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Medical Policies

Coverage for services under Medicare is primarily established through the Social Security Act. Provisions of the Social Security Act are applied to specific services based on various regulations, National Coverage Determinations established by the Centers for Medicare & Medicaid Services (CMS), various CMS guidelines, and Local Coverage Determinations (LCDs) established by CGS.

  • NCDs are developed by CMS to describe the circumstances for Medicare coverage nationwide for an item or service.
  • LCDs are developed by Medicare Administrative Contractors (MACs), including CGS, and indicate whether a particular item or service is covered in accordance with the Social Security Act, section 1862(a)(1)(A). (See list of LCDs below.)
  • NCDs and LCDs only address certain services and items; in other words, not every item or service has a corresponding NCD or LCD. In these cases, the Social Security Act, and in some cases, additional guidance published by CMS, establish the basis for coverage.
  • For more information about NCDs, LCDs, and other coverage provisions, refer to the CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 13External PDF.
  • CAC Compliance Open and Provider Touch Point Meetings

IMPORTANT NOTE: CGS does NOT house LCDs on our website. By following the links below you will be sent directly to the CMS Medicare Coverage Database (MCD). When using the individual links provided below there may be times that you will receive the message "superseded", indicating you are not viewing the most current LCD. This is due to system processes which cause a delay in updating these links. If you get the note "superseded" on a policy, please use the main link listed below for current LCDs to the MCD provided while we complete the process of updating the individual links.

The following CGS Part A Local Coverage Determinations (LCDs) are located on the Centers for Medicare & Medicaid Services (CMS) Medicare Coverage Database (MCD) webpage. CMS also provides the LCD Contractor IndexExternal Website, where providers can browse LCDs by contractor.

