Local Coverage Determinations (LCDs)

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Policy No.	Policy Name	Date Implemented	Date Last Revised	Revision Reason
LCD-4874	Rural Health Clinic	12/27/02	12/11/08	Narrative Change
LCD-26156	(Retired 02/06/09) Category III CPT Codes			Retired
LCD-23499	Cardiac Rehabilitation	09/30/06	09/01/08	Jurisdiction Change
LCD-23488	(Retired 02/06/09) Viscosupplementation Therapy			Retired
LCD-23482	(Retired 02/06/09) Audiology			Retired
LCD-23480	Cardiac CT	09/30/06	09/01/08	Jurisdiction Change
LCD-23478	(Retired 02/06/09) Virtual Colonoscopy			Retired
LCD-22951	Inpatient Rehabilitation	08/01/07	09/01/08	Jurisdiction Change
LCD-20724	(Retired 04/07/2006) Natrecor			Retired
LCD-20721	Carboplatin	09/30/05	02/23/09	Code Change
LCD-20626	[RETIRED 11/07/05] Dysphagia Services			Retired
LCD-1959	Percutaneous Vertebroplasty	09/29/02	09/01/08	Jurisdiction Change
LCD-1951	Kyphoplasty	09/29/02	09/01/08	Jurisdiction Change
LCD-1948	Infliximab	09/29/02	09/01/08	Jurisdiction Change
LCD-1944	(Retired 02/06/09) Human Skin Equivalent			Retired
LCD-1942	(Retired 06/04/2009) Erythropoietin Analog			Retired
LCD-1938	(Retired 06/04/2009) Epoetin Alfa (Epogen/EPO/Ery			Retired
LCD-1865	(Retired 02/06/09) Removal of Benign Skin Lesions			Retired
LCD-1831	Wireless Capsule Endoscopy	09/29/02	09/01/08	Jurisdiction Change
LCD-17673	(Retired 02/06/09) Low Vision Rehabilitation			Retired
LCD-17645	(Retired 02/06/09) Resynchronization Therapy/CHF			Retired
LCD-17639	Physical Medicine and Rehabilitation Modalities	09/29/04	01/06/09	Code Change
LCD-17637	Occupational Therapy	09/30/05	02/27/09	narrative change
LCD-17635	Alefacept Therapy	09/29/04	09/01/08	Jurisdiction Change
LCD-17632	Oxaliplatin for Injection (Eloxitin)	09/29/04	02/23/09	Code Change
LCD-1686	Troponin	09/28/00	09/01/08	Jurisdiction Change
LCD-1682	Transthoracic Echocardiography (TTE)	08/04/05	01/26/09	Code Update
LCD-1676	(Retired 02/06/09) Transrectal Echography/Prostate			Retired
LCD-1669	Syphilis Test	10/16/97	09/01/08	Jurisdiction Change
LCD-1664	(Retired 02/06/09) Steroid Injections			Retired
LCD-1642	Potassium	07/27/05	01/06/09	Narrative Change
LCD-1641	Hepatitis B	07/22/95	09/01/08	Jurisdiction Change
LCD-1628	Rheumatoid Factor Test	10/16/97	09/01/08	Jurisdiction Change
LCD-1626	(Retired 02/06/09) Respiratory Therapy			Retired
LCD-1605	Pulmonary Rehabilitation	06/01/02	09/01/08	Jurisdiction Change
LCD-1597	Removal Impacted Cerumen	07/27/05	01/06/09	Code Change
LCD-1594	(Retired 02/06/09) Pulmonary Perfusion Imaging			Retired
LCD-1593	Psychiatry and Psychology Services	08/05/05	08/27/08	Annual Review
LCD-1567	Urinalysis	05/15/98	09/01/08	Jurisdiction Change
LCD-1565	HCG, Human Chorionic Gonadotropin Qualitative	07/01/97	09/01/08	Jurisdiction Change
LCD-1428	Prostatic Acid Phosphatase, PAP	10/16/77	09/01/08	Jurisdiction Change
LCD-1426	(Retired 02/06/09) PRN Orders for SNF			Retired
LCD-1413	Percutaneous Transluminal Angioplasy in Renal Dise	12/27/96	09/01/08	Jurisdiction Change
