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National Government Services Local Coverage Determinations

Search for LCDs and/or Supplemental Instructions/Medical Policy Articles Information
Search for local coverage determinations and related articles by CMS Identifier (L number or A number), title, keyword, as well as HCPCS, CPT, or ICD-10 codes.

Welcome to the new Medical Policy Center. Below you will find the LCDs and Supplemental Instructions/Medical Policy Articles. The Supplemental Instructions/Medical Policy Articles can be found below the LCDs. 

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Local Coverage Determinations (LCDs)

LCD LCD # Related CPT/HCPCS Codes
Autonomic Function Testing
Related terms: tilt table, sudomotor
L36236 95921, 95922, 95923, 95924, 95943
Botulinum Toxins
Related terms: Botox, Myobloc, Dysport,Xeomin, spasticity, chemodenervation
L33646 43201, 43236, 46505, 52287, 53899, 64611, 64612, 64615, 64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647, 64650, 64653, 67345, J0585, J0586, J0587, J0588
Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography
Related terms: ultrasound, non-palpable masses, palpable masses
L33585 19030, 76641, 76642, 77053, 77054, 77058, 77059, C8903, C8904, C8905, C8906, C8907, C8908
B-type Natriuretic Peptide (BNP) Testing
Related terms: congestive heart failure, acute dyspnea
L33573 83880
Cardiac Catheterization and Coronary Angiography
Related terms: heart, circulatory
L33557 36120, 36140, 36200, 36215, 36216, 36217, 36218, 36245, 36246, 36247, 36248, 36251, 36252, 36253, 36254, 75625, 75630, 75658, 75705, 75710, 75716, 92978, 92979, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93462, 93463, 93464, 93505, 93530, 93531, 93532, 93533, 93561, 93562, 93563, 93564, 93565, 93566, 93567, 93568, 93571, 93572, G0269, G0278
Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA)
Related terms: heart, calcium, congenital, bypass
L33559 75571, 75572, 75573, 75574, 0501T, 0502T, 0503T, 0504T
Cardiovascular Nuclear Medicine
Related terms: cardiac scan, stress test, heart, coronary, ejection, perfusion, blood pool
L33560 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78494, 78496, A9500, A9501, A9502, A9505, A9512, A9520, A9538, A9560, Q9969
Cataract Extraction
Related terms: eyes, ophthalmology, complex, epinephrine
L33558 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984
Category III CPT® Codes
Related terms: experimental, emerging technology
L33392 0042T, 0054T, 0055T, 0058T, 0071T, 0072T, 0075T, 0076T, 0085T, 0095T, 0098T, 0100T,0101T, 0102T, 0106T, 0107T, 0108T, 0109T, 0110T, 0111T, 0126T, 0159T, 0163T, 0164T, 0165T, 0174T, 0175T, 0184T, 0188T, 0189T, 0190T, 0195T, 0196T, 0198T, 0200T, 0201T, 0202T, 0205T, 0206T, 0207T, 0208T, 0209T, 0210T, 0211T. 0212T, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0219T, 0220T, 0221T, 0222T, 0228T, 0229T, 0230T, 0231T, 0232T, 0234T, 0235T, 0236T, 0237T, 0238T, 0249T, 0253T, 0254T, 0263T, 0264T, 0265T, 0266T, 0267T. 0268T, 0269T, 0270T, 0271T, 0272T, 0273T, 0274T, 0278T, 0290T, 0295T, 0296T, 0297T, 0298T, 0312T, 0313T, 0314T, 0315T, 0316T, 0317T, 0329T, 0330T, 0331T, 0332T, 0335T, 0337T, 0338T, 0339T, 0341T, 0342T, 0346T, 0347T, 0348T, 0349T, 0350T, 0351T, 0352T, 0353T, 0354T, 0355T, 0356T, 0357T, 0358T, 0359T, 0360T, 0361T, 0362T, 0363T, 0364T, 0365T, 0366T, 0367T, 0368T, 0369T, 0370T, 0371T, 0372T, 