LCDs & Medical Policies
A Local Coverage Determination (LCD), as defined in §1869(f)(2)(B) of the Social Security Act (SSA), is a Medicare Administrative Contractor's (MAC's) determination as to whether a particular item or service is covered on a contractor–wide basis in accordance with section 1862(a)(1)(A) of the Act.
Reference the CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 13
for details about the LCD process.
CGS Resources
- Clinical Trials
- Educational Articles
- LCD & Medical Policy Stakeholder Meetings
- Request a New LCD
- Request a Revision to an Active LCD
- Submit Draft LCD Comments

How to Find CGS J15 LCDs & Articles
NOTE: CMS and MACs don't develop an NCD or LCD for each item or service that Medicare covers. In the absence of a national or local coverage policy, reference the Social Security Act, CMS Medicare Benefit Policy Manual (Pub. 100-02)
, Code of Federal Regulations, and CMS or CGS websites for coverage guidance.
- Search the Medicare Coverage Database (MCD)
(includes all national and local coverage policy document types) or MCD Archive
(contains outdated (no longer in effect) LCDs and articles). See MCD Help & Resources
for details. - Use the direct links to CGS J15 active and future LCDs and articles provided in the table below (listed alphabetically by title).
- Download a copy of the table below in Excel spreadsheet format
(Revised 11.05.2025) for additional sort and filter capabilities.
| ID | Title | Effective Date | Revision Effective Date | Last Updated | Status | HCPCS/CPT Code | Article(s) |
|---|---|---|---|---|---|---|---|
| L40056 |
Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT) | 10/26/25 | N/A | N/A | Active | 95115, 95117, 95144, 95165, 95180 | A59981 |
| L32553 |
Allergy Immunotherapy | 10/1/15 | 11/7/24 | 10/29/24 | Active | 95115, 95117, 95144, 95145, 95146, 95147, 95148, 95149, 95165, 95170, 95180, 95199 | A56424 |
| L39434 |
Allogenic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin | 2/19/23 | 2/6/25 | 2/25/25 | Active | 38240 | A59215 |
| L39575 |
Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound | 12/10/23 | N/A | N/A | Active | Q4139, Q4145, Q4155, Q4162, Q4168, Q4171, Q4174, Q4177, Q4185, Q4189, Q4192, Q4206, Q4212, Q4213, Q4215, Q4230, Q4231, Q4233, Q4240, Q4241, Q4242, Q4244, Q4245, Q4246 | A59374 |
| N/A | ArgusM II Retinal Prosthesis System | 10/1/15 | 11/16/23 | 11/7/23 | Active | L8608, 0100T | A54327 |
| L39840 |
Artificial Intelligence Enabled CT Based Quantitative Coronary Topography (AI-QCT)/Coronary Plaque Analysis (AI-CPA) | 11/24/24 | 2/14/25 | 2/14/25 | Active | 0623T, 0624T, 0625T, 0626T | A59716 |
| L36975 |
Bladder/Urothelial Tumor Markers | 3/6/17 | 2/6/25 | 1/31/25 | Active | 86294, 86316, 86386, 88120, 88121 | A56471 |
| L33944 |
Blepharoplasty | 10/1/15 | 11/7/24 | 10/29/24 | 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 |
| L36460 |
Bone Mass Measurement | 2/1/16 | 1/4/24 | 12/29/23 | Active | 76977, 77078, 77080, 77081, 77085, 78350, 78351, G0130, 0554T, 0555T, 0556T, 0557T, 0558T | A57132 |
| L33949 |
Botulinum Toxins | 10/1/15 | 2/6/25 | 1/31/25 | Active | Group 1: 31573, 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 |
| L33950 |
Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography | 10/1/15 | 12/5/24 | 11/25/24 | Active | 19030, 76641, 76642, 77046, 77047, 77048, 77049, 77053, 77054, 77063, 77065, 77066, 77067, C8903, C8905, C8906, C8908, G0279 | A56448 |
| L33943 |
B-type Natriuretic Peptide (BNP) Testing | 10/1/15 | 12/5/24 | 11/25/24 | Active | 83880 | A56425 |
| L33946 |
Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy | 10/1/15 | 11/7/24 | 10/29/24 | Active | 66820, 66821 | A56493 |
| L33959 |
