DLS CodeMap® - NCD / LCD

Tests with Medical Necessity Policies
Non-covered ICD-10-CM Codes for All Lab NCDs

Ordering Code

Test Name

CPT^® Code(s)

Medicare Coverage

Frequency Applies

5891	6-Acetylmorphine Ur. Scrn Forensic	80307	A55001
5890	6-Acetylmorphine, Ur. Scrn, Clinical	80307	A55001
701	Acetaminophen (Tylenol)	G0480	A55001
1801	Acute Hepatitis Panel	80074	NCD 190.33	Yes80074 - After a hepatitis diagnosis has been established, only individual tests, rather than the entire panel, are needed.
6719	Additional Respiratory Allergen Profile	86003 x7	A57181
6715	Aeroallergen Allergy Panel, IgE	86003 x21	A57181
241	AFP Maternal, Screen - Serum	82105	NCD 190.25
106	AFP Non-Maternal - Serum	82105	NCD 190.25
4923	Amphetamines, Clinical Urine	80307	A55001
4191	Antidepressants Screen, Urine	80307	A55001
7860	APOE Genotyping Alzheimer Risk	81401	A55094 A57384 A58996
7862	APOE Genotyping Cardiovascular Risk	81401	A55094 A57384 A58996
202	Apolipoprotein A1	82172	A57037
203	Apolipoprotein B	82172	A57037
6421	B-Cell Lymph Leukemia Panel, FISH	88271 x6 88275 x3	NCD 190.3 A57661 NCD 190.3 A57661
7619	B-CELL UNLISTED MOLECULAR PATHOLOGY, TISSUE	81479
4283	B-Natriuretic Peptide	83880	A57083
4924	Barbiturates, Clinical Urine	80307	A55001
5299	BCR-ABL Gene Rearrange, Qnt. Reflex	81206	A57421 A58996
4925	Benzodiazepines, Clinical Urine	80307	A55001
877	Benzodiazepines, Urine Forensic Screen	80307	A55001
7641	BRAF Mutation Analysis	81210	A54418
7026	BRAF Mutation Analysis	81210	A54418
5893	Buprenorphine, Urine Screen	80307	A55001
4336	C. Trachomatis PCR, SurePath/ThinPrep	87491	NCD 210.10 A58720
5147	C. Trachomatis, RNA, TMA, Urogenital	87491	NCD 210.10 A58720
348	CA 125	86304	NCD 190.28
210	CA 19-9	86301	NCD 190.30
4659	CA 27.29	86300	NCD 190.29
207	CA15-3	86300	NCD 190.29
7674	Calreticulin Mutation Analysis	81219	A57421
5143	Cardio IQ (R) LP-PLA2 Activity	83698	A57037
5129	Cardio IQ Advanced Lipid Panel	80061 83704	NCD 190.23 NCD 190.23 A57037	Yes80061 - When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia. Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL (CPT code 83721) may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved. When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia. Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.
5613	Cardio IQ Lipo Fractionation	83704	NCD 190.23 A57037
626C	Cath Urine Culture	87086	NCD 190.12
520	CBC w/o Diff	85027	NCD 190.15
522	CBC w/Platelet Count	85025	NCD 190.15
7177	CD20 + B Cells Profile	86355 86356	A57689 A57689
428	CEA	82378	NCD 190.26	Yes82378 - Serum CEA determinations are generally not indicated more frequently than once per chemotherapy treatment cycle for patients with metastatic solid tumors which express CEA or every two months post-surgical treatment for patients who have had colorectal carcinoma. It may be proper to order the test more frequently when there has been a significant change from prior CEA level or a significant change in patient status which could reflect disease progression or recurrence. Testing with a diagnosis of an in situ carcinoma is not reasonably done more frequently than once, unless the result is abnormal, in which case the test may be repeated once.
