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1 Local Coverage Determination (LCD): Category III Codes (L35490) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information Contractor Name Printed on 9/26/2017. Page 1 of 10 Contract Type Contract Number Jurisdiction State(s) MAC - Part A MAC A J - 05 Iowa MAC - Part B MAC B J - 05 Iowa MAC - Part A MAC A J - 05 Kansas MAC - Part B MAC B J - 05 Kansas MAC - Part A MAC A J - 05 MAC - Part B MAC B J - 05 Missouri - Entire State Missouri - Entire State MAC - Part A MAC A J - 05 Nebraska MAC - Part B MAC B J - 05 Nebraska MAC - Part A MAC A J - 05 Alaska Alabama Arkansas Arizona Connecticut Florida Georgia Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maine Michigan Minnesota Missouri - Entire State Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey Ohio Oregon Rhode Island South Carolina South Dakota Tennessee Utah

2 Contractor Name Back to Top Contract Type Contract Number Jurisdiction State(s) Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming MAC - Part A MAC A J - 08 Indiana MAC - Part B MAC B J - 08 Indiana MAC - Part A MAC A J - 08 Michigan MAC - Part B MAC B J - 08 Michigan LCD Information Document Information LCD ID L35490 LCD Title Category III Codes Proposed LCD in Comment Period Source Proposed LCD AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 09/01/2017 Revision Ending Date Retirement Date Notice Period Start Date 01/01/2015 Notice Period End Date 02/15/2015 The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2016 are trademarks of the American Dental Association. Printed on 9/26/2017. Page 2 of 10

3 UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. CMS National Coverage Policy Title XVIII of the Social Security Act (SSA): Section 1862(a) (1) (A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Section 1862(a) (1) (D) refers to limitations on items or devices that are investigational or experimental. CMS Publication , Medicare Benefit Policy Manual, Chapter 14- Medical Devices, Section 10, Coverage of Medical Devices. CMS Publication Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.4 Implantable Automatic Defibrillators. CMS Publication Medicare National Coverage Determinations Manual, Chapter 1, Part 2, Section Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS). CMS Publication , Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, Section 30 Services paid under the Medicare Physicians Fee Schedule. CMS Publication Claims Processing Manual, Chapter 32, Section 330 Billing Requirements for Special Services, Transmittal 2959, and CR8757. CMS Publication , Medicare Program Integrity Manual, Chapter 13, Sect.5.1 Reasonable and necessary provisions in LCDs & 7.1 Evidence supporting LCDs. MLM 8757 Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS). Transmittal 3815, CR National Coverage Determination (NCD ):Leadless Pacemakers. Italicized font represents CMS national language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national language/wording. Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity The American Medical Association (AMA) develops temporary Current Procedural Terminology (CPT) Category III codes to track the utilization of emerging technologies, services, and procedures. The CATEGORY III CPT Code description does not establish a service or procedure as safe, effective or applicable to the clinical practice of medicine. 1. The creation of a CPT Category III code by the AMA "neither implies nor endorses clinical efficacy, safety or the applicability to clinical practice." 2. Acceptance by individual health care providers, or even a limited group of health care providers, does not indicate general acceptance by the medical community. Testimonials indicating such limited acceptance, and limited case studies distributed by sponsors with financial interest in the outcome, are not sufficient evidence of general acceptance by the medical community. The available published evidence must be considered and its quality shall be evaluated before a conclusion is reached. Printed on 9/26/2017. Page 3 of 10

