Local Coverage Determinations (LCD)

CMS Internet-Only Manuals (IOMs)(external link)

LCD Reconsideration Process

The official Local Coverage Determination (LCD) is the version on the Medicare Coverage Database at http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx(external link)

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
Illinois ¦ Minnesota ¦ Wisconsin
L30312 GSURG-033 09/15/09 Active 04/01/13
Allergy Testing and Allergy Immunotherapy
Illinois ¦ Minnesota ¦ Wisconsin
L30471 ALRG-001 02/16/10 Active 05/01/13
Application of Bioengineered Skin Substitutes
Illinois ¦ Minnesota ¦ Wisconsin
L30135 GSURG-052 08/16/09 Active 01/01/13
Bariatric Surgery for Morbid Obesity
Illinois ¦ Minnesota ¦ Wisconsin
L32904 GSURG-042 02/15/13 Active 03/01/13
Bisphosphonate Drug Therapy
Illinois ¦ Minnesota ¦ Wisconsin
L30139 INJ-025 10/16/09 Active 10/22/12
Blepharoplasty, Blepharoptosis and Brow Lift
Illinois ¦ Minnesota ¦ Wisconsin
L29973 OPHTH-022 07/16/09 Active 10/22/12
Bone Mass Measurement
Illinois ¦ Minnesota ¦ Wisconsin
L31620 MS-004 08/15/11 Active 10/22/12
Botulinum Toxin Type A & Type B
Illinois ¦ Minnesota ¦ Wisconsin
L28555 INJ-018 05/16/09 Active 01/01/13
Brachytherapy
Illinois ¦ Minnesota ¦ Wisconsin
L30320 RAD-036 08/16/09 Active 05/01/13
Capsule Endoscopy
Illinois ¦ Minnesota ¦ Wisconsin
L30141 GI-009 12/16/09 Active 01/01/13
Cardiac Catheterization and Coronary Angiography
Illinois ¦ Minnesota ¦ Wisconsin
L30719 CV-006 07/16/10 Active 10/22/12
Cardiovascular Stress Testing
Illinois ¦ Minnesota ¦ Wisconsin
L28563 CV-004 02/16/09 Active 10/22/12
Cataract Surgery and Complex Cataract Surgery
Illinois ¦ Minnesota ¦ Wisconsin
L30159 OPHTH-020 12/16/09 Active 10/22/12
Category III Codes
Illinois ¦ Minnesota ¦ Wisconsin
L32569 PHYS-082 11/16/12 Active 02/01/13
Chemotherapy Drugs and their Adjuncts
Illinois ¦ Minnesota ¦ Wisconsin
L28576 HONC-010 05/16/09 Active 04/01/13
Chiropractic Services
Illinois ¦ Minnesota ¦ Wisconsin
L30328 CHIRO-001 09/15/09 Active 03/01/13
Circulating Tumor Cell Marker Assays
Illinois ¦ Minnesota ¦ Wisconsin
L32218 PATH-033 02/15/12 Active 01/01/13
Colonoscopy and Sigmoidoscopy-Diagnostic
Illinois ¦ Minnesota ¦ Wisconsin
L30304 GI-006 09/15/09 Active 10/22/12
Computed Coronary Tomography Angiography
Illinois ¦ Minnesota ¦ Wisconsin
L30288 RAD-034 08/16/09 Active 10/22/12
Computerized Corneal Topography
Illinois ¦ Minnesota ¦ Wisconsin
L31064 OPHTH-014 12/16/10 Active 10/22/12
Corneal Pachymetry
Illinois ¦ Minnesota ¦ Wisconsin
L30485 OPHTH-025 03/18/10 Active 10/22/12
Cosmetic and Reconstructive Surgery
Illinois ¦ Minnesota ¦ Wisconsin
L30733 GSURG-032 11/15/10 Active 01/01/13
