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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 13External Website for details about the LCD process.

How to Find CGS J15 LCDs & Articles

NOTE: CMS and MACs don't develop an NCD and/or LCD for each item or service that Medicare covers. In the absence of a national/local coverage policy, reference the Social Security Act, CMS Medicare Benefit Policy Manual (Pub. 100-02)External website, Code of Federal Regulations, and/or other CMS/CGS resources for coverage guidance.

  1. Search the Medicare Coverage Database (MCD)External website (includes all national/local coverage policy related document types) or the MCD ArchiveExternal website (contains outdated (no longer in effect) LCDs and articles). See the How to Use the Medicare Coverage Database MLN educational toolExternal website for details.
  2. Use the direct links to CGS J15 active and future LCDs and articles provided in the table below (listed alphabetically by title).
  3. Download a copy of the table below in Excel spreadsheet formatExcel spreadsheet format (Revised 09.23.24) for additional sort and filter capabilities.
ID Title Effective Date Revision Effective Date Last Updated Status HCPCS/CPT Code Article(s)
L32553External Website Allergy Immunotherapy 10/1/15 11/2/23 10/27/23 Active 95115, 95117, 95144, 95145, 95146, 95147, 95148, 95149, 95165, 95170, 95180, 95199 A56424 – Billing and Coding: Allergy ImmunotherapyExternal Website
L39434External Website 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 6/6/24 3/7/24 Active 38240 A59215 – Billing and Coding: Allogenic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell OriginExternal Website
L39575External Website 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 – Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-WoundExternal Website
N/A ArgusM II Retinal Prosthesis System 10/1/15 11/16/23 11/7/23 Active L8608, 0100T A54327 – Billing and Coding: ArgusM II Retinal Prosthesis SystemExternal Website
L39840External Website Artificial Intelligence Enabled CT Based Quantitative Coronary Topography (AI-QCT)/Coronary Plaque Analysis (AI-CPA) 11/24/24 N/A N/A Future 0623T, 0624T, 0625T, 0626T A59716 – Billing and Coding: Artificial Intelligence Enabled CT Based Quantitative Coronary Topography (AI-QCT)/Coronary Plaque Analysis (AI-CPA)External Website
L36975External Website Bladder/Urothelial Tumor Markers 3/6/17 2/1/24 1/25/24 Active 86294, 86316, 86386, 88120, 88121 A56471 – Billing and Coding: Bladder / Urothelial Tumor MarkersExternal Website
L33944External Website Blepharoplasty 10/1/15 11/2/23 10/27/23 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 1/4/24 12/29/23 Active 76977, 77078, 77080, 77081, 77085, 78350, 78351, G0130, 0554T, 0555T, 0556T, 0557T, 0558T A57132 – Billing and Coding: Bone Mass MeasurementExternal Website
L33949External Website Botulinum Toxins 10/1/15 12/7/23 3/6/24 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 – Billing and Coding: Botulinum ToxinsExternal Website
L33950External Website Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography 10/1/15 12/7/23 11/29/23 Active 19030, 76641, 76642, 77046, 77047, 77048, 77049, 77053, 77054, 77063, 77065, 77066, 77067, C8903, C8905, C8906, C8908, G0279 A56448 – Billing and Coding: Breast Imaging Mammography / Breast Echography (Sonography) / Breast MRI / DuctographyExternal Website
