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LCD L39385: Near-Infrared Spectroscopy in Wound and Flap Management

LCD L39385, Near-Infrared Spectroscopy in Wound and Flap Management, is the Local Coverage Determination that Palmetto GBA applies to claims from 7 states (AL, GA, NC, SC, TN, VA, WV), effective 2023-02-12. The policy text runs 29 words. No other contractor publishes a policy with this title.

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
2023-02-12
Original effective
2023-02-12
Policy text
29 words
Covered ICD-10 codes (articles)
0

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 L39385
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 A59158 (Billing and Coding: Near-Infrared Spectroscopy in Wound and Flap Management) 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.

A59158: Billing and Coding: Near-Infrared Spectroscopy in Wound and Flap Management (Billing and Coding, effective 2024-01-01)

Covered ICD-10-CM codes
0
0 groups
Non-covered ICD-10-CM codes
0
Procedure codes listed
2
Full article
cms.gov record

Procedure codes: 0640T, 0859T.

Coverage indications, limitations and medical necessity

This is a NON-coverage policy for non-contact near-infrared spectroscopy use in acute or chronic wound assessment and management and for use in flap or micro-flap assessment intra- or post-operatively.

Summary of evidence (opening)

Introduction

Limb threatening diabetic wounds are a significant and common health problem within the Medicare beneficiary population. Acute and chronic wound treatment is determined by many to still be subjectively rooted in clinical experience rather than having an actual evidence-based objective approach. It is understood that effective objective wound healing evaluation is needed in order to pursue an evidence-based medical approach that is logical and likely to have a positive outcome. For decades wound analysis with methods such as analysis of dermal microcirculation in wound punch biopsies, video-capillaroscopy, laser Doppler flow or pulse oximetry have been studied but all have been limited by the need to make contact with open wounds. Thus, optical spectroscopic methods are considered for wound monitoring based on radiation absorption in the visible and near-infrared spectral ranges.

The focus of this policy is on near-infrared spectroscopy (NIRS). NIRS relies on 2 principles: (a) that tissue is relatively transparent to near-infrared light, and (b) that compounds in tissue exist in which absorption of light is dependent on the oxygenation status of the tissue. NIRS is able to differentiate between oxygenated and deoxygenated blood.

Evidence

The contractor cites 14 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.

Dates, lineage and related policies

Original determination effective
2023-02-12
Current revision effective
2023-02-12
Last reviewed by the contractor
2022-11-16
MCD version
6

Other related documents: A59281 (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 Palmetto GBA hub lists every other active policy from the same contractor.

Frequently asked questions

What does LCD L39385 cover?

This is a NON-coverage policy for non-contact near-infrared spectroscopy use in acute or chronic wound assessment and management and for use in flap or micro-flap assessment intra- or post-operatively. 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 L39385 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 L39385?

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 L39385?

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.