Cranial Stereotactic Radiosurgery (SRS) and Cranial Stereotactic Radiotherapy (SRT)
Illinois ¦ Minnesota ¦ Wisconsin
L30318 RAD-018 08/16/09 Active 10/22/12
CT Colonography (Virtual Colonoscopy [VC])
Illinois ¦ Minnesota ¦ Wisconsin
L30300 RAD-035 11/15/09 Active 10/22/12
Cytogenetic Studies
Illinois ¦ Minnesota ¦ Wisconsin
L30487 PATH-027 03/18/10 Active 10/22/12
Diagnostic Pap Tests
Illinois ¦ Minnesota ¦ Wisconsin
L31080 GU-020 11/15/10 Active 05/01/13
Drugs and Biologics (Non-chemotherapy)
Illinois ¦ Minnesota ¦ Wisconsin
L32013 INJ-041 11/15/11 Active 01/01/13
Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring)
Illinois ¦ Minnesota ¦ Wisconsin
L29584 CV-016 10/16/09 Active 01/01/13
Electroconvulsive Therapy (ECT)
Illinois ¦ Minnesota ¦ Wisconsin
L30493 PSYCH-025 07/15/10 Active 10/22/12
Electromagnetic Navigation Bronchoscopy (ENB)
Illinois ¦ Minnesota ¦ Wisconsin
L30510 PULM-007 02/15/10 Active 10/22/12
Endoscopic Treatment of GERD
Illinois ¦ Minnesota ¦ Wisconsin
L30473 GI-010 04/15/10 Active 01/01/13
Epidural and Transforaminal Epidural Injections
Illinois ¦ Minnesota ¦ Wisconsin
L30481 NEURO-007 04/15/10 Active 10/22/12
Erythropoiesis Stimulating Agents - Epoetin alfa, Darbepoetin alfa, Peginesatide
Illinois ¦ Minnesota ¦ Wisconsin
L31074 INJ-023 12/15/10 Active 04/01/13
Flow Cytometry
Illinois ¦ Minnesota ¦ Wisconsin
L30161 PATH-016 11/16/09 Active 04/01/13
Health and Behavior Assessment/Intervention
Illinois ¦ Minnesota ¦ Wisconsin
L30514 PSYCH-015 03/18/10 Active 04/01/13
Heavy Metal Testing
Illinois ¦ Minnesota ¦ Wisconsin
L31067 PATH-028 12/16/10 Active 10/22/12
Hemophilia Clotting Factors
Illinois ¦ Minnesota ¦ Wisconsin
L31078 INJ-003 11/15/10 Active 10/22/12
Home and Domiciliary Services
Illinois ¦ Minnesota ¦ Wisconsin
L31613 PHYS-081 06/15/11 Active 01/01/13
Human Granulocyte/Macrophage Colony Stimulating Factors
Illinois ¦ Minnesota ¦ Wisconsin
L30306 INJ-019 09/15/09 Active 10/22/12
Immune Globulins
Illinois ¦ Minnesota ¦ Wisconsin
L30147 INJ-012 11/15/09 Active 04/01/13
Immunizations
Illinois ¦ Minnesota ¦ Wisconsin
L31084 ALRG-003 11/15/10 Active 05/01/13
Independent Diagnostic Testing Facilities (IDTFs)
Illinois ¦ Minnesota ¦ Wisconsin
L31626 PHYS-078 09/15/11 Active 08/20/12
Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma
Illinois ¦ Minnesota ¦ Wisconsin
L30153 MS-007 10/16/09 Active 10/22/12
Intra-articular Injections of Hyaluronan
Illinois ¦ Minnesota ¦ Wisconsin
L30149 INJ-033 10/16/09 Active 10/22/12
Intra-operative Neurophysiological Testing
Illinois ¦ Minnesota ¦ Wisconsin
L30721 GSURG-034 02/15/11 Active 01/01/13
Low Vision Services
Illinois ¦ Minnesota ¦ Wisconsin
L32007 OPHTH-026 02/15/12 Active 10/22/12