L33943External Website B-type Natriuretic Peptide (BNP) Testing 10/1/15 12/7/23 11/29/23 Active 83880 A56425 – Billing and Coding: B-type Natriuretic Peptide (BNP) TestingExternal Website
L33946External Website Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy 10/1/15 11/2/23 10/27/23 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 11/2/23 10/27/23 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 – Billing and Coding: Cardiac Catheterization and Coronary AngiographyExternal Website
L33947External Website Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) 10/1/15 10/3/24 9/27/24 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 12/7/23 11/29/23 Active 93228, 93229, 93268, 93270, 93271, 93272, 93799 A56452 – Billing and Coding: Cardiac Event DetectionExternal Website
L33960External Website Cardiovascular Nuclear Medicine 10/1/15 2/1/24 1/25/24 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 1/4/24 12/29/23 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 2/1/24 1/25/24 Active 69209, 69210, G0268 A56454 – Billing and Coding: Cerumen (Earwax) RemovalExternal Website
L39741External Website Cervical Fusion 7/7/2024 N/A N/A Active 22548, 22551, 22552, 22554, 22590, 22595, 22600, 22800, 22802, 22808, 22810, 22812 A59608 – Billing and Coding: Cervical FusionExternal Website
L37254External Website Chiropractic Services 11/6/17 2/1/24 1/25/24 Active 98940, 98941, 98942 A56455 – Billing and Coding: Chiropractic ServicesExternal Website
N/A Clinical Trials – Medical Policy Article 10/1/15 11/16/23 11/7/23 Active N/A A52430 – Clinical Trials – Medical Policy ArticleExternal Website
L37126External Website Coenzyme Q10 (CoQ10) 7/10/17 2/1/24 1/25/24 Active 82542 A55715 – Billing and Coding: Coenzyme Q10 (CoQ10)External Website
L38777External Website Colon Capsule Endoscopy (CCE) 3/29/21 1/30/22 12/10/21 Active N/A A58362 – Billing and Coding: Colon Capsule EndoscopyExternal Website
L34005External Website Colonoscopy/Sigmoidoscopy/ Proctosigmoidoscopy 10/1/15 2/1/24 1/25/24 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
L38694External Website Computed Tomography Cerebral Perfusion Analysis (CTP) 6/17/21 6/17/21 5/30/24 Active 0042T A58218 – Billing and Coding: Computed Tomography Cerebral Perfusion Analysis (CTP)External Website
L34008External Website Computerized Corneal Topography 10/1/15 2/1/24 1/25/24 Active 92025 A56816 – Billing and Coding: Computerized Corneal TopographyExternal Website
L33999External Website Corneal Pachymetry 10/1/15 2/1/24 1/25/24 Active 76514 A56457 – Billing and Coding: Billing and Coding for Corneal PachymetryExternal Website
L39506External Website 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 – Billing and Coding: Cosmetic and Reconstructive SurgeryExternal Website
L37598External Website Cystatin C Measurement 12/17/18 1/4/24 12/29/23 Active 82610 A56988 – Billing and Coding: Cystatin C MeasurementExternal Website
L34032External Website Debridement Services 10/1/15 10/3/24 9/27/24 Active 11000, 11001, 11042, 11043, 11044, 11045, 11046, 11047 A56459 – Billing and Coding: Debridement ServicesExternal Website
L34062External Website Dialysis Access Maintenance 10/1/15 2/1/24 1/25/24 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
L38992External Website Electroretinography (ERG) 1/30/22 1/12/23 1/4/23 Active 92273, 92274, 0509T A58706 – Billing and Coding: Electroretinography (ERG)External Website
L34081External Website Endoscopy by Capsule 10/1/15 3/7/24 2/28/24 Active Group 1: 91110