4 Indications and Limitations: Section 1862(a)(1)(A) of the Social Security Act (SSA) is the statutory basis for denying payment for types of care, items, services, and procedures, not excluded by any other statutory clause while meeting all technical requirements for coverage, that are determined to be any of the following: 1. Not generally accepted by the medical community as safe and effective in the setting and for the condition for which it is used; 2. Not proven safe and effective based on peer review or scientific literature; 3. Experimental; 4. Not medically necessary for a particular patient; 5. Furnished at a level, duration, or frequency that is not medically appropriate; 6. Not furnished in accordance with accepted standards of medical practice; or 7. Not furnished in a setting appropriate to the patient s medical needs and condition. Items and services must be established as safe and effective to be considered medically necessary. That is, the items and services must be: 1. Consistent with the symptoms of diagnosis of the illness or injury under treatment; and 2. Necessary for, and consistent with, generally accepted professional medical standards of care (e.g., not experimental) and; 3. Not furnished primarily for the convenience of the patient, the provider or supplier; and 4. Furnished at the most appropriate level of care that can be provided safely and effectively to the patient. Medical devices that are not approved for marketing by the Food and Drug Administration (FDA) are considered investigational and are not considered reasonable and necessary under SSA 1862(a)(1)(A). Medicare payment, therefore, may not be made for procedures performed using devices that have not been approved for marketing by the FDA unless performed within the context of a clinical trial qualifying under the National Coverage Determination (NCD) for Routine Costs in Clinical Trials (310.1) or in approved FDA Investigational Device Exemption (IDE) trial. FDA designation/ determination of a device as 510(k) mean(s) that the device has been approved for marketing by the FDA because it is similar to something already on the market that was "grandfathered in" by the FDA and therefore these devices are eligible for coverage. In addition, items, services, or devices may also be not covered under SSA 1862 (a) (1) (D) (E) or (O). If a provider believes that any Category III code not included in this LCD qualifies for coverage (is proven to be safe and effective as well as reasonable and necessary), that provider may request inclusion of the Category III code in this LCD through the LCD Reconsideration Process. Peer reviewed scientific evidence is required for consideration. Summary of Evidence Analysis of Evidence (Rationale for Determination) Back to Top Coding Information Printed on 9/26/2017. Page 4 of 10

5 Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes. CPT/HCPCS Codes Group 1 Paragraph: The following lists Category III services determined by WPS GHA to be reasonable and medically necessary. Coverage will only be allowed when the service is delivered in clinical situations meeting medical necessity. For services addressed in a separate LCD all criteria addressed in that LCD must be met Group 1 Codes: TRANSCATHETER PLACEMENT OF EXTRACRANIAL VERTEBRAL ARTERY STENT(S), INCLUDING 0075T RADIOLOGIC SUPERVISION AND INTERPRETATION, OPEN OR PERCUTANEOUS; INITIAL VESSEL TRANSCATHETER PLACEMENT OF EXTRACRANIAL VERTEBRAL ARTERY STENT(S), INCLUDING 0076T RADIOLOGIC SUPERVISION AND INTERPRETATION, OPEN OR PERCUTANEOUS; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) EXCISION OF RECTAL TUMOR, TRANSANAL ENDOSCOPIC MICROSURGICAL APPROACH (IE, TEMS), 0184T INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS) INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, 0191T INTERNAL APPROACH, INTO THE TRABECULAR MESHWORK; INITIAL INSERTION 0249T LIGATION, HEMORRHOIDAL VASCULAR BUNDLE(S), INCLUDING ULTRASOUND GUIDANCE EXTERNAL ELECTROCARDIOGRAPHIC RECORDING FOR MORE THAN 48 HOURS UP TO 21 DAYS BY 0295T CONTINUOUS RHYTHM RECORDING AND STORAGE; INCLUDES RECORDING, SCANNING ANALYSIS WITH REPORT, REVIEW AND INTERPRETATION EXTERNAL ELECTROCARDIOGRAPHIC RECORDING FOR MORE THAN 48 HOURS UP TO 21 DAYS BY 0296T CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION AND INITIAL RECORDING) EXTERNAL ELECTROCARDIOGRAPHIC RECORDING FOR MORE THAN 48 HOURS UP TO 21 DAYS BY 0297T CONTINUOUS RHYTHM RECORDING AND STORAGE; SCANNING ANALYSIS WITH REPORT EXTERNAL ELECTROCARDIOGRAPHIC RECORDING FOR MORE THAN 48 HOURS UP TO 21 DAYS BY 0298T CONTINUOUS RHYTHM RECORDING AND STORAGE; REVIEW AND INTERPRETATION INSERTION OF OCULAR TELESCOPE PROSTHESIS INCLUDING REMOVAL OF CRYSTALLINE LENS OR 0308T INTRAOCULAR LENS PROSTHESIS INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, 0376T INTERNAL APPROACH, INTO THE TRABECULAR MESHWORK; EACH ADDITIONAL DEVICE INSERTION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) HIGH DOSE RATE ELECTRONIC BRACHYTHERAPY, SKIN SURFACE APPLICATION, PER FRACTION, 0394T INCLUDES BASIC DOSIMETRY, WHEN PERFORMED HIGH DOSE RATE ELECTRONIC BRACHYTHERAPY, INTERSTITIAL OR INTRACAVITARY TREATMENT, PER 0395T FRACTION, INCLUDES BASIC DOSIMETRY, WHEN PERFORMED Group 2 Paragraph: For claims with dates of service on or after January 9, 2014, PILD, procedure code 0275T, is a covered service only when billed as part of a clinical trial approved by CMS per NCD All Percutaneous Image-Guided Lumbar Decompression for Lumbar Spinal Stenosis (PILD for LSS) claims: 12/31/2014 and earlier should be processed with code 0275T. Printed on 9/26/2017. Page 5 of 10