7010	Celiac Disease Genotyping	81376 81383	A57970 A57384 A57441
963	Cell Markers, 1	88184	A57689
976	Cell Markers, 10	88184 88185 x9 88187	A57689 A57689 A57689
977	Cell Markers, 11	88184 88185 x10 88187	A57689 A57689 A57689
979	Cell Markers, 12	88184 88185 x11 88187	A57689 A57689 A57689
981	Cell Markers, 13	88184 88185 x12 88187	A57689 A57689 A57689
982	Cell Markers, 14	88184 88185 x13 88187	A57689 A57689 A57689
983	Cell Markers, 15	88184 88185 x14 88187	A57689 A57689 A57689
985	Cell Markers, 16	88184 88185 x15 88187	A57689 A57689 A57689
989	Cell Markers, 17	88184 88185 x16 88187	A57689 A57689 A57689
990	Cell Markers, 18	88184 88185 x17 88187	A57689 A57689 A57689
4910	Cell Markers, 19	88184 88185 x18 88187	A57689 A57689 A57689
4539	Cell Markers, 2	88184 88185 88187	A57689 A57689 A57689
4911	Cell Markers, 20	88184 88185 x19 88187	A57689 A57689 A57689
4912	Cell Markers, 21	88184 88185 x20 88187	A57689 A57689 A57689
4913	Cell Markers, 22	88184 88185 x21 88187	A57689 A57689 A57689
5663	Cell Markers, 23	88184 88185 x22 88187	A57689 A57689 A57689
5664	Cell Markers, 24	88184 88185 x23 88187	A57689 A57689 A57689
5665	Cell Markers, 25	88184 88185 x24 88187	A57689 A57689 A57689
5666	Cell Markers, 26	88184 88185 x25 88187	A57689 A57689 A57689
5667	Cell Markers, 27	88184 88185 x26 88187	A57689 A57689 A57689
6557	Cell Markers, 28	88184 88185 x27 88187	A57689 A57689 A57689
6558	Cell Markers, 29	88184 88185 x28 88187	A57689 A57689 A57689
4540	Cell Markers, 3	88184 88185 x2 88187	A57689 A57689 A57689
6559	Cell Markers, 30	88184 88185 x29 88187	A57689 A57689 A57689
6560	Cell Markers, 31	88184 88185 x30 88187	A57689 A57689 A57689
6561	Cell Markers, 32	88184 88185 x31 88187	A57689 A57689 A57689
955	Cell Markers, 4	88184 88185 x3 88187	A57689 A57689 A57689
967	Cell Markers, 5	88184 88185 x4 88187	A57689 A57689 A57689
968	Cell Markers, 6	88184 88185 x5 88187	A57689 A57689 A57689
986	Cell Markers, 7	88184 88185 x6 88187	A57689 A57689 A57689
974	Cell Markers, 8	88184 88185 x7 88187	A57689 A57689 A57689
975	Cell Markers, 9	88184 88185 x8 88187	A57689 A57689 A57689
5324	Chlamydia & Chlamydophila Ab Panel	86631 x6 88632 x3	NCD 210.10
5324	Chlamydia & Chlamydophila Ab Panel	86631	NCD 210.10
4960	Chlamydia & Chlamydophila Ab, IgG	86631	NCD 210.10
4960	Chlamydia & Chlamydophila Ab, IgG	86631	NCD 210.10
4961	Chlamydia & Chlamydophila Ab, IgM	86632	NCD 210.10
5842	Chlamydia / GC TMA, Rectal	87491	NCD 210.10 A58720
7162	Chlamydia / GC TMA, Throat	87491	NCD 210.10 A58720
4328	Chlamydia and GC, PCR	87591	NCD 210.10 A58720
484	Chlamydia Trachomatis PCR	87491	NCD 210.10 A58720
5848	Chlamydia Trachomatis TMA, Rectal	87491	NCD 210.10 A58720
5846	Chlamydia Trachomatis TMA, Throat	87491	NCD 210.10 A58720
4183	Chlamydia Trachomatis, Culture	87110	NCD 210.10
4336	Chlamydia Trachomatis, PCR	87491	NCD 210.10 A58720
484	Chlamydia, PCR	87491	NCD 210.10 A58720
183	Chlamydia/GC PCR, Urine or Genital	87591	NCD 210.10 A58720
183	Chlamydia/GC, PCR	87491	NCD 210.10 A58720
4328	Chlamydia/GC, PCR, SurePath/ThinPrep	87491	NCD 210.10 A58720
142	Cholesterol	82465	NCD 190.23	Yes82465 - When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia. Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL (CPT code 83721) may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved. Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.