LCD-1412	(Retired 02/06/09) Pelvic Echo for Prostate F/U			Retired
LCD-1406	(Retired 02/06/09) Patient Education			Retired
LCD-1379	Partial Hospitalization	07/26/05	01/26/09	Code Change
LCD-13725	(Retired 02/06/09)Psychiatric Inpt Hospitalization			Retired
LCD-1372	Psychiatric Services - Outpatient Hospital Based	09/28/00	09/01/08	Jurisdiction Change
LCD-1363	(Retired 02/06/09) Occult Blood - Feces			Retired
LCD-13570	Wound Care	12/06/03	01/06/09	Code Change
LCD-1352	Noninvasive Vascular Studies	12/27/96	09/01/08	Jurisdiction Change
LCD-1348	Barium Swallow (Vedio/Cine)	10/16/97	09/01/08	Jurisdiction Change
LCD-1343	Bone Density Measurement	01/01/98	09/01/08	Jurisdiction Change
LCD-1340	Magnesium	07/26/05	09/01/08	Jurisdiction Change
LCD-1338	Lumbosacral Spine X-ray	07/26/05	01/06/09	Code Change
LCD-13302	(Retired 02/06/09) Dialysis Frequency			Retired
LCD-13295	Renal and Iliac Angio and Aortography	09/30/03	09/01/08	Jurisdiction Change
LCD-13281	ESWT for Musculoskeletal Problems	09/30/03	09/01/08	Jurisdiction Change
LCD-1326	Lumbar Spine MRI	07/26/05	09/01/08	Jurisdiction Change
LCD-13243	Adenosine (Adenocard)	09/30/03	09/01/08	Jurisdiction Change
LCD-13239	Neupogen and Neulasta	09/30/03	04/28/09	Attachment Maintenan
LCD-13232	Ferrlecit and Venofer	09/30/03	09/01/08	Jurisdiction Change
LCD-13228	Intensity Modulated Radiation Therapy (IMRT)	09/30/03	01/06/09	Code Change
LCD-13225	Mohs Micrographic Surgery	12/08/05	09/01/08	Jurisdiction Change
LCD-1321	Botulinum Toxin Type A	12/27/96	01/06/09	Code Change
LCD-13202	(Retired 02/06/09) Non-Covered Services			Retired
LCD-1316	(Retired 02/06/09) Blood Glucose Testing			Retired
LCD-13121	Off-Label Coverage of FDA Approved Drugs and Bio	09/30/03	01/06/09	Code Change
LCD-13093	(Retired 04/01/2006) Bariatric Surgery			Retired
LCD-1306	Blepharoplasty	09/28/00	09/01/08	Jurisdiction Change
LCD-1303	Bladder Tumor Antigen	07/1997	09/01/08	Jurisdiction Change
LCD-1293	(Retired 02/06/09) Bacterial Culture			Retired
LCD-1290	(Retired 02/06/09)Anesth forTransvenous Pacemaker			Retired
LCD-1281	(Retired 02/06/09)Acute Care: Inpt, Obs/Treatment			Retired
LCD-1266	Leuprolide/Goserelin	10/16/97	01/23/09	Code Change
LCD-1264	(Retired 02/06/09) Laser Assist Uvulo (LAUP)			Retired
LCD-1257	Ionized Calcium	07/26/05	09/01/08	Jurisdiction Change
LCD-1253	IVIG Intravenous Immunoglobin	06/01/02	09/01/08	Jurisdiction Change
LCD-1249	Interventional Cardiology	12/27/96	09/01/08	Jurisdiction Change
LCD-1248	(Retired 02/06/09) Injection, Tendon, Liga Trigge			Retired
LCD-1247	Injectable Iron Preparation	07/19/05	01/06/09	Code Change
LCD-1244	Indocyanine Green Angiography	12/27/96	09/01/08	Jurisdiction Change
LCD-1243	Impotency Treatment	08/04/05	09/01/08	Jurisdiction Change
LCD-1242	Ifosfamide (Ifex)	07/26/05	01/23/09	Code Change
LCD-1241	Electrocardiographic Monitoring for 24 hours	07/12/00	01/06/09	Code Change
LCD-1162	Ground Ambulance	06/01/02	09/01/08	Jurisdiction Change