Group 2: 91111, 91299
A56461 – Billing and Coding: Endoscopy by CapsuleExternal Website
L39015External Website 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 – Billing and Coding: Epidural Steroid Injections for Pain ManagementExternal Website
L34356External Website Erythropoiesis Stimulating Agents (ESA) 10/1/15 3/7/24 2/29/24 Active J0881, J0882, J0885, J0890. Q4081, Q5105, Q5106 A56462 – Billing and Coding: Erythropoiesis Stimulating Agents (ESA)External Website
L38773External Website Facet Joint Interventions for Pain Management 5/2/21 7/9/24 7/7/24 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 – Billing and Coding: Facet Joint Interventions for Pain ManagementExternal Website
N/A FDA Approved CLL Companion Diagnostic Test 6/5/18 2/1/24 1/25/24 Active 88271, 88275, 88291, 88374, 88377 A56050 – Billing and Coding: FDA Approved CLL Companion Diagnostic TestExternal Website
L34037External Website Flow Cytometry 10/1/15 3/7/24 2/29/24 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 4/4/24 3/29/24 Active C2596, 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 4/4/24 3/29/24 Active Group 1: 87505, 87506

Group 2: 87507
A56596 – Billing and Coding: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs)External Website
L37575External Website Frequency of Hemodialysis 4/1/19 3/7/24 2/29/24 Active 90999 A56159 – Billing and Coding: Frequency of HemodialysisExternal Website
L36906External Website GlycoMark® Testing for Glycemic Control 3/6/17 4/4/24 3/29/24 Active 84378, 84999 A56465 – Billing and Coding: GlycoMark® Testing for Glycemic ControlExternal Website
L38307External Website Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea 4/1/20 3/7/24 2/29/24 Active 64582 A57149 – Billing and Coding: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep ApneaExternal Website
L38268External Website Immune Thrombocytopenia (ITP) Therapy 4/1/20 3/7/24 2/29/24 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
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 – Billing and Coding: Implantable Automatic DefibrillatorsExternal Website
L38662External Website Implantable Continuous Glucose Monitors (I-CGM) 11/2/20 11/4/24 9/27/24 Active 0446T, 0447T, 0448T A58127 – Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM)External Website
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 – Billing and Coding: Influenza Diagnostic TestsExternal Website
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 – Billing and Coding: Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach (0192T 66183)External Website
L35891External Website Intravenous Immune Globulin 10/1/15 4/4/24 3/29/24 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 4/4/24 3/29/24 Active 52647, 52648, 52649 A56467 – Billing and Coding: Laser Ablation of the ProstateExternal Website
N/A Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) 11/1/18 3/7/24 2/29/24 Active 11042, 11043, 11044, 11045, 11046, 11047, 97597, 97598, 97602, 97607, 97608, 97610 A56175 – Low frequency, non-contact, non-thermal ultrasound (CPT code 97610)External Website
L37790External Website Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor 10/1/18 9/5/24 8/26/24 Active 0398T A58323 – Billing and Coding: Magnetic Resonance Guided Focused Ultrasound Surgery System (MRgFUS) for the treatment of neurologic conditionsExternal Website
L37608External Website MDS FISH 5/6/19 8/8/24 7/29/24 Active 88271, 88273, 88274, 88275, 88291 A56926 – Billing and Coding: MDS FISHExternal Website
L37578External Website Micro-Invasive Glaucoma Surgery (MIGS) 3/19/18 11/17/24 9/27/24 Future Group 1: 66989, 66991

Group 2: 66183, 0449T, 0671T

Group 3: 0253T, 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 1/4/24 12/29/23 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 5/9/24 4/30/24 Active 17311, 17312, 17313, 17314, 17315 A56836 – Billing and Coding: Mohs Micrographic SurgeryExternal Website
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 – MolDX: Algorithm definition as a component of a laboratory testExternal Website
L36139External Website MolDX: Biomarkers in Cardiovascular Risk Assessment 10/5/15 3/2/23 2/24/23 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) TestingExternal Website

A57386 – Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk AssessmentExternal Website
L38249External Website MolDX: Blood Product Molecular Antigen Typing 11/1/20 5/23/24 9/6/24 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 – Billing and Coding: MolDX: Blood Product Molecular Antigen TypingExternal Website
L36425External Website MolDX: Breast Cancer Assay: Prosigna® 2/1/16 2/15/24 2/6/24 Active 81520 A56989 – Billing and Coding: MolDX: Breast Cancer Assay: Prosigna®External Website
L37832External Website MolDX: Breast Cancer Index® (BCI) Gene Expression Test 4/1/19 11/2/23 10/27/23 Active 81518 A56884 – Billing and Coding: MolDX: Breast Cancer Index™ (BCI) Gene Expression TestExternal Website
N/A MolDX: Clarification of Order Requirements for Laboratory and Molecular Diagnostic services 5/2/24 N/A N/A Active N/A A59792 – MolDX: Clarification of Order Requirements for Laboratory and Molecular Diagnostic servicesExternal website
L37130External Website MolDX: DecisionDx-UM (Uveal Melanoma) 7/10/17 5/18/23 5/8/23 Active 81552 A56981 – Billing and Coding: MolDX: DecisionDx-UM (Uveal Melanoma)External Website
N/A MolDX: Defining panel services in MolDX 2/29/24 N/A 2/22/24 Active N/A A59698 – MolDX: Defining panel services in MolDXExternal Website
L37356External Website MolDX: EndoPredict Breast Cancer Gene Expression Test 3/6/18 4/11/24 4/5/24 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 6/29/23 5/6/24 Active 81554 A56985 – Billing and Coding: MolDX: Envisia™, Veracyte™, Idiopathic Pulmonary Fibrosis Diagnostic TestExternal Website
L36117External Website MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease 10/5/15 5/16/24 5/6/24 Active 81206, 81207, 81208, 81479, 0040U