6736	Chromogranin A	86316	A55028
7984	Chromosome Analysis Amniotic Fluid	88235 88269 88280 88285	NCD 190.3 NCD 190.3 NCD 190.3 NCD 190.3
7960	Chromosome Analysis, Blood	88230 88262	NCD 190.3 NCD 190.3
6648	Chromosome Analysis, Leukemic Blood	88237 88264	NCD 190.3 NCD 190.3
87	Chromosome Analysis, POC	88233 88262	NCD 190.3 NCD 190.3
4734	Clinical Substance Abuse Panel 10	80307	A55001
4735	Clinical Substance Abuse Panel 10A	80307	A55001
5575	Clinical Substance Abuse Panel 11 E	80307	A55001
4736	Clinical Substance Abuse Panel 11A	80307	A55001
4731	Clinical Substance Abuse Panel 5	80307	A55001
885	Clinical Substance Abuse Panel 5A	80307	A55001
4732	Clinical Substance Abuse Panel 7	80307	A55001
5868	Clinical Substance Abuse Panel 8 Ox	80307	A55001
725	Clinical Substance Abuse Panel 8A	80307	A55001
4733	Clinical Substance Abuse Panel 9A	80307	A55001
7933	CNS Demyelinating Disease Evaluation, Serum	86053 86363	A57689 A57689
4915	Cocaine / Amphetamine Urine Screen	80307	A55001
4926	Cocaine Metabolite	80307	A55001
4391	Coenzyme Q10	82542	A55769
4367	Collagen Cross-Linked, NTX, 24 Hr Urine	82523	NCD 190.19	Yes82523 - Current recommendations for appropriate utilization include: one or two base-line assays from specified urine collections on separate days; followed by a repeat assay about three months after starting anti-resorptive therapy; followed by a repeat assay in 12 months after the three-month assay; and thereafter not more than annually, unless there is a change in therapy in which circumstance an additional test may be indicated three months after the initiation of new therapy.
4978	Collagen Cross-Linked, NTX, Random Urine	82523	NCD 190.19	Yes82523 - Current recommendations for appropriate utilization include: one or two base-line assays from specified urine collections on separate days; followed by a repeat assay about three months after starting anti-resorptive therapy; followed by a repeat assay in 12 months after the three-month assay; and thereafter not more than annually, unless there is a change in therapy in which circumstance an additional test may be indicated three months after the initiation of new therapy.
5553	Collagen Type I C-Telopeptide	82523	NCD 190.19	Yes82523 - Current recommendations for appropriate utilization include: one or two base-line assays from specified urine collections on separate days; followed by a repeat assay about three months after starting anti-resorptive therapy; followed by a repeat assay in 12 months after the three-month assay; and thereafter not more than annually, unless there is a change in therapy in which circumstance an additional test may be indicated three months after the initiation of new therapy.
N/A	Colorectal Cancer Screening Tests	82272	NCD 190.34
N/A	Colorectal Cancer Screening Tests	G0328	NCD 210.3
7120	Comprehensive Drug Screen, Serum	80307	A55001
4784	Comprehensive Urine Drug Screen	80307	A55001
5461	CRP (High Sensitivity)	86141	A57037
5127	CT / NG RNA, TMA, Urogenital	87491	NCD 210.10 A58720
626	Culture, Urine	87086	NCD 190.12
5843	CYP2C19	81225	A57384
6422	Cystatin C	82610	A57643
N/A	Cytopath, Pap Smear (Neopath & Manual Rescreen)	G0148	NCD 210.2
N/A	Cytopath, Pap Smear (Neopath Only)	G0147	NCD 210.2
6738	Cytopath, Thin Prep & Manual Screen	G0123	NCD 210.2
437	Digoxin	80162	NCD 190.24
811M	Drug Screen # 4 (Medical)	80307	A55001
471	Drugs of Abuse Screen (7 Panel), Meconium	80307	A55001
6700	Dust / Mite Allergen Panel, IgE	86003 x4	A57181
7027	EGFR Mutation Analysis	81235	A54422
7642	EGFR Mutation Analysis	81235	A54422
5778	Electrolyte & Osmolality Panel, Fecal	83735	A57189
530	Eosinophil Count, Total	85048	NCD 190.15
6701	Epithelia Allergen Panel, IgE	86003 x6	A57181
4605	Ethanol, Clinical Urine	80307	A55001
879	Ethanol, Urine Forensic Screen	80307	A55001
7710	Ethyl Glucuronide, Random Urine	80307	A55001
7220	Ethyl Glucuronide, Urine Screen	80307	A55001
4567	Factor V Leiden Mutation Analysis	81241	A57423
415	Ferritin	82728	NCD 190.18	Yes82728 - If a normal serum ferritin level is documented, repeat testing would not ordinarily be medically necessary unless there is a change in the patient's condition, and ferritin assessment is needed for the ongoing management of the patient. When an End Stage Renal Disease (ESRD) patient is tested for ferritin, testing more frequently than every three months (the frequency authorized by 3167.3, Fiscal Intermediary manual) requires documentation of medical necessity [e.g., other than Chronic Renal Failure (ICD-9-CM 585) or Renal Failure, Unspecified (ICD-9-CM 586)].
