| ID |
Title |
Effective Date |
Revision Effective Date |
End Date |
Last Approval / Revision Date |
| L28229 | 3D Interpretation and Reporting of Imaging Studies | 9/2/2008 | 10/1/2009 | N/A | 10/8/2009 |
| L28230 | Abdominal and Retroperitoneal Ultrasound | 9/2/2008 | 10/1/2009 | N/A | 10/9/2009 |
| L28231 | Ablative Therapy: Intra-thoracic and Intra-abdominal | 9/2/2008 | 11/5/2009 | N/A | 11/15/2009 |
| L28232 | Actinic Keratosis | 9/2/2008 | 2/26/2009 | N/A | 10/9/2009 |
| L28233 | Allergen Immunotherapy | 9/2/2008 | 2/26/2009 | N/A | 10/15/2009 |
| L28234 | Allergy Testing | 9/2/2008 | 10/22/2009 | N/A | 10/15/2009 |
| L28235 | Ambulance Services | 9/2/2008 | 1/1/2010 | N/A | 12/11/2009 |
| L28236 | Anorectal Manometry, Anal Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters | 9/2/2008 | 2/26/2009 | N/A | 10/15/2009 |
| L28238 | Bariatric Surgery | 9/2/2008 | 10/29/2009 | N/A | 10/22/2009 |
| L28239 | Blepharoplasty, Blepharoptosis and Brow Lift | 9/2/2008 | 2/18/2010 | N/A | 2/12/2010 |
| L28240 | Blocks and Destruction of Somatic and Sympathetic Nerves | 9/2/2008 | 2/26/2009 | N/A | 11/15/2009 |
| L28241 | Bone Mass Measurement | 9/2/2008 | 10/1/2009 | N/A | 8/14/2009 |
| L28242 | Botulinum Toxin Types A and B Policy | 9/2/2008 | 12/17/2009 | N/A | 2/26/2010 |
| L28243 | Brachytherapy: Non-Intracoronary | 9/2/2008 | 10/29/2009 | N/A | 11/15/2009 |
| L28244 | Cardiac Catheterization, Diagnostic | 9/2/2008 | 10/1/2009 | N/A | 11/15/2009 |
| L28245 | Cardiology, Interventional | 9/2/2008 | 4/16/2009 | N/A | 4/3/2009 |
| L28246 | Cardiovascular Nuclear Medicine: Myocardial Perfusion Imaging and Cardiac Blood Pool Studies | 9/2/2008 | 1/1/2010 | N/A | 12/11/2009 |
| L28247 | Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography | 9/2/2008 | 12/24/2009 | N/A | 12/17/2009 |
| L28248 | Category III CPT Codes | 9/2/2008 | 1/1/2010 | N/A | 12/17/2009 |
| L28249 | Chiropractic Services | 9/2/2008 | 2/26/2009 | N/A | 12/17/2009 |
| L28250 | CT Colonography (Virtual Colonoscopy) | 9/2/2008 | 1/1/2010 | N/A | 12/4/2009 |
| L28251 | Cytogenetic Studies | 9/2/2008 | 2/18/2010 | N/A | 2/12/2010 |
| L28252 | Diabetes Mellitus Therapy Using Hepatic Activation or PIVIT Therapy | 9/2/2008 | 12/24/2009 | 3/9/2010 | 12/23/2009 |
| L28253 | Diagnostic Colonoscopy | 9/2/2008 | 11/25/2009 | N/A | 11/19/2009 |
| L28254 | Echocardiography, Transthoracic and Transesophageal | 9/2/2008 | 11/12/2009 | N/A | 11/3/2009 |
| L28255 | Electrocardiograms | 9/2/2008 | 2/26/2009 | N/A | 4/10/2009 |
| L28256 | Endoscopic Treatment of GERD | 9/2/2008 | 4/16/2009 | N/A | 4/10/2009 |