81170

81206, 81207, 81208, 81219, 81270, 81279, 81338, 81339 81450 81479, 0027U, 0040U
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 7/20/23 6/27/24 Active 81240, 81241, 81291 A56980 – Billing and Coding: MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)External Website
L36485External Website MolDX: HLA-DQB1*06:02 Testing for Narcolepsy 2/15/16 9/19/24 9/14/24 Active 81383 A56881 – Billing and Coding: MolDX: HLA-DQB1*06:02 Testing for NarcolepsyExternal Website
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 – Billing and Coding: MolDX: HLA Testing for Transplant HistocompatibilityExternal Website
L37903External Website MolDX: Inivata™, InVisionFirst®, Liquid Biopsy for Patients with Lung Cancer 5/13/19 6/27/24 6/18/24 Active 81479, 0388U A56982 – Billing and Coding: MolDX: Inivata™, InVisionFirst®, Liquid Biopsy for Patients with Lung CancerExternal Website
L39017External Website MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer 8/21/22 4/18/24 4/12/24 Active Group 1: 81202, 81215, 81217, 81293, 81296, 81299, 81308, 81318, 81322, 81353, 81403, 81404, 81405, 81406, 81432, 81433, 81435, 81436, 81437, 81438, 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 – Billing and Coding: Germline testing for use of PARP inhibitorsExternal Website

A58734 – Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with CancerExternal Website
L38016External Website MolDX: Melanoma Risk Stratification Molecular Testing 6/24/19 5/18/23 5/12/23 Active 81479, 81529, 81599 A57165 – Billing and Coding: MolDX: Melanoma Risk Stratification Molecular TestingExternal Website
L36113External Website MolDX: MGMT Promoter Methylation Analysis 10/5/15 8/22/24 8/14/24 Active 81287 A56983 – Billing and Coding: MolDX: MGMT Promoter Methylation AnalysisExternal Website
L38822External Website MolDX: Minimal Residual Disease Testing for Cancer 12/26/21 11/2/23 10/27/23 Active Group 1: 81445, 81479, 0340U

Group 2: 81479, 0422U

Group 3: 81479,0356U

Group 1: 81450, 81479

Group 2: 81479

Group 3: 81206, 81207, 81208, 81310, 81315, 81316, 81334, 81401, 81479, 0040U

Group 4: 81261, 81263, 81264, 81340, 81342, 81450, 81479
A58434 – Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor CancersExternal Website

A58998 – Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic CancersExternal Website
L39389External Website MolDX: Molecular Assays for the Diagnosis of Cutaneous Melanoma 8/6/23 5/16/24 5/9/24 Active 81479, 0090U, 0314U A59163 – Billing and Coding: MolDX: Molecular Assays for the Diagnosis of Cutaneous MelanomaExternal Website
L39585External Website MolDX: Molecular Biomarker Testing for Risk Stratification of Cutaneous Squamous Cell Carcinoma 8/18/24 N/A N/A Active 81479, 0315U A59382 – Billing and Coding: MolDX: Molecular Biomarker Testing for Risk Stratification of Cutaneous Squamous Cell CarcinomaExternal Website
L39427External Website MolDX: Molecular Biomarker Testing to Guide Targeted Therapy Selection in Rheumatoid Arthritis 10/15/23 8/22/24 8/23/24 Active 81599, 0456U A59529 – Billing and Coding: MolDX: Molecular Biomarker Testing to Guide Targeted Therapy Selection in Rheumatoid ArthritisExternal Website
L39658External Website MolDX: Molecular Biomarkers for Risk Stratification of Indeterminate Pulmonary Nodules Following Bronchoscopy 10/13/24 N/A N/A Active 81479 A59482 – Billing and Coding: MolDX: Molecular Biomarkers for Risk Stratification of Indeterminate Pulmonary Nodules Following BronchoscopyExternal Website
L38997External Website MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer 7/17/22 3/14/24 3/6/24 Active Group 1: 0005U, 81313, 81479, 81551