6705	Fish Allergen Panel, IgE	86003 x7	A57181
6724	Food Allergy Panel	86003 x15	A57181
6716	Food Allergy Profile (Phadia)	86003 x12	A57181
5986	Free PSA with Total PSA	84153	NCD 190.31	Yes84153 - For patients with lower urinary tract signs or symptoms, total PSA is performed only once per year unless there is a change in the patient's medical condirtion. Medicare covers a screening total PSA test one each year for men over 50 years of age.
4700	Fructosamine	82985	NCD 190.21
6708	Fruit Allergen Panel, IgE	86003 x6	A57181
226	FTA-ABS	86780	NCD 210.10
172	Gamma GT	82977	NCD 190.32	Yes82977 - When used to determine if other abnormal enzyme tests reflect liver abnormality rather than other tissue, it generally is not necessary to repeat a GGT more than one time per week.
479	GC, PCR	87591	NCD 210.10 A58720
4008	GC/MS NIDA Lab	80307	A55001
176	Glucose	82947	NCD 190.20	Yes82947 - In stable, non-hospitalized patients who are unable or unwilling to do home glucose monitoring, it may be reasonable and necessary to measure quantitative blood glucose up to 4 times annually. Depending on the age and condition of the patient, the type of diabetes, degree of control, and other co-morbid conditions, more frequent testing may be reasonable and necessary.
6707	Grain Allergen Panel, IgE	86003 x6	A57181
6702	Grass Allergen Panel, IgE	86003 x8	A57181
6723	Hawaii Regional Respiratory Allergy Panel	86003 x25	A57181
6718	Hawaii Regional Respiratory Allergy Profile (Phadia)	86003 x17	A57181
468P	HCG, Quant Pregnancy	84702	NCD 190.27	Yes84702 - Not more than once per month for diagnostic purposes. As needed for monitoring of patient progress and treatment. Qualitative hCG assays (CPT 84703) are not appropriate for medically managing patients with known or suspected germ cell neoplasms.
468T	HCG, Quant, Tumor	84702	NCD 190.27	Yes84702 - Not more than once per month for diagnostic purposes. As needed for monitoring of patient progress and treatment. Qualitative hCG assays (CPT 84703) are not appropriate for medically managing patients with known or suspected germ cell neoplasms.
189	HDL - Cholesterol	83718	NCD 190.23	Yes83718 - When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia. Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL (CPT code 83721) may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved. Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.
4182	HDL Cholesterol Subclasses	83701	NCD 190.23 A57037
536	Hematocrit	85014	NCD 190.15
538	Hemoglobin	85018	NCD 190.15
537	Hemoglobin & Hematocrit	85014 85018	NCD 190.15 NCD 190.15
4779	Hemoglobin A1C	83036	NCD 190.21	Yes83036 - It is not considered reasonable and necessary to perform glycated hemoglobin tests more often than every three months on a controlled diabetic patient to determine whether the patient's metabolic control has been on average within the target range. It is not considered reasonable and necessary for these tests to be performed more frequently than once a month for diabetic pregnant women. Testing for uncontrolled type one or two diabetes mellitus may require testing more than four times a year. Medical necessity documentation must support such testing in excess of the above guidelines.
