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National Government Services Local Coverage Determinations

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Local Coverage Determinations

LCD LCD # Billing and Coding
Related CPT/HCPCS Codes
Autonomic Function Testing
Related terms: tilt table, sudomotor
L36236 A57024 95921, 95922, 95923, 95924, 95943
Biomarker Testing (Prior to Initial Biopsy) for Prostate Cancer Diagnosis
Related terms: N/A
L37733
N/A 81539, 84153, 84154, 86316, 81479, 0005U
Biomarker Testing for Neuroendocrine Tumors/Neoplasms
Related terms: N/A
L37851  A57059 0007M
Botulinum Toxins
Related terms: Botox, Myobloc, Dysport,Xeomin, spasticity, chemodenervation
L33646 A52848
43201, 43236, 46505, 52287, 64611, 64612, 64615, 64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647, 64650, 64653, 67345, J0585, J0586, J0587, J0588
Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography
Related terms: ultrasound, non-palpable masses, palpable masses
L33585 A52849
19030, 76641, 76642, 77046, 77047, 77048, 77049, 77053, 77054, C8903, C8905, C8906, C8908
B-type Natriuretic Peptide (BNP) Testing
Related terms: congestive heart failure, acute dyspnea
L33573 A56826
83880
Cardiac Catheterization and Coronary Angiography
Related terms: heart, circulatory
L33557 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)
Related terms: heart, calcium, congenital, bypass
L33559 A56737
75571, 75572, 75573, 75574, 0501T, 0502T, 0503T, 0504T
Cardiovascular Nuclear Medicine
Related terms: cardiac scan, stress test, heart, coronary, ejection, perfusion, blood pool
L33560 A56743
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 A56544 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984
Category III CPT® Codes
Related terms: experimental, emerging technology
L33392 A56195 0042T, 0054T, 0055T, 0058T, 0071T, 0072T, 0075T, 0076T, 0085T, 0095T, 0098T, 0100T, 0101T, 0102T, 0106T, 0107T, 0108T, 0109T, 0110T, 0111T, 0126T, 0163T, 0164T, 0165T, 0174T, 0175T, 0184T, 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, 0338T, 0339T, 0341T, 0342T, 0347T, 0348T, 0349T, 0350T, 0351T, 0352T, 0353T, 0354T, 0355T, 0356T, 0357T, 0358T, 0362T, 0373T, 0375T, 0377T, 0378T, 0379T, 0380T, 0381T, 0382T, 0383T, 0384T, 0385T, 0386T, 0394T, 0395T, 0396T, 0397T, 0399T, 0400T, 0401T, 0402T, 0403T, 0404T, 0405T, 0408T, 0409T, 0410T, 0411T, 0412T, 0413T, 0414T, 0415T, 0416T, 0417T, 0418T, 0419T, 0420T, 0421T, 0422T, 0423T, 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, 0510T, 0511T, 0512T, 0513T, 0514T, 0515T, 0516T, 0517T, 0518T, 0519T, 0520T, 0521T, 0522T, 0523T, 0524T, 0525T, 0526T, 0527T, 0528T, 0529T, 0530T, 0531T, 0532T, 0533T, 0534T, 0535T, 0536T, 0537T, 0538T, 0539T, 0540T, 0541T, 0542T
Chiropractic Services
Related terms: chiro, manipulation, subluxation, dynamic thrust, P.A.R.T.
