Corporate

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 When using the individual links provided below there may be times that you will receive the message "superseded", indicating you are not viewing the most current LCD.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 If you get the note "superseded" on a policy, please use the main link listed below for current LCDs to the MCD provided while we complete the process of updating the individual links.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 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 IndexExternal Website, where providers can browse LCDs by contractor.

ID Title Effective Date Revision Effective Date Last Updated Status HCPC/CPT code
L32553External Website Allergy Immunotherapy 10/1/2015 3/28/2019 3/22/2019 Active N/A
L33943External Website B-type Natriuretic Peptide (BNP) Testing 10/1/2015 3/28/2019 3/22/2019 Active N/A
L36975External Website Bladder/Urothelial Tumor Markers 3/6/2017 4/4/2019 3/28/2019 Active N/A
L33944External Website Blepharoplasty 10/1/2015 3/28/2019 3/25/2019 Active N/A
L36460External Website Bone Mass Measurement 2/1/2016 7/1/2018 3/20/2019 Active 76977, 77078, 77080, 77081, 77085, 78350, 78351, G0130, 0508T
L33949External Website Botulinum Toxins 10/1/2015 4/4/2019 3/29/2019 Active N/A
L33950External Website Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography 10/1/2015 1/1/2019 3/25/2019 Active N/A
L33946External Website Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy 10/1/2015 4/18/2019 4/8/2019 Active N/A
L33959External Website Cardiac Catheterization and Coronary Angiography 10/1/2015 4/18/2019 4/8/2019 Active N/A
L33947External Website Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) 10/1/2015 4/4/2019 3/29/2019 Active N/A
L33952External Website Cardiac Event Detection 10/1/2015 4/4/2019 3/29/2019 Active N/A
L33960External Website Cardiovascular Nuclear Medicine 10/1/2015 4/18/2019 4/8/2019 Active N/A
L33954External Website Cataract Extraction 10/1/2015 10/1/2016 5/15/2019 Active N/A
L34370External Website Category III CPT® Codes 10/1/2015 3/18/2018 12/26/2018 Active N/A
L33945External Website Cerumen (Earwax) Removal 10/1/2015 4/4/2019 3/28/2019 Active N/A
L34093External Website Chemotherapy and Biologicals 10/1/2015 8/22/2019 8/16/2019 Active N/A
L37254External Website Chiropractic Services 11/6/2017 4/4/2019 3/29/2019 Active N/A
L37126External Website Coenzyme Q10 (CoQ10) 7/10/2017 2/7/2019 6/11/2019 Active N/A
L34005External Website Colonoscopy/Sigmoidoscopy/ Proctosigmoidoscopy 10/1/2015 4/4/2019 3/29/2019 Active N/A
L34008External Website Computerized Corneal Topography 10/1/2015 8/8/2019 7/31/2019 Active N/A
L36029External Website Controlled Substance Monitoring and Drugs of Abuse Testing 10/5/2015 10/1/2018 5/6/2019 Active 80305, 80306, 80307, G0480, G0481, G0482, G0483, G0659
L33999External Website Corneal Pachymetry 10/1/2015 4/4/2019 3/28/2019 Active N/A
L34032External Website Debridement Services 10/1/2015 4/4/2019 3/29/2019 Active N/A
L34062External Website Dialysis Access Maintenance 10/1/2015 4/4/2019 3/29/2019 Active N/A