499	Hepatitis B Core Antibody, Total	86704 G0499	NCD 210.6 NCD 210.6
5509	Hepatitis B DNA, Quant	87517	A58720
501	Hepatitis B Surface Ag, Confirmation	87341 G0499	NCD 210.6 NCD 210.6
500	Hepatitis B Surface Antibody	86706 G0499	NCD 210.6 NCD 210.6
495	Hepatitis B Surface Antigen	87340 G0499	NCD 210.6 NCD 210.6
5691	Hepatitis BsAg w/Reflex to Confirmation	87340 G0499	NCD 210.6 NCD 210.6
542	Hepatitis C Antibody	G0472	NCD 210.13
5442	Hepatitis C RNA, Quant	87522	A58720
5275	HIV-1 DNA, Qualitative, PCR	87535	NCD 190.14 A58720	Yes87535 - If initial serologic tests are HIV EIA negative and there is no indication for confirmation of infection by viral RNA detection, the interval prior to retesting is 3-6 months.
4609	HIV-1 RNA, Quant	87536	NCD 190.13 A58720	Yes87536 - Measurement of plasma HIV RNA levels should be performed at the time of establishment of an HIV infection diagnosis. For an accurate baseline, 2 specimens in a 2-week period are appropriate.
7760	HIV-1/2 Ag/Ab Screen with Reflex	G0475	NCD 210.7
7760	HIV-1/2 Ag/Ab Screen with Reflex	86701 86702 87390	NCD 190.14 NCD 190.14 NCD 190.14	Yes86701 - If initial serologic tests are HIV EIA negative and there is no indication for confirmation of infection by viral RNA detection, the interval prior to retesting is 3-6 months. Yes86702 - If initial serologic tests are HIV EIA negative and there is no indication for confirmation of infection by viral RNA detection, the interval prior to retesting is 3-6 months. Yes87390 - If initial serologic tests are HIV EIA negative and there is no indication for confirmation of infection by viral RNA detection, the interval prior to retesting is 3-6 months.
7139	HLA A,B Typing (Platelet Refractory)	86813	NCD 190.1
7140	HLA-A,B,C,DR,DQ Typing (TRALI)	81370	A57970
7136	HLA-A,B,C,DR,DQ, Renal	81370	A57970
7137	HLA-A,B,C,DR,DQA,DQB,DP Deceased	81370 81376	A57970 A57970
5808	HLA-B*5701 Typing	81381	A57384
458	HLA-B27	86812	NCD 190.1
7148	HLA-C	81373	A57970
7151	HLA-DQB	81376	A57970
4686	Homocysteine, Total Serum	83090	A57037
7614	HPV	87624	A58720
7707	HPV High Risk PCR 16/18 Genotype	87624	A58720
5885	HPV, High Risk by PCR, Anal	87624	A58720
5088	HTLV I/II Ab, Western Blot	86689	NCD 190.14	Yes86689 - If initial serologic tests are HIV EIA negative and there is no indication for confirmation of infection by viral RNA detection, the interval prior to retesting is 3-6 months.
5892	Hydrocodone, Ur. Scrn, Clinical	80307	A55001
1ID	ID, Organism, Urine 1	87088	NCD 190.12
2ID	ID, Organism, Urine 2	87088	NCD 190.12
3ID	ID, Organism, Urine 3	87088	NCD 190.12
4ID	ID, Organism, Urine 4	87088	NCD 190.12
5ID	ID, Organism, Urine 5	87088	NCD 190.12
6ID	ID, Organism, Urine 6	87088	NCD 190.12
5078	IHC Morphometry	88361	A57611
7169	Immunodeficieny Panel 1 Profile	86355 86359 86360	A57689 A57689 A57689
7170	Immunodeficieny Panel 2 Profile	86355 86357 86359 86360	A57689 A57689 A57689 A57689
6725	Infant Allergen Panel, IgE	86003 x16	A57181
6255	Influenza A/B/RSV, RT PCR	87502 87798	A58720 A59055 A55326 A58720
6234	Influenza type A and B, RT PCR	87502	A58720 A59055
276	Iron Binding Capacity	83540 83550	NCD 190.18 NCD 190.18
287	Iron, Total	83540	NCD 190.18
6614	JAK2 Exon 12 Mutation Analysis	81403	A58679
5047	JAK2 V617F Mutation Analysis	81270	A57421
6613	JAK2, V617F Mutation, Qual w/ Reflex Exon 12	81270	A57421
7025	KRAS Mutation Analysis	81275	A54498
7654	KRAS Mutation Analysis	81275	A54498
5449	LDL-Cholesterol, Direct	83721	NCD 190.23 A57037	Yes83721 - When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia. Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL (CPT code 83721) may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.