L33613 N/A 98940, 98941, 98942
Computed Tomographic (CT) Colonography for Diagnostic Uses
Related terms: virtual colonoscopy
L33562 A57026 74261, 74262
Corneal Hysteresis
Related terms: N/A
L38014
A56529
92145
Corneal Pachymetry
Related terms: cornea, ophthalmology, eyes
L33630 A56548 76514, 92499
Debridement Services
Related terms: N/A
L33614 A56617
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 A52855
N/A
EEG – 24 Hour Monitoring
Related terms: electroencephalogram
L33399 A57030 95950, 95951, 95953, 95956
Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
Related terms: Radiofrequency, Neurotomy, pain, cervical, lumbar, thoracic
L35936 N/A 64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636
Frequency of Hemodialysis
Related terms: dialysis, kidney disease, end stage renal disease
L37475 A55672 90999
Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases
Related terms: N/A
L37606 A56793
81450
Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms
Related terms: N/A
L37810 A56867
0048U, 81445
Heavy Metal Testing 
Related terms: metal toxicity, aluminum, arsenic, iron, lead, nickel, zinc, mercury
L35074 A56767
82108, 82175, 82300, 82495, 82525, 83015, 83018, 83655, 83785, 83825, 83885, 84255, 84285, 84630, 84999
Implantable Miniature Telescope (IMT)
Related terms: eye, blindness
L33584 A57411
C1840, 0308T
Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures
Related terms: paronychia, skin, carbuncle, boil
L33563 A56766
10060, 10061, 10080, 10081, 10140, 10160, 10180
Lumbar Epidural Injections
Related terms: spine, pain, transforaminal, sacral, steroid, spinal
L35937  A57494 62322, 62323, 62326, 62327, 64483, 64484
Magnetic Resonance Angiography (MRA)
Related terms: gadolinium, contrast, imaging
L33633 A56747
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 A57435
0398T
Micro-Invasive Glaucoma Surgery (MIGS)
Related terms: N/A
L37244 N/A 0191T, 0376T, 0449T, 0450T, 0474T
Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint
Related terms: iFuse
L36406 A57431
27279
Molecular Pathology Procedures
Related terms: genetic testing, genetic counseling, gene, Tier 1, Tier 2
L35000 A56199 81120, 81121, 81162, 81163, 81164, 81165, 81166, 81167, 81170, 81175, 81176, 81206, 81207, 81208, 81209, 81210, 81212, 81215, 81216, 81217, 81218, 81219, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81235, 81236, 81237, 81245, 81246, 81256, 81261, 81262, 81263, 81264, 81265, 81266, 81267, 81268, 81270, 81272, 81273, 81275, 81276, 81287, 81301, 81305, 81310, 81311, 81313, 81314, 81315, 81316, 81332, 81334, 81335, 81340, 81341, 81342, 81345, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 81518, 81519, 81520, 81595, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81233, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81306, 81312, 81317, 81318, 81319, 81320, 81321, 81322, 81323, 81333, 81343, 81344, 81599, 81105‒81112, 81161, 81171, 81172, 81173, 81174, 81200, 81201, 81202, 81203, 81204, 81205, 81227, 81228, 81229, 81230, 81231, 81232, 81234, 81238, 81239, 81240, 81241, 81242, 81243, 81244, 81247,  81248, 81249, 81250, 81251, 81252, 81253, 81254, 81255, 81257, 81258, 81259, 81260, 81269, 81271, 81274, 81283, 81284, 81285, 81286, 81289, 81290, 81291, 81302, 81303, 81304, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81336, 81337, 81346, 81350, 81355, 81361‒81364, 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, 81443, 81448, 81455, 81460, 81465, 81470, 81471, 81493, 81500, ,81503, 81504, 81507, 81521, 81525, 81535, 81536, 81538, 81540, 81541, 81545, 81551
Nerve Conduction Studies and Electromyography
Related terms: electrodiagnostic, neurologic, EMG, NCS, neuromuscular, motor, needle
L35098 A57668
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 N/A 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 A56758
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 A56787
76881, 76882
Ophthalmic Biometry for Intraocular Lens Power Calculation
Related terms: cataract, biometry, eyes
L33621 A56549 76519, 92136
Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)
Related terms: retinal, retinopathy, chorioretinitis, vitreous
L33567 A56726 92225, 92226, 92227, 92228, 92250
Osteopathic Manipulative Treatment
Related terms: somatic, skeletal, dysfunction
L33616 A56954
98925, 98926, 98927, 98928, 98929
Outpatient Physical and Occupational Therapy Services
Related terms: maintenance, restorative, skilled, modality, therapeutic, exercise, manual, cast, splint, biofeedback
L33631 N/A 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, 97533, 97535, 97537, 97542, 97602, 97605, 97606, 97607, 97608, 97750, 97755, 97760, 97761, 97763, 97799, G0281, G0283, G0295, G0329, G0515
Pain Management
Related terms: spine, spinal, trigger, injection, ganglion
L33622 A52863
20526, 20550, 20551, 20552, 20553, 20612, 27096, 28899, G0260
Panretinal (Scatter) Laser Photocoagulation
Related terms: N/A
L33628 A56550 67228
Percutaneous Coronary Intervention