0373T, 0374T, 0375T, 0377T, 0378T, 0379T, 0380T, 0381T, 0382T, 0383T, 0384T, 0385T, 0386T, 0394T, 0395T, 0396T, 0397T, 0399T, 0400T, 0401T, 0402T, 0403T, 0404T, 0405T, 0406T, 0407T, 0408T, 0409T, 0410T, 0411T, 0412T, 0413T, 0414T, 0415T, 0416T, 0417T, 0418T, 0419T, 0420T, 0421T, 0422T, 0423T, 0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T, 0437T, 0439T, 0440T, 0441T, 0442T, 0443T, 0444T, 0445T, 0446T, 0447T, 0448T, 0451T, 0452T, 0453T, 0454T, 0455T, 0456T, 0457T, 0458T, 0459T, 0460T, 0461T, 0462T, 0463T, 0465T, 0466T, 0467T, 0468T, 0470T, 0471T, 0472T, 0473T, 0475T, 0476T, 0477T, 0478T, 0479T, 0480T, 0481T, 0482T, 0483T, 0484T, 0485T, 0486T, 0487T, 0488T, 0489T, 0490T, 0491T, 0492T, 0493T, 0494T, 0495T, 0496T, 0497T, 0498T, 0499T, 0500T, 0505T, 0506T, 0507T, 0508T
Chiropractic Services
Related terms: chiro, manipulation, subluxation, dynamic thrust, P.A.R.T.
L33613 98940, 98941, 98942
Computed Tomographic (CT) Colonography for Diagnostic Uses
Related terms: virtual colonoscopy
L33562 74261, 74262
Corneal Pachymetry
Related terms: cornea, ophthalmology, eyes
L33630 76514, 92499
Debridement Services
Related terms: N/A
L33614 11000, 11001, 11042, 11043, 11044, 11045, 11046, 11047, 97597, 97598
Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
Related terms: administration, compendia, FDA
L33394 N/A
EEG – 24 Hour Monitoring
Related terms: electroencephalogram
L33399 95950, 95951, 95953, 95956
Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
Related terms: Radiofrequency, Neurotomy, pain, cervical, lumbar, thoracic
L35936 64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636
Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases
Related terms: N/A
L37606 81450
Genomic Sequence Analysis Panels in the Treatment of Non-Small Cell Lung Cancer
Related terms: Molecular, genes, genetic testing lab
L36376 81445
Heavy Metal Testing 
Related terms: metal toxicity, aluminum, arsenic, iron, lead, nickel, zinc, mercury
L35074 82108, 82175, 82300, 82495, 82525, 83015, 83018, 83655, 83785, 83825, 83885, 84255, 84285, 84630, 84999
Implantable Miniature Telescope (IMT)
Related terms: eye, blindness
L33584 C1840, 0308T
Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures
Related terms: paronychia, skin, carbuncle, boil
L33563 10060, 10061, 10080, 10081, 10140, 10160, 10180
Lumbar Epidural Injections
Related terms: spine, pain, transforaminal, sacral, steroid, spinal
L35937 62322, 62323, 62326, 62327, 64483, 64484
Magnetic Resonance Angiography (MRA)
Related terms: gadolinium, contrast, imaging
L33633 70544, 70545, 70546, 70547, 70548, 70549, 71555, 72159, 72198, 73225, 73725, 74185, C8900, C8901, C8902, C8909, C8910, C8911, C8912, C8913, C8914, C8918, C8919, C8920, C8931, C8932, C8933, C8934, C8935, C8936
Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor
Related terns: N/A
L37421 0398T
Micro-Invasive Glaucoma Surgery (MIGS)
Related terms: N/A
L37244 0191T, 0376T, 0449T, 0450T, 0474T
Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint
Related terms: iFuse
L36406 27279
Molecular Pathology Procedures
Related terms: genetic testing, genetic counseling, gene, Tier 1, Tier 2