Group 2: 0005U, 0339U
A58713 – Billing and Coding: MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate CancerExternal Website
L36021External Website MolDX: Molecular Diagnostic Tests (MDT) 10/1/15 8/22/24 8/14/24 Active See the Coding Information section in the article(s). A54242 – Billing and Coding: MolDX: 9p21 Genotype TestExternal Website

A55716 – Billing and Coding: MolDX: Abbott RealTime IDH1 and IDH2 testing for Acute Myeloid Leukemia (AML)External Website

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

A54244 – Billing and Coding: MolDX: ApoE GenotypeExternal Website

A54188 – Billing and Coding: MolDX: bioTheranostics Cancer TYPE ID®External Website

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

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

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

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

A54688 – Billing and Coding: MolDX: FDA-Approved KRAS TestsExternal Website

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

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

A54194 – Billing and Coding: MolDX: MammaPrintExternal Website

A54278 – Billing and Coding: MolDX: MECP2 Genetic TestingExternal 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

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

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

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

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

A54197 – Billing and Coding: MolDX: Progensa® PCA3 Assay Coverage UpdateExternal Website

A59646 – Billing and Coding: MolDX: Proteomics TestingExternal Website

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

A54830 – Billing and Coding: Short Tandem Repeat (STR) Markers and Chimerism (CPT® codes 81265-81268)External Website

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

A54901 – Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Next Generation Sequencing Testing in CancerExternal Website

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

A54200 – Billing and Coding: MolDX: therascreen® KRAS PCR Kit GuidelinesExternal Website
L39038External Website MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing 7/16/22 4/25/24 4/18/24 Active Group 1: 87631, 87636, 87637, 87801, 0240U, 0241U

Group 2: 87505

Group 3: 87483

Group 4: 87154

Group 5: 81513, 81514, 87800, 87801, 87999, 0352U, 0353U, 0402U

Group 6: 87632, 87633, 87801, 87999, 0115U, 0202U, 0223U, 0225U

Group 7: 87506, 87507

Group 8: 92 codes

Groups 9-11: 87999
A58747 – Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification TestingExternal Website
L39276External Website MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia 6/4/23 2/29/24 2/19/24 Active 81479, 0114U A59051 – Billing and Coding: MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and NeoplasiaExternal Website
L39650External Website MolDX: Molecular Testing for Risk Stratification of Thyroid Nodules 10/13/24 N/A N/A Active 81479, 81546 A59474 – Billing and Coding: MolDX: Molecular Testing for Risk Stratification of Thyroid NodulesExternal Website
L38582External Website MolDX: Molecular Testing for Solid Organ Allograft Rejection 6/6/21 7/27/23 7/21/23 Active 81479, 81595, 81599, 0118U A58061 – Billing and Coding: MolDX: Molecular Testing for Solid Organ Allograft RejectionExternal Website
L38067External Website MolDX: Next-Generation Sequencing for Solid Tumors 2/10/20 8/22/24 8/14/24 Active 81445, 81449, 81457, 81458, 81459, 81479, 0244U, 0250U, 0329U, 0334U, 0379U, 0391U 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 3/28/24 3/22/24 Active 81450, 81451, 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 7/27/23 7/21/23 Active 81311, 81479 A56998 – Billing and Coding: MolDX: NRAS Genetic TestingExternal Website
L36951External Website MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) 3/6/17 9/28/23 9/20/23 Active 0045U A56887 – Billing and Coding: MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™)External Website
L38394External Website MolDX: Pharmacogenomics Testing 8/3/20 8/24/23 8/14/23 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, 0380U, 0411U, 0419U A58324 – Billing and Coding: MolDX: Pharmacogenomics TestingExternal Website
L38584External Website MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells 7/25/21 5/16/24 5/9/24 Active 81479 A58063 – Billing and Coding: MolDX: Phenotypic Biomarker Detection from Circulating Tumor CellsExternal Website
L38111External Website MolDX: Pigmented Lesion Assay 3/30/20 10/26/23 10/19/23 Active 0089U A57915 – Billing and Coding: MolDX: Pigmented Lesion AssayExternal Website
L38065External Website MolDX: Plasma-Based Genomic Profiling in Solid Tumors 7/27/20 10/26/23 10/19/23 Active Group 1: 81445, 81479, 0326U, 0409U, 0428U, 0485U