Cardiac Catheterization and Coronary Angiography | 10/1/15 | 11/7/24 | 10/29/24 | Active | Group 1: 92978, 92979, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93462, 93463, 93464, 93503, 93505, 93563, 93564, 93565, 93566, 93567, 93568, 93571, 93572, 93593, 93594, 93595, 93596, 93597, 93598, 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 |
| L33947 |
Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) | 10/1/15 | 10/9/25 | 9/30/25 | Active | 75571, 75572, 75573, 75574 | A56451 |
| L33952 |
Cardiac Event Detection | 10/1/15 | 12/5/24 | 11/25/24 | Active | 93228, 93229, 93268, 93270, 93271, 93272, 93799 | A56452 |
| L33960 |
Cardiovascular Nuclear Medicine | 10/1/15 | 2/6/25 | 1/31/25 | 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 |
| L33954 |
Cataract Extraction | 10/1/15 | 1/4/24 | 12/29/23 | Active | 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984 | A56453 |
| L33945 |
Cerumen (Earwax) Removal | 10/1/15 | 2/6/25 | 1/31/25 | Active | 69209, 69210, G0268 | A56454 |
| L39741 |
Cervical Fusion | 7/7/2024 | 2/6/25 | 1/29/25 | Active | 22548, 22551, 22552, 22554, 22590, 22595, 22600 | A59608 |
| L37254 |
Chiropractic Services | 11/6/17 | 2/6/25 | 1/31/25 | Active | 98940, 98941, 98942 | A56455 |
| N/A | Clinical Trials Medical Policy Article | 10/1/15 | 11/16/23 | 11/7/23 | Active | N/A | A52430 |
| L37126 |
Coenzyme Q10 (CoQ10) | 7/10/17 | 2/6/25 | 1/31/25 | Active | 82542 | A55715 |
| L38777 |
Colon Capsule Endoscopy (CCE) | 3/29/21 | 1/30/22 | 12/10/21 | Active | N/A | A58362 |
| L34005 |
Colonoscopy/Sigmoidoscopy/ Proctosigmoidoscopy | 10/1/15 | 2/6/25 | 1/31/25 | 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 |
| L38694 |
Computed Tomography Cerebral Perfusion Analysis (CTP) | 6/17/21 | 8/7/25 | 7/31/25 | Active | 0042T | A58218 |
| L34008 |
Computerized Corneal Topography | 10/1/15 | 2/6/25 | 1/31/25 | Active | 92025 | A56816 |
| L33999 |
Corneal Pachymetry | 10/1/15 | 2/1/24 | 1/25/24 | Active | 76514 | A56457 |
| L39506 |
Cosmetic and Reconstructive Surgery | 5/28/23 | N/A | 4/6/23 | Active | Group 1: 19316, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19368, 19369, 19370, 19371, 19380, 19396 Group 2: 19318 Group 3: 19300 Group 4: 11920, 11921, 11922 Group 5: 15775, 15776 Group 6: 30400-30450, 30460, 30462, 30520 Group 7: 15788-15793 Group 8: 15830, 15847, 15877 Group 9: G0429, Q2026, Q2028 Group 10: 15828, 15829 Group 11: 11950-11954, 15780, 15782, 15783, 15819, 15824-15826, 15832-15839, 15876, 15878, 15879, 17340, 17360, 17380, 69300 |
A59299 |
| L37598 |
Cystatin C Measurement | 12/17/18 | 2/20/25 | 2/10/25 | Active | 82610 | A56988 |
| L34032 |
Debridement Services | 10/1/15 | 10/2/25 | 9/26/25 | Active | 11000, 11001, 11042, 11043, 11044, 11045, 11046, 11047 | A56459 |
| L34062 |
Dialysis Access Maintenance | 10/1/15 | 2/6/25 | 1/31/25 | 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 |
| L38992 |
Electroretinography (ERG) | 1/30/22 | 1/12/23 | 1/4/23 | Active | 92273, 92274, 0509T | A58706 |
| L34081 |
Endoscopy by Capsule | 10/1/15 | 3/6/25 | 2/25/25 | Active | Group 1: 91110 Group 2: 91111, 91299 |
A56461 |
| L39015 |
Epidural Steroid Injections for Pain Management | 12/5/21 | 11/9/23 | 10/31/23 | Active | Group 1: 62321, 62323, 64479, 64480, 64483, 64484 Group 2: 62320, 62322 |
A58731 |
| L34356 |
Erythropoiesis Stimulating Agents (ESA) | 10/1/15 | 3/6/25 | 2/25/25 | Active | J0881, J0882, J0885, J0890. Q4081, Q5105, Q5106 | A56462 |
| L38773 |
Facet Joint Interventions for Pain Management | 5/2/21 | 8/21/25 | 8/15/25 | Active | Group 1 64490, 64491, 64493, 64494, 64633, 64634, 64635, 64636 Group 2 64492, 64495, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0219T, 0220T, 0221T, 0222T |