L34081External Website Endoscopy by Capsule 10/1/2015 10/1/2017 2/26/2018 Active 91110, 91111, 91299
L34356External Website Erythropoiesis Stimulating Agents (ESA) 10/1/2015 10/1/2018 9/26/2018 Active J0881, J0882, J0885, J0890, Q4081, Q5105, Q5106
L34832External Website Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy 10/1/2015 10/1/2016 12/26/2018 Active 64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636
L34037External Website Flow Cytometry 10/1/2015 10/1/2018 2/27/2019 Active 86355, 86356, 86357, 86359, 86360, 86361, 86367, 88182, 88184, 88185, 88187, 88188, 88189
L37575 External Website Frequency of Hemodialysis 4/1/2019 N/A 1/31/2019 Future 90999
L36906External Website GlycoMark Testing for Glycemic Control 3/6/2017 3/6/2017 3/12/2019 Active 84378, 84999
L34089External Website Human Papillomavirus (HPV) Testing 10/1/2015 10/1/2015 3/12/2019 Active 87623, 87624
L35891External Website Intravenous Immune Globulin 10/1/2015 8/1/2019 7/26/2019 Active N/A
L34090External Website Laser Ablation of the Prostate 10/1/2015 4/11/2019 4/5/2019 Active N/A
L34807External Website Lumbar Epidural Steroid Injections (ESI) 10/1/2015 4/11/2019 4/5/2019 Active N/A
L37790External Website Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor 10/1/2018 4/11/2019 4/5/2019 Active N/A
L37578External Website Micro-Invasive Glaucoma Surgery (MIGS) 3/19/2018 11/8/2018 3/12/2019 Active 0191T, 0449T, 0450T, 0376T
L36494External Website Minimally-Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint 2/1/2016 2/1/2016 12/26/2018 Active 27279
L34195External Website Mohs Micrographic Surgery 10/1/2015 8/8/2019 8/1/2019 Active N/A
L36979External Website MolDX: 4Kscore Assay 3/13/2017 8/29/2019 8/19/2019 Active 81539
L37362External Website MolDX: AlloSure® Donor-Derived Cell-Free DNA Test 3/6/2018 N/A 1/28/2019 Active 81479
L36910External Website MolDX: APC and MUTYH Gene Testing 3/13/2017 8/8/2019 8/1/2019 Active N/A
L37134External Website MolDX: BDX-XL2 7/10/2017 8/29/2019 8/19/2019 Active N/A
L36139External Website MolDX: Biomarkers in Cardiovascular Risk Assessment 10/5/2015 10/1/2018 6/21/2019 Active 82172, 82610, 83090, 83695, 83698, 83700, 83701, 83704, 83719, 83721, 86141
L36456External Website MolDX: BRCA1 and BRCA2 Genetic Testing 2/15/2016 1/1/2019 12/26/2018 Active 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 81432, 81445, 81455, 81479
L36425External Website MolDX: Breast Cancer Assay: Prosigna 2/1/2016 1/1/2018 8/13/2018 Active 81520
L37832External Website MolDX: Breast CancerTM (BCI) Gene Expression Test 4/1/2019 4/1/2019 2/14/2019 Active 81518
L36006External Website MolDX-CDD: ConfirmMDx Epigenetic Molecular Assay 10/5/2015 1/1/2018 8/13/2018 Active 81551
L36675External Website MolDX- CDD: ProMark Risk Score 10/10/2016 10/17/2017 10/30/2018 Active 81479
L36973External Website MolDX: Circulating Tumor Cell Marker Assays 3/6/2017 7/20/2017 3/12/2019 Active 86152, 86153
L37787External Website MolDX: Corus® CAD Assay 11/12/2018 8/29/2019 8/19/2019 Active N/A
L35332External Website MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing 10/1/2015 1/1/2019 12/21/2018 Active Group 1:
81225