6709	Legumes/Nuts Allergen Panel, IgE	86003 x7	A57181
5181	LGV Differential Antibody Panel	86631 x8 86632 x4	NCD 210.10 NCD 210.10
915	Lipid Panel	80061	NCD 190.23	Yes80061 - When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia. Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL (CPT code 83721) may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved. When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia. Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.
231	Lipoprotein A	83695	A57037
409	Lipoprotein ELP (Phenotype)	82465 83700 84478	NCD 190.23 NCD 190.23 A57037 NCD 190.23	Yes82465 - When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia. Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL (CPT code 83721) may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved. Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved. Yes84478 - When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia. Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.
410	Lipoprotein Metabolism Profile	80061 82172 83700	NCD 190.23 A57037 NCD 190.23 A57037	Yes80061 - When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia. Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL (CPT code 83721) may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved. When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia. Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.
5144	LP-PLA2 Activity	83698	A57037
7659	Lung NGS Fusion Profile	81445	A57901 A58454 A58973
7748	Lymphocyte Subset Panel 1	86355 86357 86359 86360	A57689 A57689 A57689 A57689
200	Magnesium	83735	A57189
6212	Magnesium, RBC	83735	A57189
531	Magnesium, Urine	83735	A57189
6737	MDMA (Ecstacy), Urine Screen	80307	A55001
6704	Meat Allergen Panel, IgE	86003 x5	A57181
4716	Meconium (Mec Stat-5)	80307	A55001
4927	Methadone, Clinical Urine	80307	A55001
7766	MOG-IgG1 FACS, Serum	86363	A57689
6703	Molds Allergen Panel, IgE	86003 x13	A57181
6185	MTHFR Mutation Analysis	81291	A57423
4337	N. Gonorrhoeae PCR, SurePath/ThinPrep	87591	NCD 210.10 A58720
7178	Natural Killer Cells Profile	86357	A57689
479	Neisseria Gonorrhoeae PCR	87591	NCD 210.10 A58720
5849	Neisseria Gonorrhoeae TMA, Rectal	87591	NCD 210.10 A58720
5847	Neisseria Gonorrhoeae TMA, Throat	87591	NCD 210.10 A58720
4337	Neisseria Gonorrhoeae, PCR	87591	NCD 210.10 A58720
5898	Neisseria Gonorrhoeae, TMA, Urogenital	87591	NCD 210.10 A58720
5298	Neuron Specific Enolase (CSF)	86316	A55028
7613	NGS Oncology Melanoma Profile	81445 88381	A57901 A58454 A58973
7207	NGS Oncology Melanoma Profile (Tissue Only)	81445	A57901 A58454 A58973
7206	NGS Oncology Tumor Profile (Tissue only)	81479	A57901
7612	NGS Target Oncology Mutation Panel	81445	A57901 A58454 A58973
5141	Nicotine and Cotinine-Urine	G0480	A55001
4551	NIDA 5, GC/MS	80307	A55001
4193	NMO/AQP4 IgG FACS Reflex to Titer	86053	A57689
7662	NRAS Mutation Analysis	81403 81311	A58679 A57486
5774	NT proBNP	83880	A57083
7028	NTRK NGS Fusion Profile	81479	A57901
4928	Opiates, Clinical Urine	80307	A55001
6711	Other Food Allergen Panel, IgE	86003 x6	A57181
6423	Oxycodone, Clinical Urine	80307	A55001
4572	P, Spcl Stain Pas	88313
4839	P, Stain,Acid Fast	88312
4869	P, Stain,Group 1	88312
4870	P, Stain,Group 2	88313
4880	P, Stain,Mast Cells X3	88313 x3
7029	Pan-TRK	88342
7631	PAP and HPV Co-Testing	87624	A58720
4025	Pap in Fld (Neopath - Manual Rescreen)	G0145	NCD 210.2
