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Local Coverage Determinations (LCD)

General Information

CMS Internet-Only Manuals (IOMs)

LCD Reconsideration Process

Are you looking for our ICD-9 LCDs?

Our ICD-9 LCDs can be viewed on the Medicare Coverage Database (MCD). Use the Quick Search box to search by the ICD-9 LCD number (i.e., Document ID).

You may also link to the ICD-9 LCDs through their corresponding ICD-10 LCDs located below. Begin by opening the applicable ICD-10 LCD, then locate the LCD Information section within the policy. If a final ICD-9 LCD existed, you will see "Original ICD-9 LCD ID" with a link to the policy. Select the link to be taken to the ICD-9 LCD on the CMS website. Remember, this only applies to the ICD-10 LCDs that had a final ICD-9 policy prior to October 1, 2015.

J5 MAC B Local Coverage Determinations (LCDs)

This table is sortable by LCD Title, CMS ID#, or WPS ID #. In order to sort the table, you will need to actually select the table titles.

Title CMS ID# WPS ID# Original Effective Date Status Last Revision Date
Ablative Therapy
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34527 GSURG-033 10/01/15 Active 10/01/15
Allergy Immunotherapy
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L36408 ALRG-005 03/18/16 Final NA
Allergy Testing
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L36402 ALRG-004 03/18/16 Final NA
Allergy Testing and Allergy Immunotherapy
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34597 ALRG-001 10/01/15 Active
Retired Effective 03/17/16
Replaced by L36402 & L34608
01/01/16
Application of Bioengineered Skin Substitutes
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34593 GSURG-052 10/01/15 Active 01/01/16
Autonomic Function Testing
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35124 NEURO-015 10/01/15 Active 02/01/16
Bisphosphonate Drug Therapy
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34648 INJ-025 10/01/15 Active 10/01/15
Blepharoplasty, Blepharoptosis and Brow Lift
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34528 OPHTH-022 10/01/15 Active 10/01/15
Bone Mass Measurement
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34639 MS-004 10/01/15 Active 01/01/16
Botulinum Toxin Type A & Type B
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34635 INJ-018 10/01/15 Active 12/01/15
Capsule Endoscopy
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34613 GI-009 10/01/15 Active 10/01/15
Cardiovascular Stress Testing
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34598 CV-004 10/01/15 Active 10/01/15
Category III Codes
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35490 PHYS-084 10/01/15 Active 01/01/16
Chemotherapy Drugs and their Adjuncts
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35053 HONC-010 10/01/15 Active 02/01/16
Chiropractic Services
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34585 CHIRO-001 10/01/15 Active 10/01/15
Circulating Tumor Cell Marker Assays
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34531 PATH-033 10/01/15 Active 10/01/15
Colonoscopy and Sigmoidoscopy-Diagnostic
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34614 GI-006 10/01/15 Active 02/15/16
Coronary Computed Tomography Angiography (CCTA)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35121 RAD-043 10/01/15 Active 10/01/15
Cosmetic and Reconstructive Surgery
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34698 GSURG-032 10/01/15 Active 02/01/16
Cranial Stereotactic Radiosurgery (SRS) and Cranial Stereotactic Radiotherapy (SRT)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34656 RAD-018 10/01/15 Active 10/01/15
CT Colonography (Virtual Colonoscopy [VC])
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34697 RAD-035 10/01/15 Active 10/01/15
Drug Testing
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34645 PATH-035 10/01/15 Active 01/01/16
Drugs and Biologics (Non-chemotherapy)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34741 INJ-041 10/01/15 Active 01/01/16
Dysphagia
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34438 PHYSMED-017 10/01/15 Active 10/01/15
Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34636 CV-016 10/01/15 Active 01/01/16
Endoscopic Treatment of GERD
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34659 GI-010 10/01/15 Active 01/01/16
Epidural and Transforaminal Epidural Injections
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34622 NEURO-007 10/01/15 Active 02/01/16
Erythropoiesis Stimulating Agents (ESAs)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34633 INJ-023 10/01/15 Active 01/01/16
Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35996 NEURO-016 10/01/15 Active 11/01/15
Flow Cytometry
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34651 PATH-016 10/01/15 Active 10/01/15
Foot Care
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L36404 FT-002 02/16/2016 Final NA
Hemophilia Clotting Factors
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34439 INJ-003 10/01/15 Active 02/01/16
Home and Domiciliary Services
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34643 PHYS-081 10/01/15 Active 10/01/15
Human Granulocyte/Macrophage Colony Stimulating Factors
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34699 INJ-019 10/01/15 Active 10/01/15
Immune Globulins
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34771 INJ-012 10/01/15 Active 01/01/16
Immunizations
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34596 ALRG-003 10/01/15 Active 01/01/16
Independent Diagnostic Testing Facilities (IDTF)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34763 PHYS-078 10/01/15 Active 01/01/16
Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34589 MS-007 10/01/15 Active 12/01/15
Intra-articular Injections of Hyaluronan
