Active	51725, 51726, 51727, 51728, 51729, 51736, 51741, 51792, 51797
L34061	Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)	10/1/2015	10/1/2017	07/30/2018	Active	92133, 92134
L34062	Dialysis Access Maintenance	10/1/2015	1/1/2018	1/30/2018	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
L34063	RAST Type Tests	10/1/2015	10/1/2015	7/30/2018	Active	86001, 86003, 86005
L34064	Panretinal (Scatter) Laser Photocoagulation	10/1/2015	10/1/2016	2/26/2018	Active	67228
L34081	Endoscopy by Capsule	10/1/2015	10/1/2017	2/26/2018	Active	91110, 91111, 91299
L34082	Varicose Veins of the Lower Extremity, Treatment of	10/1/2015	1/1/2018	3/6/2018	Active	36468, 36470, 36471, 36475, 36476, 36478, 36479, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37799, 76942, 93970, 93971
L34084	Transcatheter Infusion Therapy	10/1/2015	10/1/2016	8/28/2017	Active	61650, 61651
L34085	Post-Void Residual Urine and/or Bladder Capacity by Ultrasound	10/1/2015	10/1/2016	2/26/2018	Active	51798
L34087	Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs): Office, Hospital, Web, or Non-Web Based	10/1/2015	10/1/2015	10/4/2017	Active	93282, 93283, 93284, 93287, 93289, 93292, 93295, 93296
L34089	Human Papillomavirus (HPV) Testing	10/1/2015	10/1/2015	3/28/2018	Active	87623, 87624
L34090	Laser Ablation of the Prostate	10/1/2015	10/1/2015	3/28/2018	Active	52647, 52648, 52649
L34093	Chemotherapy and Biologicals	10/1/2015	06/01/2018	08/01/2018	Active	N/A
L34171	Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation	10/1/2015	10/1/2015	5/31/2018	Active	68801 68810 68811 68815 68816 68840
L34175	Ophthalmic Angiography (Fluorescein and Indocyanine Green)	10/1/2015	10/1/2016	5/31/2018	Active	92235 92240
L34181	Ophthalmic Biometry for Intraocular Lens Power Calculation	10/1/2015	10/1/2016	5/31/2018	Active	76519 92136
L34183	Psychiatric Inpatient Hospitalization	10/1/2015	10/1/2016	2/26/2018	Active	N/A
L34195	Mohs Micrographic Surgery	10/1/2015	3/1/2017	4/30/2018	Active	17311, 17312, 17313, 17314, 17315
L34196	Psychiatric Partial Hospitalization Programs	10/1/2015	10/1/2016	2/26/2018	Active	90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90899, 96101, 96102, 96103, 96116, 96118, 96119, 96120,G0129,G0176, G0177, G0410, G0411
L34200	Removal of Benign Skin Lesions	10/1/2015	11/1/2017	07/30/2018	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
L34246	Routine Foot Care and Debridement of Nails	10/1/2015	10/1/2017	07/30/2018	Active	11055, 11056, 11057, 11719, 11720, 11721, G0127
L34337	Transesophageal Echocardiography (TEE)	10/1/2015	11/27/2017	11/27/2017	Active	76376, 76377, 93312, 93313, 93314, 93315, 93316, 93317, 93318, 93320, 93321, 93325, C8925, C8926, C8927
L34338	Transthoracic Echocardiography (TTE)	10/1/2015	10/1/2017	9/15/2017	Active	Group 1 Codes: 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 Codes: C9399, J0153, J0280, J0461, J1245, J1250, J2785, J3490
L34353	Outpatient Psychiatry and Psychology Services	10/1/2015	10/1/2016	5/31/2018	Active	90785, 90791, 90792, 90832,90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90863, 90865, 90870, 90880, 90885, 90887, 90899, 96101, 96102, 96103, 96105, 96110, 96111, 96116, 96118, 96119, 96120
L34356	Erythropoiesis Stimulating Agents (ESA)	10/1/2015	10/1/2017	7/9/2018	Active	J0881, J0882, J0885, J0890, Q4081, Q5105, Q5106
L34370	Category III CPT® Codes	10/1/2015	3/18/2018	2/26/2018	Active	N/A
L34393	Ocular Photography - External	10/1/2015	10/1/2015	4/30/2018	Active	92285
L34394	Visual Fields Testing	10/1/2015	10/1/2017	9/15/2017	Active	92081, 92082, 92083
L34399	Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)	10/1/2015	10/1/2017	5/31/2018	Active	92225 92226 92227 92228 92250
L34539	Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians	10/1/2015	10/1/2015	2/26/2018	Active	90785, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90846, 90847, 90849, 90853, 90863, 90880, 90899