A58364 |
| N/A | FDA Approved CLL Companion Diagnostic Test | 6/5/18 | 2/6/25 | 1/31/25 | Active | 88271, 88275, 88291, 88374, 88377 | A56050 |
| L34037 |
Flow Cytometry | 10/1/15 | 2/27/25 | 2/21/25 | Active | Group 1: 88182, 88184, 88185, 88187, 88188, 88189 Group 2: 86355, 86356, 86357, 86359, 86360, 86361, 86367 |
A56464 |
| L38378 |
Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH) | 4/1/20 | 12/15/25 | 10/20/25 | Future | C2596, 0421T | A57926 |
| L37575 |
Frequency of Hemodialysis | 4/1/19 | 2/27/25 | 2/21/25 | Active | 90999 | A56159 |
| L36906 |
GlycoMark® Testing for Glycemic Control | 3/6/17 | 3/27/25 | 3/18/25 | Active | 84378, 84999 | A56465 |
| L38307 |
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea | 4/1/20 | 3/6/25 | 2/25/25 | Active | 64582, 64583, 64584 | A57149 |
| L38268 |
Immune Thrombocytopenia (ITP) Therapy | 4/1/20 | 3/6/25 | 2/25/25 | Active | 38100, 38120, 90283, J1459, J1460, J1556, J1557, J1560, J1561, J1566, J1568, J1569, J1572, J1599, J2788, J2790, J2791, J2792, J8499, J9312 | A57160 |
| N/A | Implantable Automatic Defibrillators | 1/1/21 | 11/22/23 | 11/16/23 | Active | 33202, 33203, 33215, 33216, 33217, 33218, 33220, 33223, 33224, 33225, 33230, 33231, 33240, 33241, 33243, 33244, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, G0448 | A57994 |
| L38662 |
Implantable Continuous Glucose Monitors (I-CGM) | 11/2/20 | 10/9/25 | 9/30/25 | Active | 0446T, 0447T, 0448T | A58127 |
| N/A | Influenza Diagnostic Test | 7/1/21 | 11/16/23 | 11/7/23 | Active | 87252, 87253, 87254, 87275, 87276, 87400, 87501, 87502, 87503, 87804 | A58817 |
| N/A | Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach (0192T 66183) | 10/1/15 | 11/16/23 | 11/7/23 | Active | 66183 | A52432 |
| L39958 |
Intervertebral Disc Repair | 4/13/25 | N/A | N/A | Active | 0627T, 0628T, 0629T, 0630T | A59880 |
| L35891 |
Intravenous Immune Globulin | 10/1/15 | 3/27/25 | 3/18/25 | Active | J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572 | A56779 |
| L34090 |
Laser Ablation of the Prostate | 10/1/15 | 3/27/25 | 3/18/25 | Active | 52647, 52648, 52649 | A56467 |
| N/A | Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) | 11/1/18 | 2/27/25 | 2/21/25 | Active | 11042, 11043, 11044, 11045, 11046, 11047, 97597, 97598, 97602, 97607, 97608, 97610 | A56175 |
| L37790 |
Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor | 10/1/18 | 9/4/25 | 8/29/25 | Active | 61715 | A58323 |
| L37608 |
MDS FISH | 5/6/19 | 8/7/25 | 7/31/25 | Active | 88271, 88273, 88274, 88275, 88291 | A56926 |
| L37578 |
Micro-Invasive Glaucoma Surgery (MIGS) | 3/19/18 | 3/27/25 | 3/18/25 | Active | Group 1: 66989, 66991 Group 2: 66183, 0449T, 0671T Group 3: 0253T, 0450T, 0474T, |
A56491 |
| L39802 |
Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ) | 4/17/25 | 5/15/25 | 5/9/25 | Active | Group 1: 27279 Group 2: 27278 |
A59682 |
| L34195 |
Mohs Micrographic Surgery | 10/1/15 | 5/1/25 | 4/25/25 | Active | 17311, 17312, 17313, 17314, 17315 | A56836 |
| N/A | MolDX: Algorithm definition as a component of a laboratory test | 3/11/21 | 11/16/23 | 11/7/23 | Active | N/A | A58677 |
| L36139 |
MolDX: Biomarkers in Cardiovascular Risk Assessment | 10/5/15 | 2/13/25 | 2/6/25 | Active | 81439, 82172, 82610, 83090, 83695, 83698, 83700, 83701, 83704, 83719, 83721, 86141 | A54685 A57386 |
| L38249 |
MolDX: Blood Product Molecular Antigen Typing | 11/1/20 | 4/10/25 | 4/4/25 | Active | Group 1: 81403, 0001U, 0084U Group 2: 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 0180U, 0181U, 0182U, 0183U, 0184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0221U, 0222U |
A57155 |
| L36425 |
MolDX: Breast Cancer Assay: Prosigna | 2/1/16 | 2/15/24 | 2/6/24 | Active | 81520 | A56989 |
