Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
| Contract | Contractor | Type | States |
|---|---|---|---|
| 11202 | Palmetto GBA | A and B and HHH MAC | SC |
| 11302 | Palmetto GBA | A and B and HHH MAC | VA |
| 11402 | Palmetto GBA | A and B and HHH MAC | WV |
| 11502 | Palmetto GBA | A and B and HHH MAC | NC |
| 10112 | Palmetto GBA | A and B MAC | AL |
| 10212 | Palmetto GBA | A and B MAC | GA |
| 10312 | Palmetto GBA | A and B MAC | TN |
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A56784 (Billing and Coding: Pulmonary Stress Testing) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A56784: Billing and Coding: Pulmonary Stress Testing (Billing and Coding, effective 2026-10-01)
- Covered ICD-10-CM codes
- 204
- 1 group
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 4
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| B44.81 | — |
| C33 | Malignant neoplasm of trachea |
| C34.01 | — |
| C34.02 | — |
| C34.11 | — |
| C34.12 | — |
| C34.2 | — |
| C34.31 | — |
| C34.32 | — |
| C34.81 | — |
| C34.82 | — |
| C34.91 | — |
| C34.92 | — |
| C78.01 | — |
| C78.02 | — |
| C78.31 | — |
| C78.39 | — |
| D14.2 | — |
| D14.31 | — |
| D14.32 | — |
| D86.0 | — |
| D86.1 | — |
| D86.2 | — |
| D86.3 | — |
Procedure codes: 94617, 94618, 94619, 94621.
Coverage indications, limitations and medical necessity
Exercise testing is done to evaluate functional capacity and to assess the severity and type of impairment of existing, as well as undiagnosed conditions. The pulmonary stress test will be considered medically necessary for these conditions:
INDICATIONS:
Evaluation of exercise tolerance
• Determination of functional impairment or capacity
• Determination of exercise-limiting factors and pathophysiologic mechanisms
Evaluation of undiagnosed exercise intolerance
• Assessing contribution of cardiac and pulmonary etiology in coexisting disease
• Symptoms disproportionate to resting pulmonary and cardiac tests
• Unexplained dyspnea when initial cardiopulmonary testing is nondiagnostic
Evaluation of patients with cardiovascular disease
• Functional evaluation and prognosis in patients with heart failure
• Selection for cardiac transplantation
• Exercise prescription and monitoring response to exercise training for cardiac rehabilitation (special circumstances; i.e., pacemakers)
Evaluation of patients with respiratory disease
• Functional impairment assessment (see specific clinical applications)
• Chronic obstructive pulmonary disease:
- Establishing exercise limitation(s) and assessing other potential contributing factors, especially occult heart disease (ischemia)
- Determination of magnitude of hypoxemia and for O2 prescription
- When objective determination of therapeutic intervention is necessary and not adequately addressed by standard pulmonary function testing
• Interstitial lung diseases:
- Detection of early (occult) gas exchange abnormalities
- Overall assessment/monitoring of pulmonary gas exchange
- Determination of magnitude of hypoxemia and for O2 prescription
- Determination of potential exercise-limiting factors
- Documentation of therapeutic response to potentially toxic therapy
• Pulmonary vascular disease (careful risk–benefit analysis required)
• Cystic fibrosis
• Exercise-induced bronchospasm
Specific clinical applications include:
1) Preoperative evaluation for:
• Surgery involving lung resection
• Elderly patients undergoing major abdominal surgery
• Lung volume reduction surgery for emphysema
2) Clinical decision making:
• Exercise evaluation and prescription for pulmonary rehabilitation
• Evaluation for impairment–disability
• Evaluation for lung, heart–lung transplantation
LIMITATIONS:
Absolute and relative contraindications to exercise testing (field walking tests) include:
Absolute Contraindications
• Acute myocardial infarction (3-5 days)
• Unstable angina
• Uncontrolled arrhythmias causing symptoms or hemodynamic compromise
• Syncope
• Active endocarditis
• Acute myocarditis or pericarditis
• Symptomatic severe aortic stenosis
• Uncontrolled heart failure
• Acute pulmonary embolus or pulmonary infarction
• Thrombosis of lower extremities
• Suspected dissecting aneurysm
• Uncontrolled asthma
• Pulmonary edema
• SpO2 = 85% on room air
• Acute respiratory failure
• Acute non-cardiopulmonary disorder that may affect exercise performance or be aggravated by exercise (i.e., infection, renal failure, thyrotoxicosis)
• Mental impairment leading to inability to cooperate with the testing
Relative Contraindications
• Left main coronary artery stenosis or its equivalent
• Moderate stenotic valvular heart disease
• Severe untreated arterial hypertension at rest (200mmHg systolic, 120mmHg diastolic)
• Tachyarrythmias or bradyarrythmias
• High degree atrioventricular block
• Hypertrophic cardiomyopathy
• Significant pulmonary hypertension
• Advanced or complicated pregnancies
• Electrolyte abnormalities
• Orthopedic impairment that prevents walking
Summary of evidence (opening)
N/A
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-10-01
- Current revision effective
- 2025-01-02
- Last reviewed by the contractor
- 2024-11-20
- MCD version
- 42
- Derived from
- L31753
The contractor lists one National Coverage Determination as related: NCD 240.7 Postural Drainage Procedures and Pulmonary Exercises. Where an NCD speaks, it controls; the LCD can only address what the NCD leaves open.
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Palmetto GBA hub lists every other active policy from the same contractor.
Frequently asked questions
What does LCD L33444 cover?
Exercise testing is done to evaluate functional capacity and to assess the severity and type of impairment of existing, as well as undiagnosed conditions. The pulmonary stress test will be considered medically necessary for these conditions: The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L33444 apply to?
Palmetto GBA applies it to Medicare claims in AL, GA, NC, SC, TN, VA, WV. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L33444?
The companion billing and coding article A56784 lists 204 ICD-10-CM codes in 1 group that support medical necessity; the first 24 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L33444?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.