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 A59121 (Billing and Coding: MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia) 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.
A59121: Billing and Coding: MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia (Billing and Coding)
- Covered ICD-10-CM codes
- 0
- 0 groups
- Non-covered ICD-10-CM codes
- 3
- Procedure codes listed
- 2
- Full article
- cms.gov record
Procedure codes: 0114U, 81479.
Coverage indications, limitations and medical necessity
Current molecular diagnostic tests that identify individuals with upper gastrointestinal metaplasia, dysplasia, and neoplasia are non-covered by this contractor.
We expect these types of tests to meet the following criteria:
• The beneficiary is being actively managed for chronic gastroesophageal reflex disease (GERD) and/or non-dysplastic Barrett’s esophagus (NDBE); and
• They also have at least 3 additional risk factors for Barrett’s esophagus (BE) as described in nationally recognized guidelines.
• The beneficiary has not been previously diagnosed with dysplasia or esophageal carcinoma; and
• The beneficiary is tested no more than recommended by established national or society guidelines; and
• The test identifies patients with dysplastic disease that may benefit from endoscopic treatment or surveillance, or patients with non-dysplastic disease who may benefit from surveillance; and
• The test results will be used in determining treatment or management of the beneficiary.
• The beneficiary is within the population for which the test was developed and validated. The laboratory providing the test is responsible for clearly indicating to treating clinicians the population and indication for test use.
• The test demonstrates analytical validity (AV) including an analytical and clinical validation for any given measured analytes, and has demonstrated equivalence or superiority for sensitivity or specificity of detecting dysplasia to other already accepted methods for the same intended use measuring the same or comparable analytes.
• Clinical validity (CV) of any analyte measured must be demonstrated in the published peer-reviewed literature, establishing a clear and significant biological/molecular basis for stratifying patients and subsequently selecting (either positively or negatively) their clinical management decision within a clearly defined population.
• The test successfully completes a Technical Assessment that will ensure that criteria set in this policy are met to establish the test as Reasonable and Necessary.
Summary of evidence (opening)
Esophageal adenocarcinoma (EAC) has become one of the most rapidly increasing cancers in Western countries. 1-3 Although the 5-year survival rate for EAC has improved from 5% in the 1970s to nearly 20%, it is still among one of the lowest survival rates for all cancers in the United States. 3,4 Prognosis is strongly related to stage at diagnosis, with the 5-year survival rate dropping to less than 3% in patients with a late stage presentation with 40% of patients also having distal metastases. 5,6 As such, there is a need to improve the ability to detect and prevent EAC at an earlier stage with options of curative therapy.
Virtually all EAC arises from BE, a pre-cancerous condition of the distal esophagus where there is metaplastic replacement of the normal stratified squamous epithelium by an intestinal-type columnar epithelium with dysplasia. 7 Individuals with BE have an over 10-fold increased risk of developing EAC as compared to those without BE. 8 The prevalence of BE is estimated to be 1.6% in the general population, and higher in patients with GERD. 9-11 Additional risk factors for BE include: male, age >50, Caucasian race, smoking history, central obesity, and family history of BE or EAC. 7,12 Importantly, the risk of BE increases additively when there is GERD plus the presence of any additional risk factor. 13
Progression of BE to EAC often follows a prolonged course through multiple stages of dysplasia encompassing NDBE, BE with low-grade dysplasia (LGD), high grade dysplasia (HGD), intramucosal carcinoma, and finally EAC. The risk of progression of patients with NDBE to EAC is estimated to be between 0.1% and 0.6%. 8,14-17 However, once LGD develops, the risk of cancer progression increases with reported ranges between 0.6-13.4%. 14,15,18 A systematic review of over 20 studies encompassing 2700 patients by Singh et al,19 concluded an annual progression rate from BE-LGD to EAC of 0.54% (1 in 185 patients) annually, albeit with variability across the various studies.
The concept of cellular progression has led to the hypothesis that early surveillance followed by intervention will lead to a decreased incidence of EAC. 20,21 Studies have shown that patients diagnosed through surveillance programs have earlier stage tumors and better survival than those who present with cancer. 22,23 However, guidelines from major gastroenterology societies on early endoscopic surveillance vary. 7,24-26 For example, the American Society for Gastrointestinal Endoscopy (ASGE), only conditionally recommends surveillance endoscopy in patients with NDBE based on very low quality of evidence when compared to no surveillance. 25 In addition, the ASGE states that if endoscopy for the identification of BE is performed, it should only be in at-risk patients such as those with a family history (high risk) or those with GERD plus at least 1 other risk factor (moderate risk). The American College of Gastroenterology (ACG) recommends assessing men with chronic (>5 years), and/or weekly or more symptoms of GERD, and 2 or more risk factors for BE or EAC through a single screening endoscopy and that for patients without dysplasia, endoscopic surveillance should take place at intervals of 3-5 years. 7
The contractor cites 49 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2023-05-14
- Current revision effective
- 2025-02-28
- Last reviewed by the contractor
- 2025-02-18
- MCD version
- 5
Other related documents: A59360 (Response to Comments).
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 Wisconsin Physicians Service Insurance Corporation 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.
Frequently asked questions
What does LCD L39356 cover?
• They also have at least 3 additional risk factors for Barrett’s esophagus (BE) as described in nationally recognized guidelines. 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 L39356 apply to?
Wisconsin Physicians Service Insurance Corporation applies it to Medicare claims in AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY. 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 L39356?
The current export links no billing and coding article with a diagnosis list to this LCD, so coverage is decided on the indications in the policy text and the documentation in the record rather than by an automated diagnosis edit.
How do I appeal a denial under LCD L39356?
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.