L35000 0004M, 0006M, 0007M, 0008M, 0009M, 81161, 81162, 81170, 81200, 81201, 81202, 81203, 81205, 81206, 81207, 81208, 81209, 81210, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81218, 81219, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 81232, 81235, 81240, 81241, 81242, 81243, 81244, 81245, 81246, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81260, 81261, 81262, 81263, 81264, 81265, 81266, 81267, 81268, 81270, 81272, 81273, 81275, 81276, 81287, 81288, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81310, 81311, 81313, 81314, 81315, 81316, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81330, 81331, 81332, 81340, 81341, 81342, 81350, 81355, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81420, 81422, 81425, 81426, 81427, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, 81440, 81442, 81455, 81460, 81465, 81470, 81471, 81479, 81493, 81500, 81503, 81504, 81507, 81519, 81525, 81535, 81536, 81538, 81540, 81545, 81595, 81599
Nerve Conduction Studies and Electromyography
Related terms: electrodiagnostic, neurologic, EMG, NCS, neuromuscular, motor, needle
L35098 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
Noncovered Services
Related terms: noncovered, preoperative, galectin, lipid, cholesterol, prostatic, spirometry, vestibular, neuroplasty, decompression
L33629 01470, 28035, 53860, 64702, 64704, 64708, 64712, 64714, 64722, 64726, 64727, 71010, 71015, 71020, 71021, 71022, 71023, 71030, 71034, 71035, 75571, 81500, 81503, 82172, 82777, 83006, 83719, 84066, 84999, 86152, 86153, 92700, 93000, 93005, 93010, 93040, 93041, 93042, 94014, 94015, 94016
Noninvasive Vascular Studies
Related terms: NonInvasive, leg, clot, plethysmography, duplex scan, Doppler, cerebrovascular, arterial, venous, hemodialysis
L33627 93880, 93882, 93886, 93888, 93890, 93892, 93893, 93922, 93923, 93924, 93925, 93926, 93930, 93931, 93970, 93971, 93975, 93976, 93978, 93979, 93970, 93971, 93990, G0365
Nonvascular Extremity Ultrasound
Related terms: clot, plantar fasciitis
L33619 76881, 76882
Ophthalmic Biometry for Intraocular Lens Power Calculation
Related terms: cataract, biometry, eyes
L33621 76519, 92136
Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)
Related terms: retinal, retinopathy, chorioretinitis, vitreous
L33567 92225, 92226, 92227, 92228, 92250
Osteopathic Manipulative Treatment
Related terms: somatic, skeletal, dysfunction
L33616 98925, 98926, 98927, 98928, 98929
Outpatient Physical and Occupational Therapy Services
Related terms: maintenance, restorative, skilled, modality, therapeutic, exercise, manual, cast, splint, biofeedback
L33631 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, 95992, 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, 97532, 97533, 97535, 97537, 97542, 97602, 97605, 97606, 97607, 97608, 97750, 97755, 97760, 97761, 97762, 97799, G0281, G0283, G0295, G0329
Pain Management
Related terms: spine, spinal, trigger, injection, ganglion
L33622 20526, 20550, 20551, 20552, 20553, 20612, 27096, 28899, G0260
Panretinal (Scatter) Laser Photocoagulation
Related terms: N/A
L33628 67228
Percutaneous Coronary Intervention
Related terms: heart, angina, intracoronary
L33623 92920, 92921, 92924, 92925, 92928, 92929, 92933, 92934, 92937, 92938, 92941, 92943, 92944, 92973, 92975, 92978, 92979, 93571, 93572, C9600, C9601, C9602, C9603, C9604, C9605, C9606, C9607, C9608
Peripheral Nerve Blocks
Related terms: N/A
L36850 64400, 64402, 64405, 64413, 64415, 64416, 64417, 64418, 64420, 64421, 64425, 64430,64445, 64446, 64447, 64448, 64449, 64450, 64455
Posterior Tibial Nerve Stimulation for Voiding Dysfunction