Group 2:
81226, 0070U

Group 3:
81227, 81355
Group 4: 81479
L37598External Website MolDX: Cystatin C Measurement 12/17/2018 N/A 10/24/2018 Active 82610
L37834External Website MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease 4/29/2019 5/9/2019 5/17/2019 Active 81479
L36656External Website MolDX: Decipher® Prostate Cancer Classifier Assay 10/10/2016 5/9/2019 5/17/2019 Active 81479
L38016External Website MolDX: DecisionDx-Melanoma 6/24/2019 N/A 4/10/2019 Future 81599
L37130External Website MolDX: DecisionDx-UM (Uveal Melanoma) 7/10/2017 1/1/2019 5/28/2019 Active 0081U
L37356External Website MolDX: EndoPredict Breast Cancer Gene Expression Test 3/6/2018 8/23/2018 1/28/2019 Active 81599
L37905External Website MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test 5/20/2019 5/20/2019 3/29/2019 Active 81479
L37364External Website MolDX: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs) 1/7/2019 5/23/2019 5/17/2019 Active N/A
L35443External Website MolDX: GeneSight Assay for Refractory Depression 10/1/2015 8/22/2019 8/16/2019 Active N/A
L36117External Website MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease 10/5/2015 10/5/2017 6/13/2019 Active 81206, 81207, 81208, 81219, 81270, 81402, 81403, 81445, 81450, 81455, 81479
L35984External Website MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) 10/1/2015 12/31/2015 6/19/2019 Active 81240, 81241, 81291
L35349External Website MolDX: Genetic Testing for Lynch Syndrome 10/1/2015 9/3/2018 10/30/2018 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
L36206External Website MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay 10/5/2015 1/1/2018 5/28/2019 Active 81479
L37366External Website MolDX: Guardant360® Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC) 11/19/2018 N/A 9/25/2018 Active 81479
L36048External Website MolDX: HLA-B*15:02 Genetic Testing 10/5/2015 2/26/2018 5/28/2019 Active 81381
L36485External Website MolDX: HLA-DQB1*06:02 Testing for Narcolepsy 2/15/2016 3/6/2017 12/26/2018 Active 81383
L37903External Website MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer 5/13/2019 5/13/2019 3/26/2019 Active 81479
L37608External Website MolDX: MDS FISH 5/6/2019 8/22/2019 8/14/2019 Active N/A
L36113External Website MolDX: MGMT Promoter Methylation Analysis 10/5/2015 10/5/2017 5/28/2019 Active 81287
L36011External Website MolDX: Molecular RBC Phenotyping 10/5/2015 1/1/2018 6/13/2019 Active 0001U
L37348External Website MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels 12/3/2018 12/3/2018 10/11/2018 Active 87631, 87632, 87633
L37907External Website MolDX: myPath Melanoma Assay 6/30/2019 N/A 4/11/2019 Active 81479
L37836External Website MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC) 3/25/2019 N/A 1/28/2019 Future 81479
L36951External Website MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) 3/6/2017 10/1/2018 12/12/2018 Active 0045U
L37354External Website MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer 3/6/2018 1/1/2019 2/14/2019 Active 0047U
L36908External Website MolDX: Percepta® Bronchial Genomic Classifier 3/13/2017 7/20/2017 11/26/2018 Active 81479
L36002External Website MolDX: Prolaris™ Prostate Cancer Genomic Assay 10/5/2015 1/1/2018 7/22/2019 Active N/A
L37142External Website MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease 7/10/2017 8/22/2019 8/14/2019 Active N/A
L37352External Website MolDX: Prometheus IBD sgi Diagnostic Policy 11/6/2017 8/29/2019 8/19/2019 Active N/A
L36021External Website Molecular Diagnostic Tests (MDT) 10/1/2015 10/01/2018 11/26/2018 Active 81105-81112, 81120, 81121, 81161-81599, 84999, 85999, 86152, 86153, 86849, 87999, 88120, 88121, 88199, 88299, 0001M, 0002M, 0003M, 0004M, 0006M, 0007M, 0009M, 0011M, 0012M, 0013M, 0001U, 0002U, 0003U, 0005U-0014U, 0016U-0019U, 0021U-0027U, 0029U-0044U
L34171External Website Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation 10/1/2015 10/1/2015 5/28/2019 Active 68801 68810 68811 68815 68816 68840
L35249External Website Nerve Blocks for Peripheral Neuropathy 10/1/2015 10/1/2015 4/10/2019 Active 64450 76881 76882 76942 76999 97032 97139 G0282 G0283
L35897External Website Nerve Conduction Studies and Electromyography 10/1/2015 10/1/2018 4/10/2019 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
L34045External Website Non-Invasive Vascular Studies 10/1/2015 7/11/2019 7/5/2019 Active N/A
L34393External Website Ocular Photography - External 10/1/2015 10/1/2018 4/10/2019 Active 92285
L34181External Website Ophthalmic Biometry for Intraocular Lens Power Calculation 10/1/2015 6/6/2019 5/29/2019 Active 76519 92136
L34181External Website Ophthalmic Biometry for Intraocular Lens Power Calculation 10/1/2015 10/1/2016 5/6/2019 Active 76519 92136
L34399External Website Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) 10/1/2015 10/1/2017 5/31/2018 Active 92225 92226 92227 92228 92250
L34049External Website Outpatient Physical and Occupational Therapy Services 10/1/2015 1/1/2018 5/28/2019 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
L34353External Website Outpatient Psychiatry and Psychology Services 10/1/2015 1/1/2019 5/29/2019 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
L34064External Website Panretinal (Scatter) Laser Photocoagulation 10/1/2015 10/1/2016 2/27/2019 Active 67228
L36902External Website Polysomnography and Other Sleep Studies 3/6/2017 3/6/2017 1/28/2019 Active Group 1 95782, 95783, 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400