External Website
ID Title Effective Date Revision Effective Date Last Updated Status HCPC/CPT code
L32553External Website Allergy Immunotherapy 10/1/2015 9/19/2019 9/11/2019 Active N/A
L33943External Website B-type Natriuretic Peptide (BNP) Testing 10/1/2015 9/19/2019 9/13/2019 Active N/A
L36975External Website Bladder/Urothelial Tumor Markers 3/6/2017 9/19/2019 9/13/2019 Active N/A
L33944External Website Blepharoplasty 10/1/2015 9/19/2019 9/11/2019 Active N/A
L36460External Website Bone Mass Measurement 2/1/2016 9/26/2019 9/23/2019 Active N/A
L33949External Website Botulinum Toxins 10/1/2015 9/19/2019 9/13/2019 Active N/A
L33950External Website Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography 10/1/2015 9/12/2019 9/13/2019 Active N/A
L33946External Website Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy 10/1/2015 9/19/2019 9/13/2019 Active N/A
L33959External Website Cardiac Catheterization and Coronary Angiography 10/1/2015 9/18/2019 9/13/2019 Active N/A
L33947External Website Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) 10/1/2015 9/19/2019 9/13/2019 Active N/A
L33952External Website Cardiac Event Detection 10/1/2015 9/19/2019 9/13/2019 Active N/A
L33960External Website Cardiovascular Nuclear Medicine 10/1/2015 9/19/2019 9/13/2019 Active N/A
L33954External Website Cataract Extraction 10/1/2015 9/19/2016 9/13/2019 Active N/A
L34370External Website Category III CPT® Codes 10/1/2015 9/26/2019 9/18/2019 Active N/A
L33945External Website Cerumen (Earwax) Removal 10/1/2015 9/19/2019 9/13/2019 Active N/A
L34093External Website Chemotherapy and Biologicals 10/1/2015 10/3/2019 9/25/2019 Active N/A
L37254External Website Chiropractic Services 11/6/2017 9/19/2019 9/13/2019 Active N/A
L37126External Website Coenzyme Q10 (CoQ10) 7/10/2017 9/19/2019 9/13/2019 Active N/A
L34005External Website Colonoscopy/Sigmoidoscopy/ Proctosigmoidoscopy 10/1/2015 9/19/2019 9/13/2019 Active N/A
L34008External Website Computerized Corneal Topography 10/1/2015 9/19/2019 9/13/2019 Active N/A
L36029External Website Controlled Substance Monitoring and Drugs of Abuse Testing 10/5/2015 9/19/2019 9/13/2019 Active N/A
L33999External Website Corneal Pachymetry 10/1/2015 9/19/2019 9/13/2019 Active N/A
L34032External Website Debridement Services 10/1/2015 9/12/2019 9/13/2019 Active N/A
L34062External Website Dialysis Access Maintenance 10/1/2015 9/19/2019 9/13/2019 Active N/A
L34081External Website Endoscopy by Capsule 10/1/2015 9/19/2019 9/13/2019 Active N/A
L34356External Website Erythropoiesis Stimulating Agents (ESA) 10/1/2015 10/3/2019 9/23/2019 Active N/A
L34832External Website Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy 10/1/2015 9/26/2019 9/19/2019 Active N/A
L34037External Website Flow Cytometry 10/1/2015 10/1/2018 9/13/2019 Active N/A
L37575 External Website Frequency of Hemodialysis 4/1/2019 10/1/2019 9/13/2019 Active N/A
L36906External Website GlycoMark Testing for Glycemic Control 3/6/2017 9/5/2019 9/13/2019 Active N/A
L34089External Website Human Papillomavirus (HPV) Testing 10/1/2015 9/19/2019 9/13/2019 Active N/A
L35891External Website Intravenous Immune Globulin 10/1/2015 9/19/2019 9/13/2019 Active N/A
L34090External Website Laser Ablation of the Prostate 10/1/2015 9/19/2019 9/13/2019 Active N/A
L34807External Website Lumbar Epidural Steroid Injections (ESI) 10/1/2015 9/19/2019 9/13/2019 Active N/A
L37790External Website Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor 10/1/2018 9/19/2019 9/23/2019 Active N/A
L37578External Website Micro-Invasive Glaucoma Surgery (MIGS) 3/19/2018 11/8/2018 3/12/2019 Active 0191T, 0449T, 0450T, 0376T
L36494External Website Minimally-Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint 2/1/2016 9/19/2019 9/13/2019 Active N/A
L34195 Mohs Micrographic Surgery 10/1/2015 8/8/2019 9/13/2019 Active N/A
L36979External Website MolDX: 4Kscore Assay 3/13/2017 9/13/2019 9/13/2019 Active N/A
L37362External Website MolDX: AlloSure® Donor-Derived Cell-Free DNA Test 3/6/2018 9/12/2019 9/20/2019 Active N/A
L36910External Website MolDX: APC and MUTYH Gene Testing 3/13/2017 9/19/2019 9/13/2019 Active N/A
L37134External Website MolDX: BDX-XL2 7/10/2017 9/19/2019 9/13/2019 Active N/A