| L37832 |
MolDX: Breast Cancer Index (BCI) Gene Expression Test | 4/1/19 | 10/23/25 | 10/16/25 | Active | 81518 | A56884 |
| N/A | MolDX: Clarification of Order Requirements for Laboratory and Molecular Diagnostic services | 5/2/24 | N/A | N/A | Active | N/A | A59792 |
| L37130 |
MolDX: DecisionDx-UM (Uveal Melanoma) | 7/10/17 | 5/22/25 | 5/13/25 | Active | 81552 | A56981 |
| N/A | MolDX: Defining panel services in MolDX | 2/29/24 | N/A | 2/22/24 | Active | N/A | A59698 |
| L37356 |
MolDX: EndoPredict Breast Cancer Gene Expression Test | 3/6/18 | 5/1/25 | 4/25/25 | Active | 81522 | A56997 |
| L37905 |
MolDX: Envisia , Veracyte , Idiopathic Pulmonary Fibrosis Diagnostic Test | 5/20/19 | 5/22/25 | 5/13/25 | Active | 81554 | A56985 |
| L39648 |
MolDX: Gene Expression Profile Tests for Decision-Making in Castration Resistant and Metastatic Prostate Cancers | 9/22/24 | N/A | N/A | Active | 81479, 81542 | A59472 |
| L39938 |
MolDX: Genetic Testing for Heritable Thoracic Aortic Disease | 8/17/25 | N/A | N/A | Active | 81410, 81411, 81479 | A59860 |
| L35984 |
MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) | 10/1/15 | 6/19/25 | 6/11/25 | Active | 81240, 81241, 81291 | A56980 |
| L36485 |
MolDX: HLA-DQB1*06:02 Testing for Narcolepsy | 2/15/16 | 8/7/25 | 7/29/25 | Active | 81383 | A56881 |
| N/A | MolDX: HLA Testing for Transplant Histocompatibility | 8/15/19 | 11/16/23 | 11/10/23 | Active | 81370, 81371, 81372, 81373, 81375, 81376, 81378, 81379, 81380, 81382 | A56885 |
| L37903 |
MolDX: Inivata , InVisionFirst , Liquid Biopsy for Patients with Lung Cancer | 5/13/19 | 6/19/25 | 6/11/25 | Active | 81479, 0388U | A56982 |
| L39017 |
MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer | 8/21/22 | 3/13/25 | 3/4/25 | Active | Group 1: 81202, 81215, 81217, 81293, 81296, 81299, 81308, 81318, 81322, 81353, 81403, 81404, 81405, 81406, 81432, 81435, 81437, 81479, 0101U, 0102U, 0103U, 0129U Group 2: 81163, 81164, 81165, 81166, 81167, 81201, 81203, 81212, 81216, 81292, 81294, 81295, 81297, 81298, 81300, 81307, 81317, 81319, 81321, 81323, 81351 |
A54689 A58734 |
| L38016 |
MolDX: Melanoma Risk Stratification Molecular Testing | 6/24/19 | 6/26/25 | 5/20/25 | Active | 81479, 81529, 81599 | A57165 |
| L36113 |
MolDX: MGMT Promoter Methylation Analysis | 10/5/15 | 8/7/25 | 8/1/25 | Active | 81287 | A56983 |
| L38822 |
MolDX: Minimal Residual Disease Testing for Cancer | 12/26/21 | 11/21/24 | 11/13/24 | Active | Group 1: 81445, 81479, 0340U Group 2: 81479, 0422U Group 3: 81479, 0356U Group 1: 81450, 81479 Group 2: 81479, 0364U Group 3: 81206, 81207, 81208, 81310, 81315, 81316, 81334, 81401, 81479, 0040U Group 4: 81261, 81263, 81264, 81340, 81342, 81450, 81479 |
A58434 A58998 |
| L39389 |
MolDX: Molecular Assays for the Diagnosis of Cutaneous Melanoma | 8/6/23 | 5/16/24 | 5/9/24 | Active | 81479, 0090U, 0314U | A59163 |
| L39585 |
MolDX: Molecular Biomarker Testing for Risk Stratification of Cutaneous Squamous Cell Carcinoma | 8/18/24 | 5/22/25 | 5/13/25 | Active | 81479, 0315U | A59382 |
| L39427 |
MolDX: Molecular Biomarker Testing to Guide Targeted Therapy Selection in Rheumatoid Arthritis | 10/15/23 | 8/7/25 | 7/29/25 | Active | 81599, | A59529 |
| L39658 |
MolDX: Molecular Biomarkers for Risk Stratification of Indeterminate Pulmonary Nodules Following Bronchoscopy | 10/13/24 | 6/19/25 | 6/11/25 | Active | 81479 | A59482 |
| L38997 |
MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer | 7/17/22 | 7/3/25 | 6/27/25 | Active | Group 1: 0403U, 81313, 81479, 81551 Group 2: 0339U, 0403U |
A58713 |
| L36021 |