Related terms: heart, angina, intracoronary
L33623 A56823
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 A57452
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 A57453
64566
Prostate Rectal Spacers
Related terms: N/A
L37485 A56539
55874
Proton Beam Therapy
Related terms: radiation, radiotherapy

L35075

A56827
77520, 77522, 77523, 77525
Psychiatric Inpatient Hospitalization
Related terms: active treatment
L33624 A56865

Psychiatric Partial Hospitalization Programs
Related terms: mental illness, family counseling, vocational training
L33626 A56850
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 N/A 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, 96112, 96113, 96116, 96121, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146, G0451
RAST Type Tests
Related terms: FAST, Radioallergosorbent, fluoroallergosorbent, antigen, allergen, IGE
L33591 A56844
86001, 86003, 86005, 86008
Reduction Mammaplasty
Related terms: breast reconstruction, cosmetic surgery
L35001 A56837
19316, 19318
Routine Foot Care and Debridement of Nails
Related terms: feet, toes, toenails, corns, calluses, trimming of nails, systemic disease
L33636 N/A 11055, 11056, 11057, 11719, 11720, 11721, G0127
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
Related terms: OCT, eyes, cornea, glaucoma
L34380 A56537 92132, 92133, 92134
Select Minimally Invasive GERD Procedures
Related terms: N/A
L35080 A56863
43210, 43257, 43284, 43499, 43999, 49999
Speech-Language Pathology
Related terms: dysphagia, swallowing, communication
L33580 N/A 31579, 92507, 92508, 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92609, 92626, 92627, 96105, 96110, 96112, 96113, 97533, G0451, G0515
Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) Related terms: Related terms: ionizing, stereotactic guidance, robotic L35076 A56874
77371, 77372, 77373, 77432, 77435, G0339, G0340
Total Joint Arthroplasty
Related terms: Knee, TKA, Hip, THA
L36039 A57428
27130, 27132, 27134, 27137, 27138, 27445, 27447, 27486, 27487
Transcranial Magnetic Stimulation
Related terms: depression, major depressive disorder, magnetic field
L33398 A57528
90867, 90868, 90869
Transesophageal Echocardiography (TEE)
Related terms: ultrasound, esophagus, doppler, color flow, contrast, heart
L33579 A52868
76376, 76377, 93312, 93313, 93314, 93315, 93316, 93317, 93318, 93320, 93321, 93325, C8925, C8926, C8927
Transrectal Ultrasound
Related terms: prostate, ultrasound, echography
L33578 A57427
76872, 76873
Transthoracic Echocardiography (TTE)
Related terms: cardiac, doppler, stress, cardovascular, myocardial, heart, contrast
L33577 A56781
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
Transvenous Phrenic Nerve Stimulation in the Treatment of Central Sleep Apnea
Related Terms: N/A
L37929 A57548
0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T, C1787, C1823
Urine Drug Testing
Related terms: UDT, substance use disorder, SUD, chronic opioid therapy, COT
L36037 A56761
80305, 80306, 80307, G0480, G0481, G0482, G0483
Urodynamics
Related terms: cystometrogram, uroflowmetry, urethral pressure profile, sphincter electromyogram, sphincter electromyogram, incontinence, voiding dysfunction
L33576 A57455
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 A52870
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 A56845
37248, 37249
Vertebroplasty and Vertebral Augmentation (Percutaneous)
Related terms: compression, spine, fracture
L33569 N/A 22510, 22511, 22512, 22513, 22514, 22515, 76380
Visual Electrophysiology Testing
Related terms: N/A
L36831  A57060 92273, 92274, 95930, 0509T, 0333T, 0464T
Visual Fields Testing
Related terms: eyes, ophthalmology, vision
L33574 A56551 92081, 92082, 92083
Vitamin D Assay Testing
Related terms: Bone Density, Osteopenia
L37535 A57736
82306, 82652
Water Vapor Thermal Therapy for LUTS/BPH
Related terms: N/A
L37808
N/A 53854
HHH LCD Title LCD# Billing and Coding #
Related CPT/HCPCS Codes
Hospice - Determining Terminal Status
Related terms: Decline, life expectancy
L33393 N/A 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
Billing and Coding: Bevacizumab and biosimilars
Related Terms: drug, retinal
A52370 C9257, J9035, 67028
Billing and Coding: Bortezomib
Related Terms: drug
A52371 J9041, J9044
Billing and Coding: Denosumab (Prolia ™, Xgeva ™)
Related Terms: drug, bone
A52399 J0897, 96372
Billing and Coding: Drugs and Biologicals
Related Terms: N/A
A52855 N/A
Billing and Coding: Eculizumab
Related Terms: drug, hemolysis
A54548 J1300
Billing and Coding: Filgrastim, Pegfilgrastim, Tbo-filgrastim and biosimilars
Related Terms: drug, G-CSF
A52408 J1442, J1447, J2505, Q5101, Q5108, Q5110, Q5111
Billing and Coding: Ibandronate Sodium
Related Terms: drug, bone  , osteoporosis
A52421 J1740
Billing and Coding: Infliximab and biosimilars
Related Terms: drug
A52423 J1745, Q5103, Q5104
Billing and Coding: Intravenous Immune Globulin (IVIG)
Related Terms: drug, immunodeficiency, ITP
A52446 96365, 96366, J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599
Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs
Related Terms: drug, endometriosis, leuprolide, goserelin
A52453 11981, 11982, 11983, 96402, J1950, J3315, J3316, J9202, J9217, J9218, J9219, J9225
Billing and Coding: Nivolumab
Related Terms: drug
A54862 J9299
Billing and Coding: Omalizumab
Related Terms: drug
A52448 J2357
Billing and Coding: Paclitaxel (e.g., Taxol®/Abraxane ™)
Related Terms: drug
A52450 J9264, J9267
Billing and Coding: Ranibizumab and Aflibercept
Related Terms: eye, ophthalmology, macular
A52451 67028, J0178, J2778
Billing and Coding: Rituximab, Rituximab-abbs and Rituximab and hyaluronidase human (Rituxan Hycela™)
Related Terms: drug
A52452 J9311, J9312
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
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
Health and Behavior Assessment/Intervention – Medical Policy Article
Related Terms: mental, psychologist
A52434 96150, 96151, 96152, 96153, 96154, 96155
Billing and Coding: Hyaluronans Intra-articular Injections of
Related Terms: drug, knee, ankle
A52420 J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, 20610, 20611
Implantable Automatic Defibrillators – Coding and Billing
Related Terms: N/A
A56326 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
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
Molecular Pathology Procedures- Related to Molecular Policy Procedures LCD (L35000)
Related Terms: N/A
A56199 81120, 81121, 81162, 81163, 81164, 81165, 81166, 81167, 81170, 81175, 81176, 81206, 81207, 81208, 81209, 81210, 81212, 81215, 81216, 81217, 81218, 81219, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81235, 81236, 81237, 81245, 81246, 81256, 81261, 81262, 81263, 81264, 81265, 81266, 81267, 81268, 81270, 81272, 81273, 81275, 81276, 81287, 81301, 81305, 81310, 81311, 81313, 81314, 81315, 81316, 81332, 81334, 81335, 81340, 81341, 81342, 81345, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 81518, 81519, 81520, 81595, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81233, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81306, 81312, 81317, 81318, 81319, 81320, 81321, 81322, 81323, 81333, 81343, 81344, 81599, 81105‒81112, 81161, 81171, 81172, 81173, 81174, 81200, 81201, 81202, 81203, 81204, 81205, 81227, 81228, 81229, 81230, 81231, 81232, 81234, 81238, 81239, 81240, 81241, 81242, 81243, 81244, 81247,  81248, 81249, 81250, 81251, 81252, 81253, 81254, 81255, 81257, 81258, 81259, 81260, 81269, 81271, 81274, 81283, 81284, 81285, 81286, 81289, 81290, 81291, 81302, 81303, 81304, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81336, 81337, 81346, 81350, 81355, 81361‒81364, 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, 81443, 81448, 81455, 81460, 81465, 81470, 81471, 81493, 81500, ,81503, 81504, 81507, 81521, 81525, 81535, 81536, 81538, 81540, 81541, 81545, 81551
New Local Coverage Determination (LCD) Request Process
Related Terms: N/A
A56198
N/A
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
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: Biomarker Testing (Prior to Initial Biopsy) for Prostate Cancer Diagnosis
Related Terms: N/A
A56115
N/A
Response to Comments: Biomarker Testing for Neuroendocrine Tumors LCD L37851
Related Terms: N/A
A56247 N/A
Response to Comments: Cataract Extraction
Related Terms: N/A
A55257 N/A
Response to Comments: Corneal Hysteresis
Related Terms: N/A
A56529
N/A
Response to Comments Frequency of Hemodialysis
Related Terms: N/A
A56252 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: Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms- Related to Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms (L37810)
Related Terms: N/A
A56216 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: Transvenous Phrenic Nerve Stimulation in the Treatment of Central Sleep Apnea
Related Terms: N/A
A56267 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
Response to Comments: Water Vapor Thermal Therapy for LUTS/BPH
Related Terms: N/A
A56109
N/A
Self-Administered Drug Exclusion List - Medical Policy Article (Jurisdiction K Only)
Related Terms: SAD
A53021 C9399, J0135, J0270, J0364, J0593, J0599, J0630, J1324, J1438, J1559, J1562, J1595, J1675, J1744, J1815, J1817, J1830, J2170, J2212, J2354, J2440, J2502, J2760, J2940, J2941, J3030, J3031, 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 C9399, J0135, J0270, J0364, J0593, J0599, J0630, J1324, J1438, J1559, J1562, J1595, J1675, J1744, J1815, J1817, J1830, J2170, J2212, J2354, J2440, J2502, J2760, J2940, J2941, J3030, J3031, 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
Speech-Language Pathology – SIA
Related Terms: dysphagia, SLP
A52866 31579, 92507, 92508, 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92609, 92626, 92627, 96105, 96110, 96112, 96113, 97532, 97533, G0451, G0515
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
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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