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LCD L36665: ProMark® Risk Score

LCD L36665, ProMark® Risk Score, is the Local Coverage Determination that Palmetto GBA applies to claims from 7 states (AL, GA, NC, SC, TN, VA, WV), effective 2021-12-30 and first in force 2016-10-10. The policy text runs 38 words, and its billing and coding article A56957 lists 1 ICD-10-CM codes that support medical necessity for 1 procedure codes. 3 other contractors publish a policy with the same title, so the criteria that apply depend on where the service is furnished.

QuickIntell editorial content · Legacy registry date · Review not verified

Data effective
Data currency: Medicare Coverage Database LCD export release of September 24, 2026 (effective September 20, 2026). Next CMS release: weekly (Thursdays) for the MCD.
Contractor
Palmetto GBA
States and territories
7
AL GA NC SC TN VA WV
Revision effective
2021-12-30
Original effective
2016-10-10
Policy text
38 words
Covered ICD-10 codes (articles)
1

Where this LCD applies

Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.

Contracts that apply LCD L36665
ContractContractorTypeStates
11201Palmetto GBAA and B and HHH MACSC
11301Palmetto GBAA and B and HHH MACVA
11401Palmetto GBAA and B and HHH MACWV
11501Palmetto GBAA and B and HHH MACNC
11202Palmetto GBAA and B and HHH MACSC
11302Palmetto GBAA and B and HHH MACVA
11402Palmetto GBAA and B and HHH MACWV
11502Palmetto GBAA and B and HHH MACNC
10111Palmetto GBAA and B MACAL
10211Palmetto GBAA and B MACGA
10311Palmetto GBAA and B MACTN
10112Palmetto GBAA and B MACAL
10212Palmetto GBAA and B MACGA
10312Palmetto GBAA and B MACTN

Billing and coding: diagnoses and procedure codes

Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A56957 (Billing and Coding: ProMark® Risk Score) 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.

A56957: Billing and Coding: ProMark® Risk Score (Billing and Coding, effective 2021-12-30)

Covered ICD-10-CM codes
1
1 group
Non-covered ICD-10-CM codes
0
Procedure codes listed
1
Full article
cms.gov record
First 1 covered ICD-10-CM codes in A56957
ICD-10-CMDescription (FY2027)
C61Malignant neoplasm of prostate

Procedure codes: 81479.

Coverage indications, limitations and medical necessity

This Contractor will provide limited coverage for the ProMark ® (Metamark Genetics) to help determine which patients with early stage, needle biopsy proven prostate cancer can be conservatively managed rather than treated with definitive surgery or radiation therapy.

Summary of evidence (opening)

In 2014, nearly 233,000 men in the US will be diagnosed with prostate cancer, which accounts for 14% of all new cancer diagnosis. More than 29,000 men will die from this disease representing 5% of all cancer deaths. Gratefully 98.9% of men are surviving at 5 years. 3

Many individuals do not need treatment for their prostate cancer in as much as their prognosis is excellent even without treatment. However, physicians and patients struggle to know who can safely be observed versus the subgroup that needs more aggressive treatment to achieve cure, and recognize that definitive treatment for localized prostate cancer can have lifelong morbidities. 5,8

Traditionally, clinicopathologic characteristics are utilized to determine risk and subsequent treatment. Several nomograms have been introduced to try to determine who is at risk of developing metastatic disease and who, if treated early, could avoid this outcome. A representative nomogram taken from the National Comprehensive Cancer Network (NCCN) and American Urological Association (AUA), divides early prostate cancer into several groups based initially on life expectancy, with a second stratification using clinical exam, reassessment of life expectancy, biopsy (Gleason score), prostate-specific antigen (PSA) and imaging after 5 years.

These groups are detailed below:

The contractor cites 9 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.

Dates, lineage and related policies

Original determination effective
2016-10-10
Current revision effective
2021-12-30
Last reviewed by the contractor
2021-11-08
MCD version
19

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.

The same policy title at other contractors

Contractors often adopt each other's policies and then revise them separately, so the criteria and the diagnosis lists drift apart. The topic comparison lines up every version.

L36675
CGS Administrators, LLC · 2 states · revised 2025-11-13
L36704
Noridian Healthcare Solutions, LLC · 18 states · revised 2025-10-23 · 1 covered codes
L37011
Wisconsin Physicians Service Insurance Corporation · 48 states · revised 2026-01-01 · 1 covered codes

Frequently asked questions

What does LCD L36665 cover?

This Contractor will provide limited coverage for the ProMark ® (Metamark Genetics) to help determine which patients with early stage, needle biopsy proven prostate cancer can be conservatively managed rather than treated with definitive surgery or radiation therapy. 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 L36665 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 L36665?

The companion billing and coding article A56957 lists 1 ICD-10-CM codes in 1 group that support medical necessity; 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 L36665?

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.

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.