| L29888 | Erythropoietin Stimulating Agents (ESA) | 8/10/2009 | 1/28/2010 | N/A | 1/21/2010 |
| L28258 | External Counterpulsation (ECP) | 9/2/2008 | 4/30/2009 | N/A | 4/17/2009 |
| L28259 | Filgrastim (Neupogen), Sargramostim (Leukine), and Pegfilgrastim (Neulasta) | 9/2/2008 | 10/1/2009 | N/A | 9/9/2009 |
| L28261 | Free Prostate Specific Antigen (PSA) Test | 9/2/2008 | 4/30/2009 | N/A | 4/24/2009 |
| L28262 | Fundus Photography | 9/2/2008 | 10/1/2009 | N/A | 8/21/2009 |
| L28263 | Gait Analysis | 9/2/2008 | 2/26/2009 | N/A | 12/17/2009 |
| L28265 | Gonadotropin Releasing Hormone Analogs | 9/2/2008 | 11/25/2009 | N/A | 11/9/2009 |
| L28266 | Health and Behavior Assessment/Intervention | 9/2/2008 | 6/4/2009 | N/A | 5/28/2009 |
| L28267 | Homeopathic Medicine and Transfer Factor | 9/2/2008 | 7/2/2009 | N/A | 6/26/2009 |
| L28268 | Implantable Infusion Pump for Treatment of Chronic Intractable Pain | 9/2/2008 | 11/16/2009 | N/A | 9/25/2009 |
| L28270 | Injection of Spinal Canal | 9/2/2008 | 2/18/2010 | N/A | 2/12/2010 |
| L28271 | Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma | 9/2/2008 | 2/26/2009 | N/A | 2/19/2010 |
| L28272 | Intensity Modulated Radiation Therapy (IMRT) | 9/2/2008 | 1/1/2010 | N/A | 12/11/2009 |
| L28273 | Interferons | 9/2/2008 | 2/26/2009 | N/A | 12/23/2009 |
| L28274 | Intracoronary Brachytherapy | 9/2/2008 | 2/26/2009 | N/A | 11/3/2009 |
| L28275 | Intravenous Immune Globulin (IVIg) | 9/2/2008 | 11/19/2009 | N/A | 11/9/2009 |
| L28276 | Lumbar MRI | 9/2/2008 | 10/1/2009 | N/A | 8/21/2009 |
| L28277 | Magnetic Resonance Angiography (MRA) of the Head and Neck, Chest, Abdomen & Pelvis, Lower Extremities | 9/2/2008 | 11/15/2009 | N/A | 10/19/2009 |
| L30376 | MammaPrint Test - Breast Cancer Prognosis | 11/16/2009 | 12/10/2009 | N/A | 12/4/2009 |
| L28278 | Mohs Micrographic (MMS) Surgery | 9/2/2008 | 10/1/2009 | N/A | 2/12/2010 |
| L28280 | MRI and CT Scans of Thorax/Chest (except Heart) | 9/2/2008 | 10/1/2009 | N/A | 11/3/2009 |
| L28281 | Multidetector Computed Tomography of the Heart and Great Vessels | 9/2/2008 | 2/25/2010 | N/A | 1/29/2010 |
| L28282 | Nervous System Studies - Autonomic Function, Nerve Conduction and Electromyography | 9/2/2008 | 1/1/2010 | N/A | 1/21/2010 |
| L28283 | Noninvasive Cerebrovascular Studies | 9/2/2008 | 10/1/2009 | N/A | 8/21/2009 |
| L28284 | Noninvasive Peripheral Arterial Studies | 9/2/2008 | 5/14/2009 | N/A | 5/7/2009 |
| L28285 | Noninvasive Peripheral Venous Studies | 9/2/2008 | 10/1/2009 | N/A | 8/21/2009 |
| L28287 | Oncotype DX Test - Breast Cancer Prognosis | 9/2/2008 | 2/18/2010 | N/A | 2/12/2010 |