6 01/01/2015 and after use 2 different codes: - G0276 for clinical trial with Identifier NCT Is a blinded randomized controlled clinical trial which includes a CMS-approved placebo procedure arm (See CR 8954); T for all other clinical trials (See CR 8757). Group 2 Codes: PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY 0275T AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR Group 3 Paragraph: Effective for dates of service on or after January 18, 2017, contractors shall cover leadless pacemakers through CED when procedures are performed in CMS-approved CED studies per NCD Group 3 Codes: 0387T TRANSCATHETER INSERTION OR REPLACEMENT OF PERMANENT LEADLESS PACEMAKER, VENTRICULAR PROGRAMMING DEVICE EVALUATION (IN PERSON) WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE 0389T DEVICE TO TEST THE FUNCTION OF THE DEVICE AND SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WITH ANALYSIS, REVIEW AND REPORT, LEADLESS PACEMAKER SYSTEM PERI-PROCEDURAL DEVICE EVALUATION (IN PERSON) AND PROGRAMMING OF DEVICE SYSTEM 0390T PARAMETERS BEFORE OR AFTER A SURGERY, PROCEDURE OR TEST WITH ANALYSIS, REVIEW AND REPORT, LEADLESS PACEMAKER SYSTEM INTERROGATION DEVICE EVALUATION (IN PERSON) WITH ANALYSIS, REVIEW AND REPORT, INCLUDES 0391T CONNECTION, RECORDING AND DISCONNECTION PER PATIENT ENCOUNTER, LEADLESS PACEMAKER SYSTEM ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: The following ICD-10 Codes apply to CPT code 0191T and 0376T to support medical necessity. Group 1 Codes: ICD-10 Codes Description H Primary open-angle glaucoma, right eye, mild stage H Primary open-angle glaucoma, right eye, moderate stage H Primary open-angle glaucoma, left eye, mild stage H Primary open-angle glaucoma, left eye, moderate stage H Primary open-angle glaucoma, bilateral, mild stage H Primary open-angle glaucoma, bilateral, moderate stage H Low-tension glaucoma, right eye, mild stage H Low-tension glaucoma, right eye, moderate stage H Low-tension glaucoma, left eye, mild stage H Low-tension glaucoma, left eye, moderate stage H Low-tension glaucoma, bilateral, mild stage H Low-tension glaucoma, bilateral, moderate stage H Pigmentary glaucoma, right eye, mild stage H Pigmentary glaucoma, right eye, moderate stage H Pigmentary glaucoma, left eye, mild stage H Pigmentary glaucoma, left eye, moderate stage H Pigmentary glaucoma, bilateral, mild stage H Pigmentary glaucoma, bilateral, moderate stage H Capsular glaucoma with pseudoexfoliation of lens, right eye, mild stage H Capsular glaucoma with pseudoexfoliation of lens, right eye, moderate stage Printed on 9/26/2017. Page 6 of 10