Group 2: 0179U, 0487U
A57917 – Billing and Coding: MolDX: Plasma-Based Genomic Profiling in Solid TumorsExternal Website
L38284External Website MolDX: Predictive Classifiers for Early Stage Non-small Cell Lung Cancer 7/27/20 10/20/22 10/10/22 Active 81479, 0288U A58038 – Billing and Coding: MolDX: Predictive Classifiers for Early Stage Non-Small Cell Lung CancerExternal Website
L38586External Website MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer 7/18/21 3/21/24 3/14/24 Active 81401, 81403, 81404, 81445, 81479, 0016M A58065 – Billing and Coding: MolDX: Prognostic and Predictive Molecular Classifiers for Bladder CancerExternal Website
L37352External Website MolDX: Prometheus IBD sgi Diagnostic® Policy 11/6/17 2/29/24 2/21/24 Active 81479 A56940 – Billing and Coding: MolDX: Prometheus IBD sgi Diagnostic PolicyExternal Website
L38303External Website MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease 11/9/20 7/25/24 7/17/24 Active 81541, 81542, 0047U A58371 – Billing and Coding: MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized DiseaseExternal Website
L38288External Website MolDX: Repeat Germline Testing 6/7/20 4/25/24 4/18/24 Active See the Coding Information section in the article. A57141 – Billing and Coding: MolDX: Repeat Germline TestingExternal Website
N/A MolDX: Testing of Multiple Genes 1/1/20 11/22/23 11/15/23 Active N/A A57910 – Billing and Coding: MolDX: Testing of Multiple GenesExternal Website
L34171External Website Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation 10/1/15 6/6/24 5/31/24 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 5/9/24 4/30/24 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 5/9/24 4/30/24 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 – Billing and Coding: Nerve Conduction Studies and ElectromyographyExternal Website
L38771External Website Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease 04/25/21 9/5/24 8/26/24 Active 75580 A58359 – Billing and Coding: Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart DiseaseExternal Website
L34045External Website Non-Invasive Vascular Studies 10/1/15 11/2/23 10/27/23 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, 93978, 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 5/9/24 4/30/24 Active 92285 A57068 – Billing and Coding: Ocular Photography – ExternalExternal Website
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 – Off-Label Use of Chemotherapeutic Drugs and Biologicals for Non-Cancer IndicationsExternal Website
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 – Off-Label Use of Drugs and Biologicals for Anti-Cancer Chemotherapeutic RegimenExternal Website
L38920External Website Off-label Use of Rituximab and Rituximab Biosimilars 8/8/21 6/29/23 6/22/23 Active J9312, Q5115, Q5119 A58582 – Billing and Coding: Off-label Use of Rituximab and Rituximab BiosimilarsExternal Website
L34175External Website Ophthalmic Angiography (Fluorescein and Indocyanine Green) 10/1/15 6/6/24 5/31/24 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 6/6/24 5/31/24 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 6/6/24 5/31/24 Active 92201, 92202, 92227, 92228, 92250 A57071 – Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)External Website
N/A Osteopathic Manipulative Treatment 10/1/15 11/22/23 11/15/23 Active 98925, 98926, 98927, 98928, 98929 A52435 – Billing and Coding: Osteopathic Manipulative TreatmentExternal Website
L34049External Website Outpatient Physical and Occupational Therapy Services 10/1/15 6/6/24 5/31/24 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, G2012, G2250, G2251