MolDX: Molecular Diagnostic Tests (MDT) | 10/1/15 | 8/21/25 | 8/15/25 | Active | See the Coding Information section in the article(s). | A55716 MolDX: Abbott RealTime IDH1 and IDH2 testing for Acute Myeloid Leukemia (AML) A54188 MolDX: bioTheranostics Cancer TYPE ID A54257 MolDX: BluePrint Test A54191 MolDX: FDA-Approved BRAF Tests A54192 MolDX: FDA-Approved EGFR Tests A54688 MolDX: FDA-Approved KRAS Tests A54269 MolDX: HTTLPR Gene Testing A54270 MolDX: IKBKAP Genetic Testing A54194 MolDX: MammaPrint A56106 MolDX: Microsatellite Instability-High (MSI-H) and Mismatch Repair Deficient (dMMR) Biomarker for Patients with Unresectable or Metastatic Solid Tumors A56973 MolDX: Molecular Diagnostic Tests (MDT) A54195 MolDX: Oncotype DX Breast Cancer Assay A54196 MolDX: Oncotype DX Colon Cancer Assay Update A54295 MolDX: PIK3CA Gene Tests A59646 MolDX: Proteomics Testing A54300 MolDx: SEPT9 Gene Test A54830 Short Tandem Repeat (STR) Markers and Chimerism (CPT codes 81265-81268) A54283 MolDX: SULT4A1 Genetic Testing A54901 MolDX: Targeted and Comprehensive Genomic Profile Next Generation Sequencing Testing in Cancer |
| L39038 |
MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing | 7/16/22 | 7/3/25 | 6/27/25 | Active | Group 1: 87631, 87636, 87637, 87801 Group 2: 87505 Group 3: 87483 Group 4: 87154 Group 5: 81513, 81514, 81515, 87800, 87801, 87999, 0402U, 0455U, 0527U Group 6: 87632, 87633, 87801, 87999, 0115U, 0202U, 0223U, 0225U, 0528U, 0563U, 0564U Group 7: 87506, 87507 Group 8: 102 codes Groups 9-12: 87999 |
A58747 |
| L39276 |
MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia | 6/4/23 | 3/13/25 | 3/4/25 | Active | 81479, 0114U | A59051 |
| L39940 |
MolDX: Molecular Testing for Identification and Management of Hereditary Transthyretin Amyloidosis | 8/17/25 | 8/17/25 | 7/15/25 | Active | 81479 | A59862 |
| L39650 |
MolDX: Molecular Testing for Risk Stratification of Thyroid Nodules | 10/13/24 | 5/22/25 | 5/13/25 | Active | 81479, 81546 | A59474 |
| L38582 |
MolDX: Molecular Testing for Solid Organ Allograft Rejection | 6/6/21 | 7/10/25 | 6/26/25 | Active | 81479, 81558, 81595, 81599, 0118U, 0320U, 0540U, 0544U | A58061 |
| L38067 |
MolDX: Next-Generation Sequencing for Solid Tumors | 2/10/20 | 8/21/25 | 8/15/25 | Active | 81445, 81449, 81457, 81458, 81459, 81479, 0244U, 0250U, 0329U, 0334U, 0379U, 0391U, 0543U | A57870 |
| L38070 |
MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies | 2/10/20 | 2/13/25 | 2/6/25 | Active | 81450, 81451, 81479 | A57873 |
| L40000 |
MolDX: Non-Next Generation Sequencing Tests for the Diagnosis of BCR-ABL Negative Myeloproliferative Neoplasms | 8/17/25 | N/A | N/A | Active | 81206, 81207, 81208, 81479, 0040U 81206, 81207, 81208, 81219, 81270, 81279, 81338, 81339, 81479, 0027U, 0040U | A54686 A59919 |
| L35442 |
MolDX: NRAS Genetic Testing | 10/1/15 | 8/21/25 | 8/15/25 | Active | 81311, 81479 | A56998 |
| L36951 |
MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™ ) | 3/6/17 | 9/4/25 | 9/26/25 | Active | 0045U | A56887 |
| L38394 |
MolDX: Pharmacogenomics Testing | 8/3/20 | 10/23/25 | 10/16/25 | Active | 81225, 81226, 81227, 81231, 81232, 81247, 81283, 81306, 81328, 81335, 81350, 81355, 81374, 81377, 81381, 81383, 81401, 81406, 81418, 81479, 0029U, 0030U, 0034U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0286U, 0345U, 0411U, 0419U | A58324 |
| L38584 |
MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells | 7/25/21 | 7/3/25 | 6/24/25 | Active | 81479 | A58063 |
| L38111 |
MolDX: Pigmented Lesion Assay | 3/30/20 | 5/22/25 | 5/13/25 | Active | 0089U | A57915 |
| L38065 |
MolDX: Plasma-Based Genomic Profiling in Solid Tumors | 7/27/20 | 11/21/24 | 11/13/24 | Active | Group 1: 81445, 81462, 81463, 81464, 81479, 0326U, 0409U, 0485U, 0487U, 0543U Group 2: 0179U, |
A57917 |