7 ICD-10 Codes Description H Capsular glaucoma with pseudoexfoliation of lens, left eye, mild stage H Capsular glaucoma with pseudoexfoliation of lens, left eye, moderate stage H Capsular glaucoma with pseudoexfoliation of lens, bilateral, mild stage H Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage Group 2 Paragraph: The following ICD-10 Codes are used to support medical necessity with CPT code 0275T. Group 2 Codes: ICD-10 Codes Description M48.05 Spinal stenosis, thoracolumbar region M48.07 Spinal stenosis, lumbosacral region Z00.6 Encounter for examination for normal comparison and control in clinical research program Group 3 Paragraph: The following ICD-10 Codes are used to support medical necessity with CPT codes 0387T, 0389T, 0390T and 0391T. Group 3 Codes: ICD-10 Codes Description Z00.6 Encounter for examination for normal comparison and control in clinical research program ICD-10 Codes that DO NOT Support Medical Necessity Group 1 Paragraph: NA Group 1 Codes: ICD-10 Additional Information Back to Top General Information Associated Information 1. The patient's medical record must contain documentation that fully supports the medical necessity for services or procedures described by Category III CPT Codes as they are covered by Medicare. (See section entitled Coverage Indications, Limitations, and/or Medical Necessity ). This documentation includes, but is not limited to, relevant medical history, physical examination, results of pertinent diagnostic tests or procedures, and any other records that describe or support the evaluation and treatment of the patient. 2. All claims containing any Category III code referenced in this LCD may be subject to review and denial if documentation is incomplete and does not support reasonable and necessary indications. 3. All claims containing a Category III code not included in the list of CPT/HCPCS codes described in this LCD or another WPS Medicare document supporting coverage will be automatically denied as investigational. Utilization Guidelines Some of the category III codes discussed in this policy may be listed in a separate WPS Medicare LCD. In those situations, the name of the policy is provided in the table below and that LCD should be referenced for necessary Printed on 9/26/2017. Page 7 of 10

8 coverage criteria. 0075T, 0076T Services described by CPT codes 0075T and 0076T are allowed when provided in accordance with NCD 20.7, Percutaneous Transluminal Angioplasty. Refer to CMS publication , Medicare National Determinations Manual, Chapter 1, Part 1, Billing instructions are listed in the CMS Publication , Medicare Claims Processing Manual, Chapter 32, Sections As directed in The CPT, use 0076T in conjunction with 0075T. 0184T The National Comprehensive Cancer Network (NCCN) guideline on treatment of rectal cancer states that, when criteria for transanal resection are met, transanal endoscopic microsurgery (TEMS) can be used when the tumor can be adequately identified in the rectum. It further states that TEMS for more proximal lesions (greater than 8 cm from anal verge) may be technically feasible. 0191T, 0376T An anterior segment aqueous drainage device, utilizing the internal approach, for use in combination with cataract surgery to reduce pressure inside the eye (intraocular pressure) in adult patients with mild or moderate open-angle glaucoma on medication. Medicare payment for glaucoma drainage device is included in the facility reimbursement for 0191T. On UB-04 claims, use revenue code 278 to report the glaucoma drainage device. 0249T Effective 05/01/2016 CPT/HCPCS code 0249T (ligation, hemorrhoidal vascular bundles(s), including ultrasound guidance) is reimbursable. It is a minimally invasive outpatient alternative to surgical hemorrhoidectomy for patients with symptomatic internal hemorrhoids. It is also known as Transanal Hemorrhoidal Dearterialization (THD). 0275T This is a procedure proposed as a treatment for symptomatic Lumbar Spinal Stenosis (LSS) unresponsive to conservative therapy. This procedure is generally described as a non-invasive procedure using specially designed instruments to percutaneously remove a portion of the lamina and debulk the ligamentum flavum. The procedure is performed under x-ray guidance (e.g., fluoroscopic, CT) with the assistance of contrast media to identify and monitor the compressed area via epiduragram. Effective for claims with dates of service on or after January 9, 2014, Percutaneous Image-Guided Lumbar Decompression (PILD) is covered by Medicare when provided in a clinical study under section 1862(a)(1)(E) through Coverage with Evidence Development (CED) for beneficiaries with LSS who are enrolled in an approved clinical study and meets the criteria listed in NCD , Transmittal T- 0298T An external electrocardiographic recording for more than 48 hours and up to 21 days. CPT/HCPCS codes 0295T, 0296T 0297T and 0298T are addressed in WPS Medicare LCD entitled Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) CV T Effective July 1, 2012 CPT/ HCPCS code 0308T (insertion of ocular telescope prosthesis including removal of crystalline lens) is payable. Further, claims submitted by Part A providers and ambulatory surgical centers for device pass-through category C1840 must be billed with HCPCS code 0308T (insertion of ocular telescope prosthesis including removal of crystalline lens) to receive pass-through payment. 0387T, 0389T, 0390T, and 0391T The leadless pacemaker eliminates the need for a device pocket and insertion of a pacing lead which are integral elements of traditional pacing systems. The removal of these elements eliminate an important source of complications associated with traditional pacing systems while providing similar benefits. Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. Effective January 18, 2017, the Centers for Medicare & Medicaid Services (CMS) covers leadless pacemakers through Coverage with Evidence Development (CED). CMS covers leadless pacemakers when procedures are performed in Food and Drug Administration (FDA) approved studies. CMS also covers, in prospective longitudinal studies, leadless pacemakers that are used in accordance with the FDA approved label for devices that have either: - an associated ongoing FDA approved post-approval study; or - completed an FDA post-approval study. Please see NCD for Leadless Pacemakers (20.8.4) for claims processing instructions (see CR 10117, Transmittal #3815, dated 07/28/2017). 0394T, 0395T High dose electronic brachytherapy for skin surface application and for interstitial or intracavitary treatment, respectively. Was code 0182T prior to 01/01/2016. It is reimbursable with documentation of medical necessity. Printed on 9/26/2017. Page 8 of 10

