Local Policies (LCD)

Home Provider Part A Policies/Coverage Active Local Policies

Title CMS ID# Original Effective Date Status Last Revision Date
Ablative Therapy L30312 09/15/09 Active 03/01/10
Allergy Testing and Allergy Immunotherapy L30471 02/16/10 Active NA
Application of Bioengineered Skin Substitutes L30135 08/16/09 Active 11/01/09
Bisphosphonate Drug Therapy L30139 10/16/09 Active 11/01/09
Blepharoplasty, Blepharoptosis and Brow Lift L29973 07/16/09 Active 08/01/09
Bone Mass Measurement L28527 03/18/09 Active 11/01/09
Brachytherapy L30320 08/16/09 Active NA
Capsule Endoscopy L30141 12/16/09 Active NA
Cardiac Catheterization L15908 07/02/04 Active 10/01/09
Cardiovascular Stress Testing L28563 02/16/09 Active 10/01/09
Cataract Surgery and Complex Cataract Surgery L30159 12/16/09 Active NA
Colonoscopy and Sigmoidoscopy-Diagnostic L30304 09/15/09 Active 10/01/09
Computed Coronary Tomography Angiography L30288 08/16/09 Active 01/01/10
Computerized Tomography (CAT Scans) L28544 03/25/09 Active 03/01/10
Corneal Pachymetry L30485 03/18/10 Final NA
Cranial Stereotactic Radiosurgery (SRS) and Cranial Stereotactic Radiotherapy (SRT) L30318 08/16/09 Active 01/01/10
CT Colonography (Virtual Colonoscopy [VC]) L30300 11/15/09 Active 01/01/10
Cytogenetic Studies L30487 03/18/10 Final NA
Dental Services L5658 08/02/02 Active 08/08/09
Dysphagia L2603 12/12/00 Active 08/08/09
Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) L29584 10/16/09 Active NA
Electroconvulsive Therapy (ECT) L14225 09/13/03 Active 02/11/09
Electromagnetic Navigation Bronchoscopy (ENB) L30510 02/15/10 Active NA
Endoscopic Treatment of GERD L30473 04/15/10 Final NA
Erythropoiesis Stimulating Agents L23363 09/29/06 Active 09/25/09
Flow Cytometry L30161 11/16/09 Active 03/01/10
Health and Behavior Assessment/Intervention L30514 03/18/10 Final NA
Helicobacter Pylori Testing L30163 10/16/09 Active 02/01/10
Hip Resurfacing prosthesis, Total (Femoral and Acetabular) L26113 09/17/07 Active 02/11/09
Human Granulocyte/Macrophage Colony Stimulating Factors L30306 09/15/09 Active 08/01/09
Immune Globulins L30147 11/15/09 Active 03/01/10
Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma L30153 10/16/09 Active NA
Inpatient Psychiatric Services L18183 11/15/04 Active 02/11/09
Intra-articular Injections of Hyaluronan L30149 10/16/09 Retire
03/18/10		 01/01/10
Intravenous Iron Therapy L2422 06/15/02 Active 11/05/07
Intravenous Vitamin D Analogues Usage for Dialysis Patients L2463 06/15/02 Active 11/05/07
Kyphoplasty L22552 06/03/06 Active 11/05/07
Levocarnitine L13187 08/30/01 Active 11/05/07
Luteinizing Hormone-Releasing Hormone (LHRH) Analogs L30479 03/18/10 Final NA
Magnetic Resonance Imaging L28723 03/25/09 Active 12/01/09
Mammoplasty, Reduction L28222 09/30/08 Active NA
Moderate (Conscious) Sedation L29582 07/16/09 Active 08/01/09
Natrecor ® (Neseritide) Usage in the Treatment of Congestive Heart Failure L19826 08/31/05 Retire
03/31/10		 11/02/09
Noninvasive Vascular Testing (N.I.V.T.) L28586 05/18/09 Active 05/01/10
Optical Coherence Tomography (OCT) L29971 10/16/09 Active 10/01/09
Optometrist Services L30157 01/16/10 Active NA
Outpatient Psychiatry and Psychology Services L28318 09/30/08 Active 08/08/09
Paravertebral Facet Joint Block and Facet Joint Denervation L30483 03/18/10 Final NA
Percutaneous Coronary Interventions (PCI) L28478 02/16/09 Active 08/01/09
Psychiatry and Psychological Services L30489 03/18/10 Final 03/01/10
Psychiatric Partial Hospitalization Program L2403 02/10/95 Active 01/01/09
Psychiatric Inpatient Hospitalization L30441 03/18/10 Final NA
Pulmonary Rehabilitation Services L5738 09/09/01 Retire
03/31/10		 01/01/10
Radiation Oncology Including Intensity Modulated Radiation Therapy (IMRT) L30316 08/16/09 Active NA
Removal of Benign Skin Lesions L30330 08/16/09 Active 03/01/10
Routine Foot Care And Debridement Of Nails L30322 08/16/09 Active 01/01/10
Selective Internal Radiation Therapy (SIRT) for Primary and Secondary Hepatic Malignancy (90YMicrosphere Hepatic Brachytherapy) L30137 10/16/09 Active NA
Sleep Studies L23358 08/01/09 Active 11/09/09
Stereotactic Body Radiation Therapy (SBRT) L26109 09/15/07 Active 11/05/07
Stereotactic Computer Assisted Volumetric and/or Navigational Procedure L29586 08/16/09 Active NA
Surgical Treatment for Obstructive Sleep Apnea (OSA) L25033 08/13/07 Active 11/05/07
Thrombopoietic Growth factor - Oprelvekin L30151 11/15/09 Active 02/01/10
Transesophageal Echocardiography (Including Intraoperative TEE) L28574 03/18/09 Active 10/01/09
Transthoracic Echocardiography (TTE) L28565 03/25/09 Active 10/01/09
Treatment of Varicose Veins of the Lower Extremities L30143 11/15/09 Active 01/01/10
Trigger Points, Local Injections L30155 10/16/09 Active NA
Vitamin B 12 Injections L30145 09/15/09 Active 02/01/10
Wound Care L28572 09/15/09 Active 10/01/09

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Page Last Updated: Thursday, 04-Mar-2010 11:51:02 CST