LCD-1140	Flow Cytometry	12/06/05	09/01/08	Jurisdiction Change
LCD-1139	Electrophysiology Studies, EPS	07/27/05	01/23/09	Code Change
LCD-1137	Electrocardiogram	04/01/98	09/01/08	Jurisdiction Change
LCD-1130	Diagnostic Mammogram	10/16/97	09/01/08	Jurisdiction Change
LCD-1116	Colonoscopy	12/27/96	09/01/08	Jurisdiction Change
LCD-1081	Chest X-ray	07/19/05	01/06/09	Code Change
LCD-1068	Cardiac Catheterization	03/15/99	09/01/08	Jurisdiction Change
LCD-104-03	(Converted to LCD) Psychiatric Inpatient Hosp	12/06/03	12/14/05	Converted to L13725
LCD-102-03	(Converted to LCD) Wound Care	12/06/03	12/14/05	Converted to L13570
LCD-100-03	(Converted to LCD) Bariatric Surgery	09/30/03	12/13/05	Converted to L13093
LCD-099-03	(Converted to LCD) Renal and Iliac Angio and	09/30/03	12/13/05	Converted to L13295
LCD-098-03	(Converted to LCD) Dialysis Frequency	09/30/03	12/13/05	Converted to L13302
LCD-097-03	(Converted to LCD) ESWT for Musculoskeletal Proble	09/30/03	12/16/05	Converted to L13281
LCD-096-03	(Converted to LCD) Adenosine (Adenocard)	09/30/03	12/16/05	Converted to L13243
LCD-095-03	(Converted to LCD) Neupogen and Neulasta	09/30/03	12/13/05	Converted to L13239
LCD-094-03	(Converted to LCD) Ferrlecit and Venofer	09/30/03	12/13/05	Converted to L13232
LCD-093-03	(Converted to LCD) Intensity Modulated Radiation	09/30/03	11/01/05	Converted to L13228
LCD-092-03	(Converted to LCD) Mohs Micrographic Surgery	09/30/03	12/08/05	Converted to L13225
LCD-091-03	(Converted to LCD) Off-Label Coverage of FDA Appr	09/30/03	12/16/05	Converted to L13121
LCD-090-02	(Converted to LCD) Erythropoietin Analogs	09/29/02	12/14/05	Converted to L1942
LCD-089-02	(Converted to LCD) Epoetin Alfa	09/29/02	12/15/05	Converted to L1938
LCD-088-02	(Converted to LCD) Infliximab	09/29/02	12/13/05	Converted to L1948
LCD-087-02	(Converted to LCD) Human Skin Equivalent	09/29/02	12/16/05	Converted to L1944
LCD-086-02	(Converted to LCD) Kyphoplasty	09/29/02	12/15/05	Converted to L1951
LCD-085-02	(Converted to LCD) Percutaneous Vertebroplasty	09/29/02	12/13/05	Converted to L1959
LCD-084-02	(Converted to LCD) Wireless Capsule Endoscopy	09/29/02	12/13/05	Converted to L1831
LCD-083-02	(Converted to LCD) Rural Health Clinic	12/27/02	12/28/05	Converted to L4874
LCD-079-01	(Converted to LCD) Pulmonary Rehabilitation	06/01/02	12/05/03	Converted to L1605
LCD-078-00	(Converted to LCD) Electrocardiographic Monitoring	07/12/00	12/13/05	Converted to L1241
LCD-077-00	(Converted to LCD) Troponin	09/28/00	12/13/05	Converted to L1686
LCD-076-00	[RETIRED 09/24/02] Self-administered Inj Drugs
LCD-075-00	(Converted to LCD) Psychiatric Services-Outpatient	09/28/00	12/15/05	Converted to L1372
LCD-074-00	(Converted to LCD) Blepharoplasty	09/28/00	10/31/02	Converted to L1306
LCD-073-99	(Converted to LCD) HCG, Human Chorionic Gonado	07/01/97	12/07/05	Converted to L1565
LCD-072-99	[RETIRED 01/13/03] CA19-9 Tumor Antigen
LCD-071-99	[RETIRED 01/13/03] CA15-CA27.29 Tumor Antigen