| L38284 |
MolDX: Predictive Classifiers for Early Stage Non-small Cell Lung Cancer | 7/27/20 | 7/3/25 | 6/20/25 | Active | 81479, 0288U | A58038 |
| L38586 |
MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer | 7/18/21 | 7/3/25 | 6/24/25 | Active | 81401, 81403, 81404, 81445, 81479, 0016M | A58065 |
| L37352 |
MolDX: Prometheus IBD sgi Diagnostic Policy | 11/6/17 | 2/20/25 | 2/10/25 | Active | 81479 | A56940 |
| L38303 |
MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease | 11/9/20 | 7/3/25 | 6/24/25 | Active | 81541, 81542, 0047U | A58371 |
| L38288 |
MolDX: Repeat Germline Testing | 6/7/20 | 4/25/24 | 4/18/24 | Active | See the Coding Information section in the article. | A57141 |
| N/A | MolDX: Testing of Multiple Genes | 1/1/20 | 11/22/23 | 11/15/23 | Active | N/A | A57910 |
| L34171 |
Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation | 10/1/15 | 6/5/25 | 5/30/25 | Active | 68801, 68810, 68811, 68815, 68816, 68840 | A57284 |
| L35249 |
Nerve Blocks for Peripheral Neuropathy | 10/1/15 | 5/1/25 | 4/25/25 | Active | Group 1: 64450 Group 2: 76881, 76882, 76942, 76999, 97032, 97139, G0282, G0283 |
A57663 |
| L35897 |
Nerve Conduction Studies and Electromyography | 10/1/15 | 5/1/25 | 4/25/25 | Active | 51784, 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 |
| L38771 |
Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease | 04/25/21 | 9/4/25 | 8/29/25 | Active | 75580 | A58359 |
| L34045 |
Non-Invasive Vascular Studies | 10/1/15 | 6/12/25 | 6/5/25 | Active | Group 1: 93880, 93882, Group 2: 93886, 93888, 93892, 93893 Group 3: 93922, 93923, 93924, 93925, 93926, 93930, 93931 Group 4: 93970, 93971 Group 5: 93975, 93976, 93978, 93979 Group 6: 93985, 93986, 93990 Group 7: 93930, 93931, 93970, 93971 Group 8: 93970, 93971 |
A56697 |
| L34393 |
Ocular Photography External | 10/1/15 | 5/1/25 | 4/25/25 | Active | 92285 | A57068 |
| N/A | Off-Label Use of Chemotherapeutic Drugs and Biologicals for Non-Cancer Indications | 1/1/22 | 11/16/23 | 11/7/23 | Active | N/A | A59006 |
| N/A | Off-Label Use of Drugs and Biologicals for Anti-Cancer Chemotherapeutic Regimen | 6/8/20 | 11/16/23 | 11/7/23 | Active | N/A | A58113 |
| L38920 |
Off-label Use of Rituximab and Rituximab Biosimilars | 8/8/21 | 8/7/25 | 7/31/25 | Active | J9312, Q5115, Q5119 | A58582 |
| L34175 |
Ophthalmic Angiography (Fluorescein and Indocyanine Green) | 10/1/15 | 6/5/25 | 5/30/25 | Active | 92137, 92235, 92240 | A57069 |
| L34181 |
Ophthalmic Biometry for Intraocular Lens Power Calculation | 10/1/15 | 5/29/25 | 5/23/25 | Active | 76519, 92136 | A57070 |
| L34399 |
Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) | 10/1/15 | 5/29/25 | 5/23/25 | Active | 92201, 92202, 92227, 92228, 92250 | A57071 |
| N/A | Osteopathic Manipulative Treatment | 10/1/15 | 11/22/23 | 11/15/23 | Active | 98925, 98926, 98927, 98928, 98929 | A52435 |
| L34049 |
Outpatient Physical and Occupational Therapy Services | 10/1/15 | 5/29/25 | 5/23/25 | Active | Group 1: 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 Group 2 98966, 98967, 98968, 98970, 98971, 98972, 98975, 98976, 98977, 98980, 98981, G2010, G2250, G2251 |
A57067 |
| L34353 |
Outpatient Psychiatry and Psychology Services | 10/1/15 | 10/9/25 | 10/3/25 | 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, 96132, 96133, 96136, 96137, 96138, 96139, 96146 | A57065 |
| L34064 |
Panretinal (Scatter) Laser Photocoagulation | 10/1/15 | 3/27/25 | 3/18/25 | Active | 67228 | A56594 |
| N/A | Pegfilgrastim (Fulphila; Neulasta; Neulasta Onpro; Nyvepria; Udenyca; Ziextenzo) J2506 | 5/26/22 | 3/14/24 | 3/5/24 | Active | 96372, 96377, J2506, Q5111 | A59126 |
| L38201 |
Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) | 11/18/19 | 10/9/25 | 9/30/25 | Active | 22510, 22511, 22512, 22513, 22514, 22515 | A57282 |
| L39023 |
Platelet Rich Plasma Injections for Non-Wound Injections | 1/3/22 | 2/14/25 | 2/14/25 | Active | G0460, M0076, P9020, 0232T | A58737 |
| L36902 |
Polysomnography and Other Sleep Studies | 3/6/17 | 2/27/25 | 2/21/25 | Active | Group 1: 95782, 95783, 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400 Group 2: 95803 |
A57049 |
| L39521 |
Positron Emission Tomography (PET) Scan for Inflammation and Infection | 8/13/23 | N/A | 6/22/23 | Active | Group 1: 78811, 78812, 78813, 78814, 78815, 78816, A9552, A9598, A9601 Group 2: 78429, 78432, 78433, 78459 Group 3: 78811, 78812, 78813, 78814, 78815, 78816 Group 4: 78608, 78609, G0219, G0235, G0252 |
A59318 |
| L34085 |
Post-Void Residual Urine and/or Bladder Capacity by Ultrasound | 10/1/15 | 4/3/25 | 3/26/25 | Active | 51798 | A57050 |
| N/A | Process for Determining Self-Administered Drug Exclusions Medical Policy Article | 10/1/15 | 8/7/25 | 7/31/25 | Active | N/A | A52535 |
| L36675 |
ProMark Risk Score | 10/10/16 | 11/14/24 | 11/8/24 | Active | 81479 | A57034 |
| L39284 |
Prostate Cancer Detection with IsoPSA | 11/20/22 | 11/7/24 | 10/29/24 | Active | 0359U | A59066 |
| L36658 |
Proton Beam Therapy | 10/24/16 | 10/2/25 | 9/26/25 | Active | 77520, 77522, 77523, 77525 | A55315 |
| L34183 |
Psychiatric Inpatient Hospitalization | 10/1/15 | 4/3/25 | 3/26/25 | Active | N/A | A57052 |
| L34196 |
Psychiatric Partial Hospitalization Programs | 10/1/15 | 4/3/25 | 3/26/25 | 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 |
| L34539 |
Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians | 10/1/15 | 4/3/25 | 3/28/25 | Active | 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90846, 90847, 90849, 90853, 90863, 90880, 90899 | A57054 |
| L34063 |
RAST Type Tests | 10/1/15 | 8/7/25 | 7/31/25 | Active | 86001, 86003, 86005 | A57043 |
| L34200 |
Removal of Benign Skin Lesions | 10/1/15 | 8/7/25 | 7/31/25 | 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 |
| N/A | Rezum System for Benign Prostatic | 1/1/18 | 8/7/25 | 7/29/25 | Active | 53854 | A56083 |
| L34246 |
Routine Foot Care and Debridement of Nails | 10/1/15 | 8/7/25 | 7/29/25 | Active | 11055, 11056, 11057, 11719, 11720, 11721, G0127 | A57193 |
| N/A | Sacral Nerve Stimulation for Urinary and Fecal Incontinence | 2/1/18 | 2/27/25 | 2/21/25 | Active | Group 1: 64561, 64581 Group 2: 64590, A4290, C1767, C1778, C1883, C1897, L8680 |
A55835 |
| L39383 |
Sacroiliac Joint Injections and Procedures | 3/19/23 | 3/27/25 | 3/18/25 | Active | Group 1: 27096, 64451 Group 2: 64625 Group 3: G0260 |
A59154 |
| L34061 |
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) | 10/1/15 | 8/7/25 | 7/29/25 | Active | 92133, 92134 | A56692 |
| N/A | Self-Administered Drug Exclusion List: and Biologicals Excluded from Coverage Medical Policy Article | 10/1/15 | 7/1/25 | 6/16/25 | Active | See the Coding Information section in the article. | A52527 |
| N/A | Sentinel Lymph Node Biopsy Medical Policy Article | 10/1/15 | 11/16/23 | 11/7/23 | Active | 38500, 38510, 38525, 38530, 38542, 38790, 38792, 38900, 78195, A4641, A4649, A9541 | A52437 |
| N/A | Single Chamber and Dual Chamber Permanent Cardiac Pacemakers Coding and Billing | 5/1/16 | 3/27/25 | 3/18/25 | Active | 33206, 33207, 33208 | A54961 |
| L39756 |
Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers | 1/1/26 | N/A | N/A | Future | Group 1: 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278 Group 2: A2019, Q4105, Q4107, Q4110, Q4121, Q4122, Q4128, Q4133, Q4158, Q4159, Q4160, Q4187, Q4203 Group 3: Q4101, Q4102, Q4106, Q4151, Q4186 Group 4: 203 codes |
A59618 |
| L35906 |