Related terms: overactive bladder, urinary urgency, urinary frequency, urinary incontinence, percutaneous electrical stimulation
L33396 64566
Prostate Rectal Spacers
Related terms: N/A
L37485 55874
Proton Beam Therapy
Related terms: radiation, radiotherapy

L35075

77520, 77522, 77523, 77525
Psychiatric Inpatient Hospitalization
Related terms: active treatment
L33624 N/A
Psychiatric Partial Hospitalization Programs
Related terms: mental illness, family counseling, vocational training
L33626 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90899, 96101, 96102, 96103, 96116, 96118, 96119, 96120, G0129, G0176, G0177, G0410, G0411
Psychiatry and Psychology Services
Related terms: psychiatric, mental illness, Psychotherapy, electroconvulsive therapy, ECT, psychological testing, vocational training, dementia
L33632 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90863, 90865, 90870, 90880, 90885, 90887, 90889, 90899, 96101, 96102, 96103, 96105, 96110, 96111, 96116, 96118, 96119, 96120, G0451
RAST Type Tests
Related terms: FAST, Radioallergosorbent, fluoroallergosorbent, antigen, allergen, IGE
L33591 86001, 86003, 86005, 86008
Reduction Mammaplasty
Related terms: breast reconstruction, cosmetic surgery
L35001 19316, 19318
Routine Foot Care and Debridement of Nails
Related terms: feet, toes, toenails, corns, calluses, trimming of nails, systemic disease
L33636 11055, 11056, 11057, 11719, 11720, 11721, G0127
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
Related terms: OCT, eyes, cornea, glaucoma
L34380 92132, 92133, 92134
Select Minimally Invasive GERD Procedures
Related terms: N/A
L35080 43210, 43257, 43284, 43499, 43999, 49999
Speech-Language Pathology
Related terms: dysphagia, swallowing, communication
L33580 31579, 92507, 92508, 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92609, 92626, 92627, 96105, 96110, 96111, 97532, 97533, G0451
Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)
Related terms: Related terms: ionizing, stereotactic guidance, robotic
L35076 77371, 77372, 77373, 77432, 77435, G0339, G0340
Total Joint Arthroplasty
Related terms: Knee, TKA, Hip, THA
L36039 27130, 27132, 27134, 27137, 27138, 27445, 27447, 27486, 27487
Transcranial Magnetic Stimulation
Related terms: depression, major depressive disorder, magnetic field
L33398 90867, 90868, 90869
Transesophageal Echocardiography (TEE)
Related terms: ultrasound, esophagus, doppler, color flow, contrast, heart
L33579 76376, 76377, 93312, 93313, 93314, 93315, 93316, 93317, 93318, 93320, 93321, 93325, C8925, C8926, C8927
Transrectal Ultrasound
Related terms: prostate, ultrasound, echography
L33578 76872, 76873
Transthoracic Echocardiography (TTE)
Related terms: cardiac, doppler, stress, cardovascular, myocardial, heart, contrast
L33577 76376, 76377, 93303, 93304, 93306, 93307, 93308, 93320, 93321, 93325, 93350, 93351, 93352, A9700, C8921, C8922, C8923, C8924, C8928, C8929, C8930, J0153, J0280, J0461, J1245, J1250, J2785, Q9955, Q9956, Q9957
Urine Drug Testing
Related terms: UDT, substance use disorder, SUD, chronic opioid therapy, COT
L36037 80305, 80306, 80307, G0480, G0481, G0482, G0483
Urodynamics
Related terms: cystometrogram, uroflowmetry, urethral pressure profile, sphincter electromyogram, sphincter electromyogram, incontinence, voiding dysfunction
L33576 51726, 51727, 51728, 51729, 51736, 51741, 51792, 51797
Varicose Veins of the Lower Extremity, Treatment of