| L28288 | Paravertebral Facet Joint Block and Facet Joint Denervation | 9/2/2008 | 1/1/2010 | N/A | 12/4/2009 |
| L28290 | Physical Medicine and Rehabilitation Policy | 9/2/2008 | 10/15/2009 | N/A | 11/15/2009 |
| L28291 | Plastic Surgery | 9/2/2008 | 12/17/2009 | N/A | 1/21/2010 |
| L28292 | Polysomnography and Sleep Studies for Testing Sleep and Respiratory Disorders | 9/2/2008 | 9/24/2009 | N/A | 1/21/2010 |
| L28293 | Psychiatric Pharmacology | 9/2/2008 | 2/26/2009 | N/A | 10/22/2009 |
| L28294 | Psychotherapy Services | 9/2/2008 | 10/1/2009 | N/A | 12/17/2009 |
| L28295 | Pulmonary Function Testing | 9/2/2008 | 1/1/2010 | N/A | 12/11/2009 |
| L28296 | Pulse Oximetry | 9/2/2008 | 10/1/2009 | N/A | 8/21/2009 |
| L28297 | Radiation Oncology: External Beam /Teletherapy | 9/2/2008 | 1/1/2010 | N/A | 12/15/2009 |
| L28298 | Radiologic Examination, Chest | 9/2/2008 | 10/1/2009 | N/A | 12/23/2009 |
| L28299 | Routine Foot Care | 9/2/2008 | 12/31/2009 | N/A | 12/23/2009 |
| L28300 | Skin Lesion (Non-Melanoma) Removal | 9/2/2008 | 10/1/2009 | N/A | 12/23/2009 |
| L28301 | Stereotactic Body Radiation Therapy | 9/2/2008 | 9/24/2009 | N/A | 1/29/2010 |
| L28302 | Stereotactic Computer Assisted Volumetric &/or Navigational Procedure | 9/2/2008 | 12/31/2009 | N/A | 12/23/2009 |
| L28303 | Stereotactic Radiosurgery | 9/2/2008 | 2/4/2010 | N/A | 1/29/2010 |
| L28304 | Symptomatic, Pathological Nail and Its Treatment | 9/2/2008 | 2/26/2009 | N/A | 12/23/2009 |
| L28305 | T-Wave Alternans Testing | 9/2/2008 | 7/9/2009 | N/A | 7/8/2009 |
| L28306 | Transcatheter Therapy - Other Than Thrombolysis, Chemotherapy, or Embolization | 9/2/2008 | 10/1/2009 | N/A | 9/4/2009 |
| L28307 | Treatment of Obstructive Sleep Apnea | 9/2/2008 | 8/10/2009 | N/A | 1/29/2010 |
| L28308 | Treatment of Ulcers & Symptomatic Hyperkeratoses | 9/2/2008 | 2/25/2010 | N/A | 1/29/2010 |
| L28309 | Treatment of Varicose Veins of the Lower Extremities | 9/2/2008 | 1/1/2010 | N/A | 12/4/2009 |
| L28310 | Trigger Point Injections | 9/2/2008 | 2/26/2009 | N/A | 10/8/2009 |
| L28311 | Upper Gastrointestinal Endoscopy and Upper Gastrointestinal Endoscopy with Ultrasound | 9/2/2008 | 10/1/2009 | N/A | 8/21/2009 |
| L28312 | Urodynamics | 9/2/2008 | 1/1/2010 | N/A | 12/4/2009 |
| L28313 | Vertebroplasty, Vertebral Augmentation; Percutaneous | 9/2/2008 | 2/25/2010 | N/A | 1/29/2010 |
| L28314 | Vestibular Function Testing | 9/2/2008 | 1/1/2010 | N/A | 12/11/2009 |
| L28315 | Vitamin B 12 Injection | 9/2/2008 | 11/12/2009 | N/A | 11/3/2009 |
| L28316 | Wireless Capsule Endoscopy | 9/2/2008 | 9/3/2009 | N/A | 8/7/2009 |