L36139External Website MolDX: Biomarkers in Cardiovascular Risk Assessment 10/5/2015 10/3/2019 9/26/2019 Active N/A
L36456External Website MolDX: BRCA1 and BRCA2 Genetic Testing 2/15/2016 9/19/2019 9/13/2019 Active N/A
L36425External Website MolDX: Breast Cancer Assay: Prosigna 2/1/2016 9/23/2019 9/23/2019 Active N/A
L37832External Website MolDX: Breast CancerTM (BCI) Gene Expression Test 4/1/2019 9/19/2019 9/13/2019 Active N/A
L36006External Website MolDX-CDD: ConfirmMDx Epigenetic Molecular Assay 10/5/2015 9/19/2019 9/23/2019 Active N/A
L36675External Website MolDX- CDD: ProMark Risk Score 10/10/2016 9/19/2019 9/13/2019 Active N/A
L36973External Website MolDX: Circulating Tumor Cell Marker Assays 3/6/2017 9/26/2019 9/19/2019 Active N/A
L37787External Website MolDX: Corus® CAD Assay 11/12/2018 9/19/2019 9/13/2019 Active N/A
L35332External Website MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing 10/1/2015 9/19/2019 9/13/2019 Active N/A
L37598External Website MolDX: Cystatin C Measurement 12/17/2018 9/19/2019 9/13/2019 Active N/A
L37834External Website MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease 4/29/2019 9/19/2019 9/13/2019 Active N/A
L36656External Website MolDX: Decipher® Prostate Cancer Classifier Assay 10/10/2016 9/12/2019 9/13/2019 Active N/A
L38016External Website MolDX: DecisionDx-Melanoma 6/24/2019 10/3/2019 9/26/2019 Active N/A
L37130External Website MolDX: DecisionDx-UM (Uveal Melanoma) 7/10/2017 9/19/2019 9/13/2019 Active N/A
L37356External Website MolDX: EndoPredict Breast Cancer Gene Expression Test 3/6/2018 9/19/2019 9/13/2019 Active N/A
L37905External Website MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test 5/20/2019 9/19/2019 9/13/2019 Active N/A
L37364External Website MolDX: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs) 1/7/2019 9/19/2019 9/13/2019 Active N/A
L35443External Website MolDX: GeneSight Assay for Refractory Depression 10/1/2015 9/19/2019 9/13/2019 Active N/A
L36117External Website MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease 10/5/2015 9/19/2019 9/13/2019 Active N/A
L35984External Website MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) 10/1/2015 9/19/2015 9/13/2019 Active N/A
L35349External Website MolDX: Genetic Testing for Lynch Syndrome 10/1/2015 9/19/2019 9/13/2019 Active N/A
L36206External Website MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay 10/5/2015 9/19/2019 9/13/2019 Active N/A
L37366External Website MolDX: Guardant360® Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC) 11/19/2018 9/19/2019 9/12/2019 Active N/A
L36048External Website MolDX: HLA-B*15:02 Genetic Testing 10/5/2015 9/19/2019 9/13/2019 Active N/A
L36485External Website MolDX: HLA-DQB1*06:02 Testing for Narcolepsy 2/15/2016 9/19/2019 9/13/2019 Active N/A
L37903External Website MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer 5/13/2019 9/19/2019 9/13/2019 Active N/A
L37608External Website MolDX: MDS FISH 5/6/2019 9/19/2019 9/13/2019 Active N/A
L36113External Website MolDX: MGMT Promoter Methylation Analysis 10/5/2015 9/19/2019 9/13/2019 Active N/A
L36011External Website MolDX: Molecular RBC Phenotyping 10/5/2015 9/19/2019 9/13/2019 Active N/A
L37348External Website MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels 12/3/2018 9/19/2019 9/13/2019 Active N/A
L37907External Website MolDX: myPath Melanoma Assay 6/30/2019 9/19/2019 9/13/2019 Active N/A
L35442External Website MolDX: NRAS Genetic Testing 10/1/2015 9/19/2019 9/12/2019 Active N/A
L37836External Website MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC) 3/25/2019 9/19/2019 9/13/2019 Active N/A
L36951External Website MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) 3/6/2017 9/19/2019 9/13/2019 Active N/A
L37354External Website MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer 3/6/2018 9/19/2019 9/13/2019 Active N/A
L36908External Website MolDX: Percepta® Bronchial Genomic Classifier 3/13/2017 9/19/2019 9/13/2019 Active N/A
L36002External Website MolDX: Prolaris™ Prostate Cancer Genomic Assay 10/5/2015 9/26/2019 9/19/2019 Active N/A
L37142External Website MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease 7/10/2017 9/19/2019 9/13/2019 Active N/A
L37352External Website MolDX: Prometheus IBD sgi Diagnostic Policy 11/6/2017 9/23/2019 9/23/2019 Active N/A