Related terms: telangiectasia, spider veins, cosmetic, ligation and stripping, Endovenous radiofrequency ablation, EFRA, laser ablation
L33575 36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37799
 
Venous Angioplasty with or without Stent Placement for the Treatment of Chronic Cerebrospinal Venous Insufficiency
Related terms: CCSVI, multiple sclerosis, MS
L35028 37248, 37249
Vertebroplasty and Vertebral Augmentation (Percutaneous)
Related terms: compression, spine, fracture
L33569 22510, 22511, 22512, 22513, 22514, 22515, 76380
Visual Electrophysiology Testing
Related terms: N/A
L36831 0333T, 0464T, 92275, 95930
Visual Fields Testing
Related terms: eyes, ophthalmology, vision
L33574 92081, 92082, 92083
Vitamin D Assay Testing
Related terms: Bone Density, Osteopenia
L37535 82306, 82652
HHH LCD Title LCD# Related CPT/HCPCS Codes
Hospice - Determining Terminal Status
Related terms: Decline, life expectancy
L33393 N/A

Supplemental Instructions/Medical Policy Articles

Article Title Article # Related CPT/HCPCS Codes
Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee – Medical Policy Article
Related Terms: injection
A52369 29877, 29999, G0289
Bevacizumab (e.g., Avastin™) - Related to LCD L33394
Related Terms: drug, retinal
A52370 C9257, J9035, 67028
Blepharoplasty - Medical Policy Article
Related Terms: eye, cosmetic
A52837 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924
Bortezomib (e.g., Velcade®) – Related to LCD L33394
Related Terms: drug
A52371 J9041, J9999
Botulinum Toxins - SIA
Related Terms: Botox, drug, muscles, injection, eye, skin, cosmetic
A52848 43201, 43236, 46505, 52287, 53899, 64611, 64612, 64615, 64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647, 64650, 64653, 67345, J0585, J0586, J0587, J0588
Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography – SIA
Related Terms: ultrasound  , magnetic
A52849 19030, 76641, 76642, 77053, 77054, 77058, 77059, C8903, C8904, C8905, C8906, C8907, C8908
Cardiac Catheterization and Coronary Angiography – SIA
Related Terms: heart, diagnostic, vascular, stent
A52850 36120, 36140, 36200, 36215, 36216, 36217, 36218, 36245, 36246, 36247, 36248, 36251, 36252, 36253, 36254, 75625, 75630, 75658, 75705, 75710, 75716, 92978, 92979, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93462, 93463, 93464, 93505, 93530, 93531, 93532, 93533, 93561, 93562, 93563, 93564, 93565, 93566, 93567, 93568, 93571, 93572, G0269, G0278
Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) - SIA
Related Terms: heart, diagnostic, vascular, stent
A52851 75571, 75572, 75573, 75574
Chiropractic Services – SIA
Related Terms: subluxation, manipulation
A52853 98940, 98941, 98942
Clinical Trials – Medical Policy Article
Related Terms: IDE, Q0, modifier
A52840 N/A
Collagen Implantation for Urinary Incontinence - Medical Policy Article
Related Terms: N/A
A52374 51715, L8603, Q3031
Colorectal Cancer Screening – Medical Policy Article
Related Terms: colonoscopy, sigmoidoscopy, barium enema
A52378 81528, 82270, G0104, G0105, G0106, G0120, G0121, G0122, G0328
CPT Code 87641 (Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique) - Medical Policy Article
Related Terms: staph, MRSA
A52379 87641
Denosumab (Prolia ™, Xgeva ™) - Related to LCD L33394
Related Terms: drug, bone
A52399 J0897, 96372
Drugs and Biologicals, Coding Article
Related Terms: N/A
A52855 N/A
Eculizumab (Soliris®) - Related to LCD L33394
Related Terms: drug, hemolysis