9 Sources of Information This bibliography presents those sources that were obtained during the development of this policy: Current Procedural Terminology (CPT ), Professional Edition (2016) American Medical Association. Bibliography Back to Top Revision History Information Revision History Date 09/01/2017 R8 01/01/2017 R7 11/01/2016 R6 10/01/2016 R5 05/01/2016 R4 01/01/2016 R3 11/01/2015 R2 10/01/2015 R1 Revision History Number Revision History Explanation 09/01/2017 Added Group 3 Paragraph for coverage of Leadless Pacemakers, added Group 3 CPT codes 0387T, 0389T, 0390T and 0391T, and added Group 3 diagnosis code Z00.6 per NCD effective 01/18/2017. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy. 01/01/2017 Annual review done 12/02/2016. Formatting changes made. Annual CPT/HCPCS code changes: description change to code 0275T; removed deleted codes 0171T, 0172T, and 0281T. 11/01/2016 Added language to Paragraph 3 to clarify claims processing for NCD Percutaneous Image-Guided Lumbar Decompression for Lumbar Spinal Stenosis (PILD for LSS) for code 0275T. Effective 10/01/ /01/2016 Per ICD-10 Code Updates: In Group 1: deleted codes H40.11X1 and H40.11X2 and added codes H , H , H , H , H , and H , effective 10/01/ /01/2016 Added 0249T to Group 1 codes effective 05/01/2016. Added 0281T to Group 4 codes effective 02/08/ /01/2016 Annual review done 12/02/2015. Annual CPT/HCPCS code changes: deleted codes 0099T and 0182T; added codes 0394T and 0395T which replaced 0182T. Removed CAC information. 11/01/2015 Added codes H40.11X1 and H40.11X2 to Group 1 Chart, to be effective 10/01/2015. Formatting changes made. 02/01/2015: CPT Code 0376T added to the policy as an add-on code to be used in conjunction with CPT Code 0191T. Reason(s) for Change Revisions Due To CPT/HCPCS Code Changes (Annual Review) Revisions Due To ICD- 10-CM Code Changes Reconsideration Request Revisions Due To CPT/HCPCS Code Changes (Diagnosis Code Update) Revisions Due To ICD- 10-CM Code Changes Revisions Due To CPT/HCPCS Code Changes Printed on 9/26/2017. Page 9 of 10

10 Back to Top Associated Documents Attachments Related Local Coverage Documents LCD(s) L Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) Related National Coverage Documents NCD(s) Leadless Pacemakers Public Version(s) Updated on 08/22/2017 with effective dates 09/01/ Updated on 12/19/2016 with effective dates 01/01/ /31/2017 Updated on 10/18/2016 with effective dates 11/01/ /31/2016 Updated on 09/20/2016 with effective dates 10/01/ /31/2016 Updated on 04/19/2016 with effective dates 05/01/ /30/2016 Some older versions have been archived. Please visit the MCD Archive Site to retrieve them. Back to Top Keywords Read the LCD Disclaimer Back to Top Printed on 9/26/2017. Page 10 of 10