L34540	Stretta Procedure	10/1/2015	10/1/2015	8/28/2017	Active	43257
L34541	Transtelephonic Spirometry	10/1/2015	10/1/2015	9/29/2016	Active	94014, 94015, 94016
L34807	Lumbar Epidural Steroid Injections (ESI)	10/1/2015	10/1/2017	12/21/2017	Active	62323, 62327, 64483, 64484,
L34832	Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy	10/1/2015	10/1/2016	12/21/2017	Active	64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636
L35249	Nerve Blocks for Peripheral Neuropathy	10/1/2015	10/1/2015	4/30/2018	Active	64450 76881 76882 76942 76999 97032 97139 G0282 G0283
L35332	MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing	10/1/2015	10/1/2017	12/22/2017	Active	81225, 81226, 81227, 81355, 81479
L35349	MolDX: Genetic Testing for Lynch Syndrome	10/1/2015	10/13/2016	10/30/2017	Active	Group 1: 81210, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81319, 81403, 81435, 81479 Group 2: 81445, 81455
L35442	MolDX: NRAS Genetic Testing	10/1/2015	1/19/2017	2/7/2017	Active	81311, 81479
L35443	MolDX: GeneSight ® Assay for Refractory Depression	10/1/2015	3/8/2018	07/24/2018	Active	81479
L35891	Intravenous Immune Globulin	10/1/2015	3/1/2018	3/28/2018	Active	J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572,
L35897	Nerve Conduction Studies and Electromyography	10/1/2015	10/1/2017	4/30/2018	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
L35906	Somatosensory Testing	10/1/2015	10/1/2017	3/28/2018	Active	95925, 95926, 95927, 95928
L35984	MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)	10/1/2015	12/31/2015	7/2/2018	Active	81240, 81241, 81291
L35986	Special Histochemical Stains and Immunohistochemical Stains	10/1/2015	8/31/2017	8/23/2017	Active	88312, 88313, 88341, 88342, 88344, 88360, 88361
L36002	MolDX: Prolaris™ Prostate Cancer Genomic Assay	10/5/2015	1/1/2018	07/30/2018	Active	81541
L36006	MolDX-CDD: ConfirmMDx Epigenetic Molecular Assay	10/5/2015	1/1/2018	12/13/2017	Active	81551
L36011	MolDX: Molecular RBC Phenotyping	10/5/2015	1/1/2018	7/2/2018	Active	0001U
L36021	Molecular Diagnostic Tests (MDT)	10/1/2015	4/5/2018	4/4/2018	Active	81161 81162 81170 81175 81176 81200 81201 81202 81203 81205 81206 81207 81208 81209 81210 81211 81212 81213 81214 81215 81216 81217 81218 81219 81220 81221 81222 81223 81224 81225 81226 81227 81228 81229 81230 81231 81232 81235 81238 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 81272 81273 81275 81276 81283 81287 81288 81290 81291 81292 81293 81294 81295 81296 81297 81298 81299 81300 81301 81302 81303 81304 81310 81311 81313 81314 81315 81316 81317 81318 81319 81321 81322 81323 81324 81325 81326 81327 81328 81330 81331 81332 81334 81335 81340 81341 81342 81346 81350 81355 81361 81362 81363 81364 81370 81371 81372 81373 81374 81375 81376 81377 81378 81379 81380 81381 81382 81383 81400 81401 81402 81403 81404 81405 81406 81407 81408 81410 81411 81412 81413 81414 81415 81416 81417 81420 81422 81425 81426 81427 81430 81431 81432 81433 81434 81435 81436 81437 81438 81439 81440 81442 81445 81448 81450 81455 81460 81465 81470 81471 81479 81490 81493 81500 81503 81504 81506 81507 81508 81509 81510 81511 81512 81519 81520 81521 81525 81528 81535 81536 81538 81539 81540 81541 81545 81551 81595 81599 84999 85999 86849 87999 88199 88299 88380 88381 88399 89398 G0452 0001M 0002M 0003M 0004M 0006M 0007M 0008M 0009M
L36029	Controlled Substance Monitoring and Drugs of Abuse Testing	10/5/2015	10/1/2017	7/2/2018	Active	80305, 80306, 80307, G0480, G0481, G0482, G0483, G0659
L36048	MolDX: HLA-B*15:02 Genetic Testing	10/5/2015	10/5/2015	5/31/2018	Active	81381
L36113	MolDX: MGMT Promoter Methylation Analysis	10/5/2015	10/5/2017	5/31/2018	Active	81287
L36117	MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease	10/5/2015	10/5/2017	7/2/2018	Active	81206, 81207, 81208, 81219, 81270, 81402, 81403, 81445, 81450, 81455, 81479