A54548 J1300
Filgrastim, Pegfilgrastim, Tbo-filgrastim and biosimilars - Related to LCD L33394
Related Terms: drug, G-CSF
A52408 J1442, J1447, J2505, Q5101, Q5108, Q5110
Health and Behavior Assessment/Intervention – Medical Policy Article
Related Terms: mental, psychologist
A52434 96150, 96151, 96152, 96153, 96154, 96155
Hyaluronans Intra-articular Injections of - Related to LCD L33394
Related Terms: drug, knee, ankle
A52420 J3490, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, 20610, 20611
Ibandronate Sodium (e.g., Boniva®) – Related to LCD L33394
Related Terms: drug, bone  , osteoporosis
A52421 J1740
Infliximab, Infliximab-dyyb, Infliximab-abda (e.g., Remicade™, Inflectra™, Renflexis) – Related to LCD L33394
Related Terms: drug
A52423 J1745, Q5103, Q5104
Intravenous Immune Globulin (IVIG) - Related to LCD L33394
Related Terms: drug, immunodeficiency, ITP
A52446 96365, 96366, J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599
Investigational Device Exemption Requests - Medical Policy Article
Related Terms: IDE, clinical, Q0 modifier
A52841 N/A
Laparoscopic Sleeve Gastrectomy (LSG) – Medical Policy Article
Related Terms: morbid, obesity, weight
A52447 43775
Local Coverage Determination (LCD) Reconsideration Process - Medical Policy Article
Related Terms: N/A
A52842 N/A
Luteinizing Hormone-Releasing Hormone (LHRH) Analogs – Related to LCD L33394
Related Terms: drug, endometriosis, leuprolide, goserelin
A52453 11981, 11982, 11983, 96402, J1950, J3315, J9202, J9217, J9218, J9219, J9225
Nivolumab (Opdivo®) - Related to LCD L33394
Related Terms: drug
A54862 J9299
Noninvasive Vascular Studies – SIA
Related Terms: scan
A52859 93880, 93882, 93886, 93888, 93890, 93892, 93893, 93922, 93923, 93924, 93925
Omalizumab (e.g., Xolair®) – Related to LCD L33394
Related Terms: drug
A52448 J2357
Paclitaxel (e.g., Taxol®/Abraxane ™) - Related to LCD L33394
Related Terms: drug
A52450 J9264, J9267
Pain Management – SIA
Related Terms: spine, back, trigger, injection , SI
A52863 20552, 20553, 20526, 20550, 20551, 20612, 28899, 27096, G0260
Polysomnography and Sleep Studies – Medical Policy Article
Related Terms: N/A
A53019 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400
Process for Determining Self-Administered Drug Exclusions – Medical Policy Article
Related Terms: SAD
A53020 N/A
Psychological Services Coverage under the Incident to Provision for Physicians and Nonphysicians – Medical Policy Article
Related Terms: psychiatric, mental
A52825 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90880, 90899
Ranibizumab (e.g., Lucentis™) and Aflibercept (e.g., Eylea™) – Related to LCD L33394
Related Terms: eye, ophthalmology, macular
A52451 67028, J0178, J2778
Removal of Benign Skin Lesions
Related Terms: cosmetic
A54602 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
Response to Comments: Autonomic Function Testing LCD
Related Terms: N/A
A54403 N/A
Response to Comments: Cataract Extraction
Related Terms: N/A
A55257 N/A
Response to Comments: Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases
Related Terms: N/A
A55974 N/A
Response to Comments: Genomic Sequence Analysis Panels in the Treatment of Acute Myelogenous Leukemia (AML)
Related Terms: N/A
A55378 N/A
Response to Comments: Genomic Sequence Analysis Panels in the Treatment of Myelodysplastic Syndromes (MDS)
Related Terms: N/A
A55701 N/A