Luteinizing Hormone-Releasing Hormone (LHRH) Analogs
Illinois ¦ Minnesota ¦ Wisconsin
L30479 INJ-039 03/18/10 Active 10/22/12
Moderate (Conscious) Sedation
Illinois ¦ Minnesota ¦ Wisconsin
L29582 AN-030 07/16/09 Active 01/01/13
Mohs Micrographic Surgery
Illinois ¦ Minnesota ¦ Wisconsin
L30713 DERM-004 07/16/10 Active 10/22/12
Myocardial Perfusion Imaging and Cardiac Blood Pool Studies
Illinois ¦ Minnesota ¦ Wisconsin
L31072 CV-017 11/15/10 Active 10/22/12
Nerve Blocks for Peripheral Neuropathy
Illinois ¦ Minnesota ¦ Wisconsin
L32565 NEURO-011 10/16/12 Active 10/22/12
Nerve Conduction Studies and Electromyography
Illinois ¦ Minnesota ¦ Wisconsin
L31346 NEURO-005 04/15/11 Active 05/01/13
Non-coronary Vascular Stents
Illinois ¦ Minnesota ¦ Wisconsin
L30798 CV-028 07/16/10 Active 10/22/12
Noninvasive Vascular Testing (N.I.V.T.)
Illinois ¦ Minnesota ¦ Wisconsin
L28586 CV-033 05/18/09 Active 11/01/12
Ophthalmic Biometry
Illinois ¦ Minnesota ¦ Wisconsin
L31624 OPHTH-006 07/16/11 Active 10/22/12
Optical Coherence Tomography (OCT)
Illinois ¦ Minnesota ¦ Wisconsin
L29971 OPHTH-015 10/16/09 Active 10/22/12
Outpatient Rehabilitation Therapy Services billed to Medicare Part B
Illinois ¦ Minnesota ¦ Wisconsin
L28531 PHYSMED-009 01/15/10 Active 03/01/13
Paravertebral Facet Joint Block and Facet Joint Denervation
Illinois ¦ Minnesota ¦ Wisconsin
L30483 NEURO-008 03/18/10 Active 10/22/12
Percutaneous Coronary Interventions (PCI)
Illinois ¦ Minnesota ¦ Wisconsin
L28478 CV-037 02/16/09 Active 03/01/13
Polysomnography and Other Sleep Studies
Illinois ¦ Minnesota ¦ Wisconsin
L31082 NEURO-009 12/16/10 Active 03/01/13
Posterior Tibial Nerve Stimulation PTNS
Illinois ¦ Minnesota ¦ Wisconsin
L28457 GSURG-043 02/16/09 Active 10/22/12
Proton Beam Therapy
Illinois ¦ Minnesota ¦ Wisconsin
L31617 RAD-040 03/17/12 Active 12/01/12
Psychiatric Partial Hospitalization Program (PHP)
Illinois ¦ Minnesota ¦ Wisconsin
L30491 PSYCH-016 10/16/10 Active 01/01/13
Psychiatry and Psychology Services
Illinois ¦ Minnesota ¦ Wisconsin
L30489 PSYCH-014 03/18/10 Active 05/01/13
Psychological and Neuropsychological Testing
Illinois ¦ Minnesota ¦ Wisconsin
L31990 PSYCH-017 05/15/2012 Active 10/22/12
Psychological Services under the "Incident to" Provision
Illinois ¦ Minnesota ¦ Wisconsin
L30715 PSYCH-013 09/16/10 Active 05/01/13
Qualitative Drug Testing
Illinois ¦ Minnesota ¦ Wisconsin
L32450 PATH-035 07/16/12 Active 10/22/12
Radiation Oncology Including Intensity Modulated Radiation Therapy (IMRT)
Illinois ¦ Minnesota ¦ Wisconsin
L30316 RAD-014 08/16/09 Active 10/22/12
Radiofrequency Treatment for Urinary Incontinence
Illinois ¦ Minnesota ¦ Wisconsin
L31615 GU-021 06/15/11 Active 03/01/13