Group 2 95803
L34085External Website Post-Void Residual Urine and/or Bladder Capacity by Ultrasound 10/1/2015 10/1/2016 2/27/2019 Active 51798
L36658External Website Proton Beam Therapy 10/24/2016 10/1/2018 9/19/2018 Active 77520, 77522, 77523, 77525
L34183External Website Psychiatric Inpatient Hospitalization 10/1/2015 10/1/2018 9/14/2018 Active N/A
L34196External Website Psychiatric Partial Hospitalization Programs 10/1/2015 1/1/2019 4/26/2019 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
L34539External Website Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians 10/1/2015 10/1/2015 2/27/2019 Active 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90846, 90847, 90849, 90853, 90863, 90880, 90899
L34063External Website RAST Type Tests 10/1/2015 10/1/2015 7/22/2019 Active 86001, 86003, 86005
L34200External Website Removal of Benign Skin Lesions 10/1/2015 10/1/2018 7/22/2019 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
L36469External Website Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder 2/8/2016 2/8/2016 12/26/2018 Active 90867, 90868, 90869
L34246External Website Routine Foot Care and Debridement of Nails 10/1/2015 10/1/2018 7/22/2019 Active 11055, 11056, 11057, 11719, 11720, 11721, G0127
L34061External Website Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) 10/1/2015 7/11/2019 7/22/2019 Active N/A
L35906External Website Somatosensory Testing 10/1/2015 10/1/2018 3/13/2019 Active 95925, 95926, 95927, 95928
L35986External Website Special Histochemical Stains and Immunohistochemical Stains 10/1/2015 8/22/2019 8/16/2019 Active N/A
L34046External Website Speech-Language Pathology 10/1/2015 1/1/2019 7/22/2019 Active 31579, 92507, 92508, 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92609, 92626, 92627, 96105, 96110, 96112, 96113, 96125, 97533, G0515
L34540External Website Stretta Procedure 10/1/2015 10/1/2015 8/13/2018 Active 43257
L34087External Website Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs): Office, Hospital, Web, or Non-Web Based 10/1/2015 10/1/2015 8/13/2018 Active 93282, 93283, 93284, 93287, 93289, 93292, 93295, 93296
L34084External Website Transcatheter Infusion Therapy 10/1/2015 10/1/2018 9/21/2018 Active 61650, 61651
L34337External Website Transesophageal Echocardiography (TEE) 10/1/2015 10/1/2018 9/20/2018 Active 76376, 76377, 93312, 93313, 93314, 93315, 93316, 93317, 93318, 93320, 93321, 93325, C8925, C8926, C8927
L34541External Website Transtelephonic Spirometry 10/1/2015 10/1/2015 9/27/2018 Active 94014, 94015, 94016
L34338External Website Transthoracic Echocardiography (TTE) 10/1/2015 10/1/2018 11/13/2018 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
L34056External Website Urodynamics 10/1/2015 10/1/2018 11/7/2018 Active 51725, 51726, 51727, 51728, 51729, 51736, 51741, 51792, 51797
L34082External Website Varicose Veins of the Lower Extremity, Treatment of 10/1/2015 1/1/2018 9/27/2018 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
L34048External Website Vertebroplasty and Vertebral Augmentation (Percutaneous) 10/1/2015 8/29/2019 8/22/2019 Active N/A
L34055External Website Virtual Colonoscopy (CT Colonography) 10/1/2015 10/1/2017 9/27/2018 Active 74261, 74262
L34394External Website Visual Fields Testing 10/1/2015 10/1/2018 9/27/2018 Active 92081, 92082, 92083
L33996External Website Vitamin D Assay Testing 10/1/2015 5/1/2017 9/27/2018 Active 82306
L36690External Website Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities 10/10/2016 7/11/2019 7/5/2019 Active N/A

Updated: 09.04.19


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