Somatosensory Testing | 10/1/15 | 3/27/25 | 3/18/25 | Active | 95925, 95926, 95927, 95928 | A57041 |
| L35986 |
Special Histochemical Stains and Immunohistochemical Stains | 10/1/15 | 8/7/25 | 7/31/25 | Active | 88341, 88342, 88360, 88361 88312, 88313, 88341, 88342, 88344, 88360, 88361 | A59295 |
| L34046 |
Speech-Language Pathology | 10/1/15 | 8/7/25 | 7/29/25 | Active | 31579, 92507, 92508, 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92609, 92626, 92627, 96105, 96110, 96112, 96113, 96125, 97129, 97130, 97533 | A57040 |
| L34540 |
Stretta Procedure | 10/1/15 | 9/4/25 | 8/29/25 | Active | 43257 | A57039 |
| L34087 |
Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs): Office, Hospital, Web, or Non-Web Based | 10/1/15 | 9/4/25 | 8/29/25 | Active | 93282, 93283, 93284, 93287, 93289, 93292, 93295, 93296 | A57038 |
| N/A | Tetanus Immunization | 10/1/15 | 1/4/24 | 12/29/23 | Active | 90702, 90714, J1670 | A52438 |
| N/A | Therapeutic Apheresis for Familial Hypercholesterolemia | 12/1/18 | 2/6/25 | 1/31/25 | Active | 36516 | A56289 |
| L34084 |
Transcatheter Infusion Therapy | 10/1/15 | 9/4/25 | 8/29/25 | Active | 37211, 37212, 37213, 61650, 61651 | A56811 |
| L36469 |
Transcranial Magnetic Stimulation (TMS) | 2/8/16 | 6/6/24 | 5/30/24 | Active | 90867, 90868, 90869 | A57047 |
| L34337 |
Transesophageal Echocardiography (TEE) | 10/1/15 | 9/4/25 | 8/29/25 | Active | 76376, 76377, 93312, 93313, 93314, 93315, 93316, 93317, 93318, 93320, 93321, 93325, C8925, C8926, C8927 | A56809 |
| L34541 |
Transtelephonic Spirometry | 10/1/15 | 10/2/25 | 9/26/25 | Active | 94014, 94015, 94016 | A56808 |
| L34338 |
Transthoracic Echocardiography (TTE) | 10/1/15 | 10/2/25 | 9/26/25 | 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 |
| N/A | Traumeel Injections | 10/1/15 | 1/4/24 | 12/29/23 | Active | N/A | A52537 |
| L39656 |
Trigger Point Injections (TPI) | 4/1/24 | 4/1/24 | 3/5/24 | Active | 20552, 20553 | A59480 |
| L39616 |
Urinary Biomarkers for Chronic Pain Management | 10/8/23 | N/A | N/A | Active | 0117U | A59423 |
| L36029 |
Urine Drug Testing | 10/5/15 | 3/6/25 | 2/25/25 | Active | 80305, 80306, 80307, G0480, G0481, G0482, G0483, G0659 | A56818 |
| L34056 |
Urodynamics | 10/1/15 | 10/2/25 | 9/26/25 | Active | 51725, 51726, 51727, 51728, 51729, 51736, 51741, 51792, 51797 | A56802 |
| L34082 |
Varicose Veins of the Lower Extremity, Treatment of | 10/1/15 | 10/9/25 | 10/3/25 | Active | 36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37799, 76942, 93970, 93971 | A57305 |
| N/A | Venipuncture Necessitating Physician's Skill for Specimen Collection Supplemental Instructions Article | 10/1/15 | 8/7/25 | 7/29/25 | Active | 36410, 36415 | A52470 |
| L34394 |
Visual Fields Testing | 10/1/15 | 10/2/25 | 9/26/25 | Active | 92081, 92082, 92083 | A56799 |
| L33996 |
Vitamin D Assay Testing | 10/1/15 | 8/7/25 | 7/29/25 | Active | 82306 | A56798 |
| L36690 |
Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities | 10/10/16 | 9/4/25 | 8/29/25 | Active | Group 1: 15002, 15003, 15004, 15005, 15040, 15050, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, A2001, C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278 Group 2: A2001, A2002, A2004, A2008, A2009, Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111, Q4115, Q4117, Q4118, Q4121, Q4122, Q4123, Q4124, Q4126, Q4127, Q4128, Q4132, Q4133, Q4134, Q4135, Q4136, Q4137, Q4140, Q4141, Q4146, Q4147, Q4148, Q4151, Q4152, Q4153, Q4154, Q4156, Q4157, Q4158, Q4159, Q4160, Q4161, Q4163, Q4164, Q4165, Q4166, Q4169, Q4170, Q4173, Q4175, Q4176, Q4178, Q4180, Q4186, Q4187, Q4188, Q4195, Q4196, Q4197, Q4201, Q4203, Q4232, Q4236, Q4253, Q4254, Q4262, Q4278, Q4304 |
A56696 |
Updated: 11.05.2025