4024	Pap in Fld (Neopath Only)	G0144	NCD 210.2
7631	Pap Smear w/ Reflex to HPV	G0476	NCD 210.2.1
516	Part. Throm. Time (PTT)	85730	NCD 190.16
6714	Perennial Allergen Panel, IgE	86003 x18	A57181
4929	Phencyclidine, Clinical Urine	80307	A55001
576	Platelet Aggregation	85049 85576 x5	NCD 190.15
546	Platelet Count	85049	NCD 190.15
5554	Platelet Morphology	85008	NCD 190.15
7212	Pneumonia Panel by Filmarray	87632	A58720
4930	Propoxyphene, Clinical Urine	80307	A55001
5823	Prostatitis Culture	87086	NCD 190.12
5428	Prothrombin G20210A Mutation (Factor II)	81240	A57423
514	Prothrombin Time (PT)	85610	NCD 190.17	Yes85610 - When an ESRD patient is tested for PT, testing more frequently than weekly requires documentation of medical necessity [e.g. other than Chronic Renal Failure (ICD-9-CM 585) or Renal Failure, Unspecified (ICD-9-CM 586)]. The need to repeat this test is determined by changes in the underlying medical condition and/or the dosing of warfarin. In a patient on stable warfarin therapy, it is ordinarily not necessary to repeat testing more than every two to three weeks.
505	PSA, Total	84153	NCD 190.31	Yes84153 - For patients with lower urinary tract signs or symptoms, total PSA is performed only once per year unless there is a change in the patient's medical condirtion. Medicare covers a screening total PSA test one each year for men over 50 years of age.
505	PSA, Total, Screen	G0103	NCD 210.1	YesG0103 - Screening prostate specific antigen tests (PSA) are covered at a frequency of once every 12 months for men who have attained age 50. The test must be ordered by a beneficiary's attending physician, physician assistant, nurse practitioner, or clinical nurse specialist who is fully knowledgeable about the beneficiary's medical condition, and who would be responsible for using the results of the test in the overall management of the beneficiary's specific medical problem.
7034	ROS1	88342
695R	RPR, Reflex to Titer	86592	NCD 210.10
7189	SAP 10 GC/MS, Ref	80307	A55001
7188	SAP 4 GC/MS, Ref	80307	A55001
6706	Shellfish Allergen Panel, IgE	86003 x6	A57181
6188	Stonerisk Diagnostic Profile	83735	A57189
7194	Synthetic Cannabinoid Metab., Urine	80307	A55001
7620	Synthetic Cannabinoids Screen, Blood	80307	A55001
7172	T Cell Subset Panel (T4/T8 Ratio)	86359 86360	A57689 A57689
971	T Helper-Inducer (CD4)	86359 86361	A57689 A57689
5174	T3 Uptake	84479	NCD 190.22	Yes84479 - Testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonable and necessary for patients whose thyroid therapy has been altered or in whom symptoms or signs of hyper- or hypothyroidism are noted.
366	T4, Free	84439	NCD 190.22	Yes84439 - Testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonable and necessary for patients whose thyroid therapy has been altered or in whom symptoms or signs of hyper- or hypothyroidism are noted.
4710	T4, Free (Direct Dialysis)	84439	NCD 190.22	Yes84439 - Testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonable and necessary for patients whose thyroid therapy has been altered or in whom symptoms or signs of hyper- or hypothyroidism are noted.
5531	T4, Total	84436	NCD 190.22	Yes84436 - Testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonable and necessary for patients whose thyroid therapy has been altered or in whom symptoms or signs of hyper- or hypothyroidism are noted.