Response to Comments: Implantable Miniature Telescope (IMT)
Related Terms: N/A
A55261 N/A
Response to Comments: Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor
Related Terms: N/A
A55848 N/A
Response to Comments: Micro-Invasive Glaucoma Surgery (MIGS)
Related Terms: N/A
A55707 N/A
Response to Comments: Molecular Pathology Procedures
Related Terms: N/A
A55334 N/A
Response to Comments: Molecular Pathology Procedures
Related Terms: N/A
A55982 N/A
Response to Comments: Osteopathic Manipulative Treatment
Related Terms: N/A
A55318 N/A
Response to Comments: Peripheral Nerve Blocks
Related Terms: N/A
A55421 N/A
Response to Comments: Prostate Rectal Spacers
Related Terms: N/A
A55948 N/A
Response to Comments: Proton Beam Therapy
Related Terms: N/A
A55124 N/A
Response to Comments: Select Minimally Invasive GERD Procedures
Related Terms: N/A
A55749 N/A
Response to Comments: Vitamin D Assay Testing
Relted Terms: N/A
A55852 N/A
Response to Comments: Visual Electrophysiology Testing
Related Terms: N/A
A55456 N/A
Rituximab (Rituxan®) - Related to LCD L33394
Related Terms: drug
A52452 J9310
Self-Administered Drug Exclusion List - Medical Policy Article (Jurisdiction K Only)
Related Terms: SAD
A53021 C9015, C9399, J0135, J0270, J0364, J0630, J1324, J1438, J1559, J1562, J1595, J1675, J1744, J1815, J1817, J1830, J2170, J2212, J2354, J2440, J2502, J2760, J2940, J2941, J3030, J3110, J3355, J3490, J3590, J7999, J9212, J9213, J9216, J9218, Q0515
Self-Administered Drug Exclusion List - Medical Policy Article (Jurisdiction 6 Only)
Related Terms: SAD
A53022 C9015, C9399, J0135, J0270, J0364, J0630, J1324, J1438, J1559, J1562, J1595, J1675, J1744, J1815, J1817, J1830, J2170, J2212, J2354, J2440, J2502, J2760, J2940, J2941, J3030, J3110, J3355, J3490, J3590, J7999, J9212, J9213, J9216, J9218, Q0515
Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – Coding and Billing
Related Terms: pacemaker
A54909 33206, 33207, 33208
Skilled Nursing Facilities (Including Swing Beds) - Medical Policy Article
Related Terms: SNF, rehab
A52828 N/A
Speech-Language Pathology – SIA
Related Terms: dysphagia, SLP
A52866 31579, 92507, 92508, 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92609, 92626, 92627, 96105, 96110, 96111, 97532, 97533, G0451
Stem Cell Transplantation – Medical Policy Article
Related Terms: marrow, BMT, autologous, allogeneic, bone
A52879 38240, 38241
Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs): Office, Hospital, Web, or Non-Web Based – Medical Policy Article
Related Terms: N/A
A53018 93282, 93283, 93284, 93287, 93289, 93292, 93295, 93296
Transesophageal Echocardiography (TEE) – SIA
Related Terms: cardiology, heart, esophagus
A52868 76376, 76377, 93312, 93313, 93314, 93315, 93316, 93317, 93318, 93320, 93321, 93325, C8925, C8926, C8927
Varicose Veins of the Lower Extremity, Treatment of - SIA
Related Terms: legs, cosmetic
A52870 36465, 36466, 36468, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37799
HHH Article Article # Related CPT/HCPCS Codes
Home Health Skilled Nursing Care: Teaching and Training for Dementia Patients with Behavioral Disturbances - Medical Policy Article
Related Terms: N/A
A52845 G0164
Hospice: Determining Terminal Status - SIA
Related Terms: prognosis, life expectancy
A52830 N/A
Local Coverage Determination Reconsideration Process - Medical Policy Article
Related Terms: N/A
A52842 N/A

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