A57067 – Billing and Coding: Outpatient Physical and Occupational Therapy ServicesExternal Website
L34353External Website Outpatient Psychiatry and Psychology Services 10/1/15 6/6/24 5/31/24 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 – Billing and Coding: Outpatient Psychiatry and Psychology ServicesExternal Website
L34064External Website Panretinal (Scatter) Laser Photocoagulation 10/1/15 4/4/24 3/29/24 Active 67228 A56594 – Billing and Coding: Panretinal (Scatter) Laser PhotocoagulationExternal Website
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 – Pegfilgrastim (Fulphila; Neulasta; Neulasta Onpro; Nyvepria; Udenyca; Ziextenzo) J2506External Website
L38201External Website Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) 11/18/19 10/3/24 9/27/24 Active 22510, 22511, 22512, 22513, 22514, 22515 A57282 – Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF)External Website
L39023External Website Platelet Rich Plasma Injections for Non-Wound Injections 1/3/22 7/21/22 2/9/23 Active G0460, M0076, P9020, 0232T A58737 – Billing and Coding: Platelet Rich Plasma Injections for Non-Wound InjectionsExternal Website
L36902External Website Polysomnography and Other Sleep Studies 3/6/17 3/7/24 2/29/24 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
L39521External Website 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 – Billing and Coding: Positron Emission Tomography (PET) Scan for Inflammation and InfectionExternal Website
L34085External Website Post-Void Residual Urine and/or Bladder Capacity by Ultrasound 10/1/15 4/4/24 3/29/24 Active 51798 A57050 – Billing and Coding: Post-Void Residual Urine and / or Bladder Capacity by UltrasoundExternal Website
N/A Process for Determining Self-Administered Drug Exclusions – Medical Policy Article 10/1/15 8/8/24 7/29/24 Active N/A A52535 – Process for Determining Self-Administered Drug Exclusions – Medical Policy ArticleExternal Website
L36675External Website ProMark® Risk Score 10/10/16 12/7/23 11/29/23 Active 81479 A57034 – Billing and Coding: ProMark® Risk ScoreExternal Website
L39284External Website Prostate Cancer Detection with IsoPSA® 11/20/22 11/2/23 10/27/23 Active 0359U A59066 – Billing and Coding: Prostate Cancer Detection with IsoPSA®External Website
L36658External Website Proton Beam Therapy 10/24/16 10/3/24 9/27/24 Active 77520, 77522, 77523, 77525 A55315 – Billing and Coding: Proton Beam TherapyExternal Website
L34183External Website Psychiatric Inpatient Hospitalization 10/1/15 4/4/24 3/29/24 Active N/A A57052 – Billing and Coding: Psychiatric Inpatient HospitalizationExternal Website
L34196External Website Psychiatric Partial Hospitalization Programs 10/1/15 4/4/24 3/29/24 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 4/4/24 3/29/24 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 8/8/24 7/29/24 Active 86001, 86003, 86005 A57043 – Billing and Coding: RAST Type TestsExternal Website
L34200External Website Removal of Benign Skin Lesions 10/1/15 8/8/24 7/29/24 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
N/A Rezum® System for Benign Prostatic 1/1/18 8/8/24 7/29/24 Active 53854 A56083 – Billing and Coding: Rezum® System for Benign ProstaticExternal Website
L34246External Website Routine Foot Care and Debridement of Nails 10/1/15 8/8/24 7/29/24 Active 11055, 11056, 11057, 11719, 11720, 11721, G0127 A57193 – Billing and Coding: Routine Foot Care and Debridement of NailsExternal Website
N/A Sacral Nerve Stimulation for Urinary and Fecal Incontinence 2/1/18 3/7/24 2/29/24 Active Group 1: 64561, 64581