L36021External Website Molecular Diagnostic Tests (MDT) 10/1/2015 9/19/2019 9/13/2019 Active N/A
L34171External Website Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation 10/1/2015 9/26/2019 9/19/2019 Active N/A
L35249External Website Nerve Blocks for Peripheral Neuropathy 10/1/2015 9/26/2019 9/20/2019 Active N/A
L35897External Website Nerve Conduction Studies and Electromyography 10/1/2015 9/26/2019 9/20/2019 Active N/A
L34045External Website Non-Invasive Vascular Studies 10/1/2015 9/26/2019 9/20/2019 Active N/A
L34393External Website Ocular Photography - External 10/1/2015 9/19/2019 9/20/2019 Active N/A
L34175External Website Ophthalmic Angiography (Fluorescein and Indocyanine Green) 10/1/2015 9/19/2019 9/20/2019 Active N/A
L34181External Website Ophthalmic Biometry for Intraocular Lens Power Calculation 10/1/2015 9/26/2019 9/20/2019 Active N/A
L34399External Website Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) 10/1/2015 9/26/2019 9/20/2019 Active N/A
L34049External Website Outpatient Physical and Occupational Therapy Services 10/1/2015 9/19/2019 9/13/2019 Active N/A
L34353External Website Outpatient Psychiatry and Psychology Services 10/1/2015 9/26/2019 9/20/2019 Active N/A
L34064External Website Panretinal (Scatter) Laser Photocoagulation 10/1/2015 10/3/2019 9/25/2019 Active N/A
L36902External Website Polysomnography and Other Sleep Studies 3/6/2017 9/26/2019 9/20/2019 Active N/A
L34085External Website Post-Void Residual Urine and/or Bladder Capacity by Ultrasound 10/1/2015 10/1/2016 9/20/2019 Active N/A
L36658External Website Proton Beam Therapy 10/24/2016 9/26/2019 9/23/2019 Active N/A
L34183External Website Psychiatric Inpatient Hospitalization 10/1/2015 9/26/2019 9/20/2019 Active N/A
L34196External Website Psychiatric Partial Hospitalization Programs 10/1/2015 9/26/2019 9/20/2019 Active N/A
L34539External Website Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians 10/1/2015 9/26/2019 9/20/2019 Active N/A
L34063External Website RAST Type Tests 10/1/2015 9/26/2019 9/16/2019 Active N/A
L34200External Website Removal of Benign Skin Lesions 10/1/2015 9/26/2019 9/16/2019 Active N/A
L36469External Website Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder 2/8/2016 9/12/2019 9/16/2019 Active N/A
L34246External Website Routine Foot Care and Debridement of Nails 10/1/2015 10/1/2018 9/23/2019 Active N/A
L34061External Website Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) 10/1/2015 10/3/2019 9/23/2019 Active N/A
L35906External Website Somatosensory Testing 10/1/2015 9/26/2019 9/20/2019 Active N/A
L35986External Website Special Histochemical Stains and Immunohistochemical Stains 10/1/2015 9/19/2019 9/13/2019 Active N/A
L34046External Website Speech-Language Pathology 10/1/2015 9/26/2019 9/20/2019 Active N/A
L34540External Website Stretta Procedure 10/1/2015 9/26/2019 9/23/2019 Active N/A
L34087External Website Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs): Office, Hospital, Web, or Non-Web Based 10/1/2015 9/26/2019 9/23/2019 Active N/A
L34084External Website Transcatheter Infusion Therapy 10/1/2015 9/26/2019 9/23/2019 Active N/A
L34337External Website Transesophageal Echocardiography (TEE) 10/1/2015 9/26/2019 9/23/2019 Active N/A
L34541External Website Transtelephonic Spirometry 10/1/2015 9/26/2019 9/26/2019 Active N/A
L34338External Website Transthoracic Echocardiography (TTE) 10/1/2015 9/26/2019 9/26/2019 Active N/A
L34056External Website Urodynamics 10/1/2015 9/26/2019 9/26/2019 Active N/A
L34082External Website Varicose Veins of the Lower Extremity, Treatment of 10/1/2015 9/26/2019 9/26/2019 Active N/A
L34048External Website Vertebroplasty and Vertebral Augmentation (Percutaneous) 10/1/2015 9/26/2019 9/26/2019 Active N/A
L34055External Website Virtual Colonoscopy (CT Colonography) 10/1/2015 9/26/2019 9/26/2019 Active N/A
L34394External Website Visual Fields Testing 10/1/2015 9/26/2019 9/26/2019 Active N/A
L33996External Website Vitamin D Assay Testing 10/1/2015 9/26/2019 9/26/2019 Active N/A
L36690External Website Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities 10/10/2016 9/23/2019 9/23/2019 Active N/A

Updated: 10.10.19


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