Radiopharmaceutical Agents
Illinois ¦ Minnesota ¦ Wisconsin
L31361 RAD-026 07/16/11 Active 05/01/13
Removal of Benign Skin Lesions
Illinois ¦ Minnesota ¦ Wisconsin
L30330 DERM-008 08/16/09 Active 10/22/12
Routine Foot Care
Illinois ¦ Minnesota ¦ Wisconsin
L30322 FT-001 08/16/09 Active 10/22/12
Sacroiliac Joint Injections
Illinois ¦ Minnesota ¦ Wisconsin
L31359 MS-009 02/15/11 Active 10/22/12
Selective Internal Radiation Therapy (SIRT) for Primary and Secondary Hepatic Malignancy (90YMicrosphere Hepatic Brachytherapy)
Illinois ¦ Minnesota ¦ Wisconsin
L30137 RAD-038 10/16/09 Active 10/22/12
Sentinel Lymph Node Biopsy
Illinois ¦ Minnesota ¦ Wisconsin
L30475 GSURG-036 07/16/10 Active 10/22/12
Somatosensory Testing
Illinois ¦ Minnesota ¦ Wisconsin
L32902 NEURO-013 02/15/13 Active NA
Stereotactic Body Radiation Therapy
Illinois ¦ Minnesota ¦ Wisconsin
L28366 RAD-039 07/16/08 Active 10/22/12
Stereotactic Computer Assisted Volumetric and/or Navigational Procedure
Illinois ¦ Minnesota ¦ Wisconsin
L29586 GSURG-050 08/16/09 Active 04/01/13
Surgical Treatment of Obstructive Sleep Apnea (OSA)
Illinois ¦ Minnesota ¦ Wisconsin
L30731 ENT-012 07/16/10 Active 10/22/12
Thrombopoietic Growth factor - Oprelvekin
Illinois ¦ Minnesota ¦ Wisconsin
L30151 INJ-034 11/15/09 Active 10/22/12
Transcranial Magnetic Stimulation (TMS)
Illinois ¦ Minnesota ¦ Wisconsin
L32220 NEURO-010 04/16/12 Active 04/01/13
Transesophageal Echocardiography (Including Intraoperative TEE)
Illinois ¦ Minnesota ¦ Wisconsin
L28574 CV-007 03/18/09 Active 05/01/13
Transthoracic Echocardiography (TTE)
Illinois ¦ Minnesota ¦ Wisconsin
L28565 CV-026 03/25/09 Active 10/22/12
Treatment of Varicose Veins of the Lower Extremities
Illinois ¦ Minnesota ¦ Wisconsin
L30143 GSURG-041 11/15/09 Active 10/22/12
Trigger Points, Local Injections
Illinois ¦ Minnesota ¦ Wisconsin
L30155 MS-008 10/16/09 Active 03/01/13
Venous Angioplasty with or without Stent Placement for the Treatment of Chronic Cerebrospinal Venous Insufficiency
Illinois ¦ Minnesota ¦ Wisconsin
L32452 CV-042 06/15/12 Active 10/22/12
Vertebroplasty (Percutaneous) and Vertebral Augmentation including cavity creation
Illinois ¦ Minnesota ¦ Wisconsin
L30516 RAD-032 07/16/10 Active 10/22/12
Visual Fields
Illinois ¦ Minnesota ¦ Wisconsin
L31348 OPHTH-054 04/15/11 Active 10/22/12
Vitamin B 12 Injections
Illinois ¦ Minnesota ¦ Wisconsin
L30145 INJ-004 09/15/09 Active 10/22/12
Vitamin D Assay Testing
Illinois ¦ Minnesota ¦ Wisconsin
L31076 PATH-032 12/15/10 Active 10/22/12
Wound Care
Illinois ¦ Minnesota ¦ Wisconsin
L28572 GSURG-051 09/15/09 Active 02/01/13

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Page Last Updated: Tuesday, 23-Apr-2013 08:44:28 CDT