LCD-070-99	[RETIRED 01/13/03] CA125 Tumor Antigen
LCD-069-99	[RETIRED 01/13/03] Alpha-fetoprotein Tumor Antigen
LCD-068-99	(Converted to LCD) Bladder Tumor Antigen	07/1997	12/07/05	Converted to L1303
LCD-067-99	[RETIRED 01/13/03] CEA Carcinoembryonic Antigen
LCD-066-99	[RETIRED 01/13/03] Blood Count (CBC)
LCD-065-99	[RETIRED 01/13/03 HIV] Testing (Diagnostic)
LCD-064-99	[RETIRED 01/13/03] Lipid Profile
LCD-063-99	(Converted to LCD) Cardiac Catheterization	03/15/99	12/07/05	Converted to L1068
LCD-062-98	(Converted to LCD) Urinalysis	05/15/98	12/07/05	Converted to L1567
LCD-061-98	(Retired 09/30/2005) Respiratory Therapy
LCD-059-98	(Retired 12/31/2005) Speech Therapy	05/15/98	02/17/05	Code Update
LCD-058-98	[RETIRED 06/01/02] Observation Room Services
LCD-057-98	(Converted to LCD) PRN Orders for Skilled Nursing	04/01/98	12/07/05
LCD-056-98	(Converted to LCD) Electrocardiogram	04/01/98	12/07/05	Converted to L1137
LCD-055-97	(Retired 12/31/2005) Physical Therapy	01/01/98	01/31/05	Text Revision
LCD-054-97	(Converted to LCD) Bone Density Measurement	01/01/98	12/07/05	Converted to L1343
LCD-053-97	[RETIRED 01/13/03] Bacterial Culture, Urine
LCD-052-97	[RETIRED] Sedimentation Rate, Erythrocyte
LCD-051-97	(Converted to LCD) Rheumatoid Factor Test	10/16/05	12/07/05	Converted to L1628
LCD-050-97	(Converted to LCD) Syphilis Test	10/16/05	12/07/05	Converted to L1669
LCD-049-97	(Converted to LCD) Prostatic Acid Phosphatase, PAP	10/16/97	12/07/05	Converted to L1428
LCD-048-97	(Converted to LCD) Bacterial Culture	10/19/05	09/18/05	Converted to L1297
LCD-047-97	(Converted to LCD) Barium Swallow (Video/Cine)	10/16/97	12/06/05	Converted to L1348
LCD-046-97	(Converted to LCD) Leuprolide/Goserelin	10/16/97	12/06/05	Converted to L1266
LCD-045-97	(Converted to LCD) Occult Blood - Feces	10/16/97	12/06/05	Converted to L1363
LCD-044-97	(Converted to LCD) Diagnostic Mammogram	10/16/97	12/06/05	Converted to L1130
LCD-043-96	[RETIRED] Immunoassay for Tumor Antigen
LCD-042-96	(Converted to LCD) Percutaneous Transluminal	12/27/96	12/06/05	Converted to L1413
LCD-041-96	[RETIRED] Serum Cholesterol
LCD-040-96	(Converted to LCD) Botulinum Toxin Type A	12/27/96	12/06/05	Converted to L1321
LCD-039-96	(Converted to LCD) Interventional Cardiology	12/27/96	12/06/05	Converted to L1249
LCD-038-96	(Converted to LCD) Colonoscopy	12/27/96	12/06/05	Converted to L1116
LCD-035-96	(Converted to LCD) Indocyanine Green Angiography	12/27/96	12/06/05	Converted to L1244
LCD-034-96	[RETIRED] CBC with Platelet Counts
LCD-033-96	(Converted to LCD) Noninvasive Vascular Studies	12/27/96	07/24/03	Converted to L1352
LCD-032-96	(Converted to LCD) Flow Cytometry	12/27/96	12/06/05	Converted to L1140
LCD-031-96	(Converted to LCD) Psychiatry and Psychology Servi	08/06/05	08/06/05	Converted to L1593
LCD-030-96	[RETIRED] Nerve Conduction/Latency Study: Motor
LCD-029-96	(Converted to LCD) Pulmonary Perfusion Imaging	08/06/05	08/06/05	Converted to L1594