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34525 INJ-033 10/01/15 Active 01/01/16
Intraoperative Neurophysiological Testing
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34623 GSURG-034 10/01/15 Active 02/01/16
Luteinizing Hormone-Releasing Hormone (LHRH) Analogs
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34590 INJ-039 10/01/15 Active 10/01/15
Mohs Micrographic Surgery
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35494 DERM-010 10/01/15 Active 01/01/16
Molecular Diagnostic Testing
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34762 PATH-037 10/01/15 Active 01/01/16
Myocardial Perfusion Imaging and Cardiac Blood Pool Studies
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34625 CV-017 10/01/15 Active 10/01/15
Nerve Blocks for Peripheral Neuropathy
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35222 NEURO-014 10/01/15 Active 10/01/15
Nerve Conduction Studies and Electromyography
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34594 NEURO-005 10/01/15 Active 10/01/15
Non-Coronary Vascular Stents
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35998 CV-049 10/01/15 Active 10/01/15
Non-Invasive Abdominal / Visceral Vascular Studies
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35755 CV-048 10/01/15 Active 10/01/15
Non-Invasive Cerebrovascular Studies
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35753 CV-045 10/01/15 Active 10/01/15
Non-Invasive Peripheral Arterial Vascular Studies
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35761 CV-046 10/01/15 Active 10/01/15
Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35751 CV-047 10/01/15 Active 10/01/15
Pelvic Floor Dysfunction: Anorectal Manometry and EMG
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35486 GU-022 10/01/15 Active 01/01/16
Percutaneous Coronary Interventions (PCI)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34761 CV-044 10/01/15 Active 12/01/15
Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L36000 GSURG-055 12/17/15 Active 02/01/16
Polysomnography and Other Sleep Studies
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34535 NEURO-009 10/01/15 Active 10/01/15
Posterior Tibial Nerve Stimulation PTNS
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34436 GSURG-043 10/01/15 Active 10/01/15
Proton Beam Therapy
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34634 RAD-040 10/01/15 Active 11/01/15
Psychiatric Inpatient Hospitalization
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35223 PSYCH-022 10/01/15 Active 10/01/15
Psychiatric Partial Hospitalization Program (PHP)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34601 PSYCH-016 10/01/15 Active 02/01/16
Psychiatry and Psychology Services
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34616 PSYCH-014 10/01/15 Active 01/01/16
Psychological and Neuropsychological Testing
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34646 PSYCH-017 10/01/15 Active 02/01/16
Radiation Oncology Including Intensity Modulated Radiation Therapy (IMRT)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34652 RAD-014 10/01/15 Active 01/01/16
Radiofrequency Treatment for Urinary Incontinence
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34642 GU-021 10/01/15 Active 10/01/15
Radiopharmaceutical Agents
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34657 RAD-026 10/01/15 Active 01/01/16
Removal of Benign Skin Lesions
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35498 DERM-011 10/01/15 Active 02/01/16
Routine Foot Care
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34586 FT-001 10/01/15 Active
Retired Effective 02/16/16
Replaced by L36404
01/01/16
Sacroiliac Joint Injections
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34443 MS-009 10/01/15 Active 01/01/16
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34760 OPHTH-015 10/01/15 Active 10/01/15
Selective Internal Radiation Therapy (SIRT) for Primary and Secondary Hepatic Malignancy (90YMicrosphere Hepatic Brachytherapy)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34524 RAD-038 10/01/15 Active 10/01/15
Somatosensory Testing
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34624 NEURO-013 10/01/15 Active 10/01/15
Stereotactic Body Radiation Therapy
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34647 RAD-039 10/01/15 Active 10/01/15
Surgical Treatment of Obstructive Sleep Apnea (OSA)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34526 ENT-012 10/01/15 Active 02/01/16
Transcranial Magnetic Stimulation (TMS)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34641 NEURO-010 10/01/15 Active 12/01/15
Treatment of Varicose Veins of the Lower Extremities
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34536 GSURG-041 10/01/15 Active 12/01/15
Trigger Points, Local Injections
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34588 MS-008 10/01/15 Active 10/01/15
Venous Angioplasty with or without Stent Placement for the Treatment of Chronic Cerebrospinal Venous Insufficiency
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34523 CV-042 10/01/15 Active 10/01/15
Vertebroplasty (Percutaneous) and Vertebral Augmentation including cavity creation
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34592 RAD-032 10/01/15 Active 02/01/16
Visual Fields
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34615 OPHTH-054 10/01/15 Active 10/01/15
Vitamin B 12 Injections
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34444 INJ-004 10/01/15 Active 02/01/16
Vitamin D Assay Testing
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34658 PATH-032 10/01/15 Active 10/01/15
Wound Care
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34587 GSURG-051 10/01/15 Active 10/01/15

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