4931	THC, Clinical Urine	80307	A55001
4875	Tissue - Stain, Immunoperoxidase	88342
7176	Total B Cells Profile	86355	A57689
6426	Tox - Clinical SAP 10 OA	80307	A55001
6734	Tox - Clinical SAP 10 XO	80307	A55001
6427	Tox - Clinical SAP 11 OA	80307	A55001
6424	Tox - Clinical SAP 6 OA	80307	A55001
6425	Tox - Clinical SAP 8 OA	80307	A55001
4729	Tox - SAP 10	80307	A55001
4737	Tox - SAP 10, GC/MS	80307	A55001
5544	Tox - SAP 11 X	80307	A55001
4730	Tox - SAP 11A	80307	A55001
4727	Tox - SAP 11A, GC/MS	80307	A55001
5484	Tox - SAP 4 w/o THC, GC/MS	80307	A55001
4742	Tox - SAP 4, GC/MS	80307	A55001
6638	Tox - SAP 5 D, GC/MS	80307	A55001
5171	Tox - SAP 5 LP, GC/MS	80307	A55001
4728	Tox - SAP 5, GC/MS	80307	A55001
5469	Tox - SAP 5, GC/MS POC	80307	A55001
5674	Tox - SAP 5, GC/MS-DISC	80307	A55001
5476	Tox - SAP 5, POC	80307	A55001
355	Tox - SAP 5A	80307	A55001
4738	Tox - SAP 5A, GC/MS	80307	A55001
4178	Tox - SAP 6 BO	80307	A55001
4682	Tox - SAP 6 NG	80307	A55001
5543	Tox - SAP 6 X	80307	A55001
4739	Tox - SAP 6, GC/MS	80307	A55001
5984	Tox - SAP 6Ab, Intake	80307	A55001
809	Tox - SAP 7	80307	A55001
4179	Tox - SAP 7 ABO	80307	A55001
4740	Tox - SAP 7, GC/MS	80307	A55001
4741	Tox - SAP 7A, GC/MS	80307	A55001
7221	Tox - SAP 7A, Intake	80307	A55001
285	Tox - SAP 7AB	80307	A55001
6191	Tox - SAP 9, GC/MS	80307	A55001
4726	Tox - SAP 9A, GC/MS	80307	A55001
6629	TPMT Genotype	81335	A57384
434	Transferrin	84466	NCD 190.18
4292	Treponema Pallidum Ab CSF	86780	NCD 210.10
228	Triglycerides	84478	NCD 190.23	Yes84478 - When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia. Any one component of the panel (CPT codes 82465, 83718 and 84478) or a measured LDL may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.
380	TSH	84443	NCD 190.22	Yes84443 - Testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonable and necessary for patients whose thyroid therapy has been altered or in whom symptoms or signs of hyper- or hypothyroidism are noted.
449	TSH / T4, Free	84439 84443	NCD 190.22 NCD 190.22	Yes84439 - Testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonable and necessary for patients whose thyroid therapy has been altered or in whom symptoms or signs of hyper- or hypothyroidism are noted. Yes84443 - Testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonable and necessary for patients whose thyroid therapy has been altered or in whom symptoms or signs of hyper- or hypothyroidism are noted.
808	Urine Drug Screen 12T	80305	A55001
810M	Urine Drug Screen, #2 (Medical)	80307	A55001
820	Urine Drug Screen, #2 (Medical)	80307	A55001
6177	Urorisk Diagnostic Profile	83735	A57189
59R	VDRL, CSF Reflex to Titer	86592	NCD 210.10
6710	Vegetable Allergen Panel, IgE	86003 x14	A57181
6712	Venom Allergen Panel, IgE	86003 x5	A57181
4990	Vitamin D (1,25 Dihydroxy)	82652	A57718
5679	Vitamin D, 25-Hydroxy (D2 & D3)	82306	A57718	YesFor frequency limitations, please review the "Indications and Limitations of Coverage" section within the Article and any associated LCD Policies indicated.
6556	Vitamin D, 25-Hydroxy, Total	82306	A57718	YesFor frequency limitations, please review the "Indications and Limitations of Coverage" section within the Article and any associated LCD Policies indicated.
564	White Blood Count	85048	NCD 190.15
6205	ZAP70	88184 88185 88187	A57689 A57689 A57689