Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A56420 (Billing and Coding: Frequency of Laboratory Tests) 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.
A56420: Billing and Coding: Frequency of Laboratory Tests (Billing and Coding, effective 2023-01-01)
- Covered ICD-10-CM codes
- 1
- 1 group
- Non-covered ICD-10-CM codes
- 1
- Procedure codes listed
- 13
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| XX000 | — |
Procedure codes: 80061, 82465, 82948, 82962, 82985, 83036, 83718, 83721, 84436, 84439, 84443, 84478, 84479.
Coverage indications, limitations and medical necessity
Notice : It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
History/Background and/or General Information
Sections 42 CFR 410.32 and 411.15 specify that for a laboratory service to be reasonable and necessary, it must not only be ordered by the physician, but the ordering physician must also use the result in the management of the beneficiary’s specific medical problem. Implicitly, the laboratory result must be reported to the physician promptly for the physician to use the result and instruct continuation or modification of patient care; this includes the physician’s order for another laboratory service. Compliance program guidance for laboratory services sets forth conditions under which a physician’s order for a repeat laboratory service can qualify as an order for another covered laboratory service. A standing order is not acceptable documentation for a covered laboratory service. A glucose monitoring laboratory service must be performed in accordance with laboratory service coverage criteria including the order and clear use of a laboratory result prior to a similar subsequent laboratory order to qualify for separate payment under the Medicare laboratory benefit.
Please note there are some specific relevant Medicare requirements with respect to glucose monitoring. Medicare Part B may pay for a glucose monitoring device and related disposable supplies under its durable medical equipment benefit if the equipment is used in the home or in an institution that is used as a home. A hospital or Skilled Nursing Facility (SNF) is not considered a home under this benefit (Section 1861(h) of the Social Security Act, 42 CFR 410.38). Routine glucose monitoring of diabetics is never covered in an SNF, whether the beneficiary is in a covered Part A stay or not. Glucose monitoring may only be covered when it meets all the conditions of a covered laboratory service, including use by the physician in modifying the patient’s treatment.
Limitations
The following are the pertinent laboratory tests for which frequency limitations will be specified, noting that lipid, thyroid, glycated hemoglobin/glycated protein, and glucose testing frequencies apply to analytes from the laboratory National Coverage Determination (NCD) via negotiated rulemaking:
• Lipids
• Thyroid testing
• Glucose testing
• Glycated hemoglobin/glycated protein
This LCD imposes frequency limitations. For frequency limitations please refer to the Utilization Guidelines section below.
Notice : Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules. Refer to Billing and Coding: Frequency of Laboratory Tests, A56420, for applicable CPT codes and diagnosis codes.
The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements of this LCD.
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
- 2019-11-07
- Last reviewed by the contractor
- 2018-09-21
- MCD version
- 60
- Derived from
- L32731
The contractor lists 4 National Coverage Determinations as related: NCD 190.20 Blood Glucose Testing, NCD 190.21 Glycated Hemoglobin/Glycated Protein, NCD 190.22 Thyroid Testing, NCD 190.23 Lipid Testing. 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 Novitas Solutions, Inc. hub lists every other active policy from the same contractor.
Frequently asked questions
What does LCD L35099 cover?
Sections 42 CFR 410.32 and 411.15 specify that for a laboratory service to be reasonable and necessary, it must not only be ordered by the physician, but the ordering physician must also use the result in the management of the beneficiary’s specific medical problem. Implicitly, the laboratory result must be reported to the physician promptly for the physician to use the result and instruct continuation or… 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 L35099 apply to?
Novitas Solutions, Inc. applies it to Medicare claims in AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX. 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 L35099?
The companion billing and coding article A56420 lists 1 ICD-10-CM codes in 1 group that support medical necessity and 1 that do not; the first 1 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L35099?
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.