Tests with Medical Necessity Policies
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Local Coverage Determination (LCD): Allergy Testing (L36241)
Test Number
Test Name
CPT® Code(s)
Medicare Coverage
Frequency Applies
8193
AFFIRM
87510
87660
87480
   L35015
   L35015
   L35015
 
 
 
9100, 9300 and 9400 SERIES
ALLERGENS (SPECIFIC IGE)
See website for individual order codes www.thepathlab.com
86003
   L36241
 
2024
ALPHA FETO PROTEIN
82105
NCD 190.25
 
4099
ANEMIA PROFILE
82728
82607
82746
83540
83550
85046
85025
NCD 190.18
   L34914
   L34914
NCD 190.18
NCD 190.18

NCD 190.15
Yes
 
 
 
 
 
 
2052
B12
82607
   L34914
 
2160
B12 AND FOLATE
82607/82746
   L34914
 
2020
CA 125
86304
NCD 190.28
 
4200
CBC
85025
NCD 190.15
 
2030
CEA
82378
NCD 190.26
Yes
8400
CHLAMY/GC AMPLIFIED
87491/87591
   L35015
 
8333
CHLAMYDIA AMPLIFIED
87491
   L35015
 
3050
CHOLESTEROL
82465
NCD 190.23    L35099
Yes
3043
CRP HS
86141
   L34856
 
370, 360
D/S MRO CHARGE
84999
   L34914 L35006 L35679 L36634
 
4230
DIFFERENTIAL
85007
NCD 190.15
 
1106
DIGOXIN
80162
NCD 190.24
 
214
DOT DRUG SCREEN COLLECTION
84999
   L34914 L35006 L35679 L36634
 
3699
DRUG SCREEN 10 PANEL PLUS ALCOHOL
80307/G0479
   L35006
 
3698
DRUG SCREEN 9 PANEL
80307/G0479
   L35006
 
3763, 3766, 3762
DRUG SCREEN UA 8 PANEL
80307
   L35006
 
3764
DRUG SCREEN UA 8 WITH ALC
80307/G0479
   L35006
 
3551
ETHANOL URINE/ ALCOHOL
80307
   L35006
 
2036
FERRITIN
82728
NCD 190.18
Yes
2054
FOLATE
82746
   L34914
 
8335
GC AMPLIFIED
87591
   L35015
 
8339
GENPROBE CHLAM/GC DNA
87490/87590
   L35015
 
8336
GENPROBE CHLYAMYDIA DNA
87490
   L35015
 
8338
GENPROBE GC DNA
87590
   L35015
 
3124
GGTP
82977
NCD 190.32
Yes
3020
GLUCOSE
82947
NCD 190.20    L34834
Yes
3110
GLUCOSE 1 HR 50 GM
82947
NCD 190.20    L34834
Yes
3112
GLUCOSE 2 HR PP
82947
NCD 190.20    L34834
Yes
2038
HCG QUANT
84702
NCD 190.27
Yes
3054
HDL
83718
NCD 190.23    L35099
Yes
4024
HEMOGLOBIN
85018
NCD 190.15
 
3010
HEMOGLOBIN A1C
83036
NCD 190.21    L35099
Yes
4215
HEMOGLOBIN AND HCT
85018/85014
NCD 190.15
 
8730P
HEPATITIS ACUTE PROFILE
80074
NCD 190.33
Yes
8725P
HEPATITIS EXPOSURE PANEL
86706-2/87340
86704
86803
86701



NCD 190.14
 
 
 
Yes
8226
HIV 1 & 2
86703
NCD 190.14
Yes
2026
IGE
82785
   L36241
 
3126
IRON
83540
NCD 190.18
 
3798
IRON AND TIBC
83540/83550
NCD 190.18
 
3128
IRON BINDING CAPACITY
83550
NCD 190.18
 
3796
IRON, TIBC, % TRANSFERRIN SAT
83540/83550
NCD 190.18
 
3057
LDL DIRECT
83721
NCD 190.23    L35099
Yes
3785
LIPID PROFILE
80061
NCD 190.23    L35099
Yes
1094
PHENOBARB
80184
   L35006
 
3991
PLAC
83698
   L34914
 
7100
PROTIME
85610
NCD 190.17
Yes
2021
PSA DIAGNOSTIC
84153
NCD 190.31
Yes
2023
PSA INDUSTRY
84153
NCD 190.31
Yes
2022
PSA MC SCREENING
G0103
NCD 210.1
Yes
7028
PTT
85730
NCD 190.16
 
8469
STOOL OCCULT BLOOD GUAIAC
82270
NCD 190.34
Yes
3076
T3 UPTAKE
84479
NCD 190.22    L35099
Yes
3078
T4
84436
NCD 190.22    L35099
Yes
3075
T4 FREE
84439
NCD 190.22    L35099
Yes
3824
THYROID PANEL
84479/84436
NCD 190.22    L35099
Yes
8194
TRICHOMONAS MOLECULAR
87798
   L35015
 
3052
TRIGLYCERIDES
84478
NCD 190.23    L35099
Yes
2050
TSH
84443
NCD 190.22    L35099
Yes
2050R
TSH W/ REFLEX TO FREE T4
84443
NCD 190.22    L35099
Yes
8010
URINE CULTURE
87086
87088
NCD 190.12
NCD 190.12
 
 
8700
VITAMIN D
82306
   L34914
  Yes
4236
WBC ONLY
85048
NCD 190.15
 

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09/25/2017 01:30:59 54.198.54.142