Group 2: 64590, A4290, C1767, C1778, C1883, C1897, L8680
A55835 – Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal IncontinenceExternal Website
L39383External Website Sacroiliac Joint Injections and Procedures 3/19/23 4/4/24 3/29/24 Active Group 1: 27096, 64451

Group 2: 64625

Group 3: G0260
A59154 – Billing and Coding: Sacroiliac Joint Injections and ProceduresExternal Website
L34061External Website Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) 10/1/15 8/8/24 7/29/24 Active 92133, 92134 A56692 – Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)External Website
N/A Self-Administered Drug Exclusion List: and Biologicals Excluded from Coverage – Medical Policy Article 10/1/15 6/30/24 5/9/24 Active See the Coding Information section in the article. A52527 – Self-Administered Drug Exclusion List: and Biologicals Excluded from Coverage – Medical Policy ArticleExternal Website
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 – Billing and Coding: Sentinel Lymph Node Biopsy – Medical Policy ArticleExternal Website
N/A Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – Coding and Billing 5/1/16 11/16/23 11/7/23 Active 33206, 33207, 33208 A54961 – Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac PacemakersExternal Website
L35906External Website Somatosensory Testing 10/1/15 4/4/24 3/29/24 Active 95925, 95926, 95927, 95928 A57041 – Billing and Coding: Somatosensory TestingExternal Website
L35986External Website Special Histochemical Stains and Immunohistochemical Stains 10/1/15 3/7/24 2/29/24 Active 88341, 88342, 88360, 88361 A59292 – Billing and Coding: Lab: Immunohistochemistry (IHC) Indications for Breast PathologyExternal Website
L34046External Website Speech-Language Pathology 10/1/15 8/8/24 7/29/24 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 9/5/24 8/26/24 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 9/5/24 8/26/24 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
N/A Tetanus Immunization 10/1/15 1/4/24 12/29/23 Active 90702, 90714, J1670 A52438 – Billing and Coding: Tetanus ImmunizationExternal Website
N/A Therapeutic Apheresis for Familial Hypercholesterolemia 12/1/18 2/1/24 1/25/24 Active 36516 A56289 – Billing and Coding: Therapeutic Apheresis for Familial HypercholesterolemiaExternal Website
L34084External Website Transcatheter Infusion Therapy 10/1/15 9/5/24 8/26/24 Active 61650, 61651 A56811 – Billing and Coding: Transcatheter Infusion TherapyExternal Website
L36469External Website Transcranial Magnetic Stimulation (TMS) 2/8/16 6/6/24 5/30/24 Active 90867, 90868, 90869 A57047 – Billing and Coding: Transcranial Magnetic Stimulation (TMS)External Website
L34337External Website Transesophageal Echocardiography (TEE) 10/1/15 9/5/24 8/26/24 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 10/3/24 9/27/24 Active 94014, 94015, 94016 A56808 – Billing and Coding: Transtelephonic SpirometryExternal Website
L34338External Website Transthoracic Echocardiography (TTE) 10/1/15 10/3/24 9/27/24 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
N/A Traumeel Injections 10/1/15 1/4/24 12/29/23 Active N/A A52537 – Traumeel InjectionsExternal Website
L39656External Website Trigger Point Injections (TPI) 4/1/24 4/1/24 3/5/24 Active 20552, 20553 A59480 – Billing and Coding: Trigger Point Injections (TPI)External Website
L39616External Website Urinary Biomarkers for Chronic Pain Management 10/8/23 N/A N/A Active 0117U A59423 – Billing and Coding: Urinary Biomarkers for Chronic Pain ManagementExternal Website
L36029External Website Urine Drug Testing 10/5/15 3/7/24 2/28/24 Active 80305, 80306, 80307, G0480, G0481, G0482, G0483, G0659 A56818 – Billing and Coding: Urine Drug TestingExternal Website
L34056External Website Urodynamics 10/1/15 10/3/24 9/27/24 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 10/3/24 9/27/24 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
N/A Venipuncture Necessitating Physician's Skill for Specimen Collection – Supplemental Instructions Article 10/1/15 8/8/24 7/29/24 Active 36410, 36415 A52470 – Billing and Coding: Venipuncture Necessitating Physician's Skill for Specimen Collection – Supplemental Instructions ArticleExternal website
L34055External Website Virtual Colonoscopy (CT Colonography) 10/1/15 10/3/24 9/27/24 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 10/3/24 9/27/24 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 8/8/24 7/29/24 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 9/5/24 8/26/24 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, 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, Q4237, Q4238, Q4239, Q4253, Q4254, Q4262, Q4278
A56696 – Billing and Coding: Wound Application of Cellular and / or Tissue Based Products (CTPs), Lower ExtremitiesExternal Website

Updated: 11.01.24

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