L36139	MolDX: Biomarkers in Cardiovascular Risk Assessment	10/5/2015	10/1/2016	7/2/2018	Active	82172, 82610, 83090, 83695, 83698, 83700, 83701, 83704, 83719, 83719, 83721, 86141
L36174	MolDX: NSCLC, Comprehensive Genomic Profile Testing	10/1/2015	10/5/2017	7/2/2018	Active	81445, 81455, 81479
L36206	MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay	10/5/2015	1/1/2018	5/31/2018	Active	81479
L36425	MolDX: Breast Cancer Assay: Prosigna	2/1/2016	1/1/2018	12/13/2017	Active	81520
L36456	MolDX: BRCA1 and BRCA2 Genetic Testing	2/15/2016	07/12/2018	07/24/2018	Active	81162, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81432, 81445, 81455, 81479
L36458	MolDX: Breast Cancer Index™ Genetic Assay	2/1/2016	2/1/2016	7/2/2018	Active	81479
L36460	Bone Mass Measurement	2/1/2016	3/1/2018	5/7/2018	Active	76977, 77078, 77080, 77081, 77085, 78350, 78351, G0130
L36469	Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder	2/8/2016	2/8/2016	12/21/2017	Active	90867, 90868, 90869
L36485	MolDX: HLA-DQB1*06:02 Testing for Narcolepsy	2/15/2016	3/6/2017	12/21/2017	Active	81383
L36494	Minimally-Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint	2/1/2016	2/1/2016	12/21/2017	Active	27279
L36656	MolDX: Decipher® Prostate Cancer Classifier Assay	10/10/2016	3/8/2018	5/23/2018	Active	81479
L36658	Proton Beam Therapy	10/24/2016	8/28/2017	8/28/2017	Active	77520, 77522, 77523, 77525
L36675	MolDX- CDD: ProMark Risk Score	10/10/2016	10/17/2017	11/2/2017	Active	81479
L36690	Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities	10/10/2016	1/1/2018	5/25/2018	Active	Group 1 Codes: 15002, 15003, 15004, 15005, 15040, 15050, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278 Group 2 Codes: Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111, Q4115, Q4117, Q4118, Q4121, Q4122, Q4123, Q4124, Q4126, Q4127, Q4128, Q4131, Q4132, Q4133, Q4134, Q4135, Q4136, Q4137, Q4140, Q4141, Q4146, Q4147, Q4148, Q4151, Q4152, Q4153, Q4154, Q4156, Q4157, Q4158, Q4159, Q4160, Q4161, Q4163, Q4164, Q4165, Q4169, Q4172, Q4173, Q4174, Q4175
L36902	Polysomnography and Other Sleep Studies	3/6/2017	3/6/2017	1/30/2018	Active	Group 1 95782, 95783, 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400 Group 2 95803
L36906	GlycoMark Testing for Glycemic Control	3/6/2017	3/6/2017	4/4/2018	Active	84378, 84999
L36908	MolDX: Percepta© Bronchial Genomic Classifier	3/13/2017	7/20/2017	7/28/2017	Active	81479
L36910	MolDX: APC and MUTYH Gene Testing	3/13/2017	3/8/2018	4/4/2018	Active	81201, 81202, 81203, 81403, 81406, 81435, 81479
L36951	MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)	3/6/2017	7/20/2017	7/24/2017	Active	81479
L36973	MolDX: Circulating Tumor Cell Marker Assays	3/6/2017	7/20/2017	3/28/2018	Active	86152, 86153
L36975	Bladder/Urothelial Tumor Markers	3/6/2017	3/23/2017	1/30/2018	Active	86294, 86316,86386, 88120 ,88121
L36979	MolDX: 4Kscore Assay	3/13/2017	N/A	1/18/2017	Active	81539
L37126	Coenzyme Q10 (CoQ10)	7/10/2017	7/10/2017	5/31/2018	Active	N/A
L37130	MolDX: DecisionDx-UM (Uveal Melanoma)	7/10/2017	7/20/2017	5/31/2018	Active	81599
L37134	MolDX: Xpresys Lung	7/10/2017	7/13/2017	5/31/2018	Active	81599
L37142	MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease	7/10/2017	1/1/2018	5/31/2018	Active	81541
L37254	Chiropractic Services	11/6/2017	1/16/2018	N/A	Active	98940, 98941, 98942
L37352	MolDX: Prometheus IBD sgi Diagnostic Policy	11/6/2017	3/8/2018	1/12/2018	Active	81479, 82397, 83520, 86140
L37354	MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer	3/6/2018	N/A	N/A	Active	81479
L37356	MolDX: EndoPredict Breast Cancer Gene Expression Test	3/6/2018	N/A	1/12/2018	Active	81599
L37362	MolDX: AlloSure® Donor-Derived Cell-Free DNA Test	3/6/2018	N/A	1/12/2018	Active	81479
L37578	Micro-Invasive Glaucoma Surgery (MIGS)	3/19/2018	3/19/2018	1/26/2018	Active	0191T, 0449T, 0450T, 0474T, 0376T

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