LCD-028-96	(Converted to LCD) Pelvic Echography for Prostate	08/04/05	08/04/05	Converted to L1412
LCD-027-96	(Converted to LCD) Transthoracic Echocardiography	08/04/05	08/04/05	Converted to LCD
LCD-026-96	(Converted to LCD) Injection, Tendon Sheath, Liga	08/04/05	08/04/05	Converted to L1248
LCD-025-96	(Converted to LCD) Injectable Iron Preparation	07/18/05	07/18/05	Converted to L1247
LCD-024-96	(Converted to LCD) Impotency Treatment	08/04/05	08/04/05	Converted to L1243
LCD-023-96	(Converted to LCD) Laser Assisted Uvulopalatoplasy	08/04/05	08/04/05	Converted to L1264
LCD-022-96	(Converted to LCD) Removal Impacted Cerumen	07/27/05	07/27/05	Converted to L1597
LCD-021-96	(Converted to LCD) Potassium - Serum	07/27/05	07/27/05	Converted to L1642
LCD-020-96	[RETIRED 01/13/03] Prothrombin Time
LCD-019-96	(Converted to LCD) Steroid Injections	7/26/05	7/26/05	Converted to L1664
LCD-018-96	(Converted to LCD) Anesthesia for Transvenous Pac	07/26/05	07/26/05	Converted to L1290
LCD-017-96	(Converted to LCD) Lumbar Spine MRI	07/26/05	07/26/05	Converted to L1326
LCD-016-96	(Converted to LCD) Lumbosacral Spine X-ray	07/26/05	07/06/05	Converted to L1338
LCD-015-96	[RETIRED] Right Heart Catheterization
LCD-014-96	(Converted to LCD) Electrophysiology Studies EPS	07/26/05	07/26/05	Converted to L1139
LCD-013-96	[RETIRED] Low Osmolar Contrast Material
LCD-012-96	[RETIRED] Additional Automated Hemogram Indices
LCD-011-96	[RETIRED] CBC with Differential
LCD-010-96	(Converted to LCD) Ionized Calcium	07/26/05	07/26/05	Converted to L1257
LCD-009-96	[RETIRED 01/13/03] Glycated Protein
LCD-008-96	(Converted to LCD) Ifosfamide (Ifex)	07/26/05	07/26/05	Converted to L1242
LCD-007-96	[RETIRED 01/13/03] Iron Studies
LCD-006-96	(Converted to LCD) Magnesium	07/26/05	07/06/05	Converted to L1340
LCD-005-96	[RETIRED 01/13/03] Thyroid Panel
LCD-005-95	(Converted to LCD) Partial Hospitalization	07/26/05	07/06/05	Converted to L1379
LCD-004-96	[RETIRED 01/13/03] Digoxin
LCD-004-95	(Converted to LCD) Patient Education	07/25/05	07/25/05	Converted to L1406
LCD-003-96	(Converted to LCD) Blood Glucose Testing	07/22/05	07/22/05	Converted to L1316
LCD-003-95	(Converted to LCD) Hepatitis B	07/22/95	12/09/03	Converted to L1641
LCD-002-96	(Retired 09/30/05) Occupational Therapy
LCD-002-95	[RETIRED 01/13/03] Prostate Specific Antigen
LCD-001-96	(Converted to LCD) Chest X-ray	07/19/05	07/19/05	Converted to L1081
LCD-001-95	[RETIRED 06/01/02] IV Immune Globin Therapy

	Reason Codes
		Correction = Major typographical text or code errors Code update = Annual update, coverage unchanged Codes added = ICD-9 list expanded, coverage unchanged Coverage = Coverage expanded Clarified = Clarification to text, coverage unchanged Billing = Revision to billing instruction, coverage unchanged Modified = Changed due to CMS instructions or after notice or comment Processing = AI processing rules changed

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Local Coverage Determinations (LCDs)