B39.4 coverage policies: Medicare and commercial payers

44 active Medicare policies list B39.4, and 9 commercial payer policies list it. See each policy's status for the code and its official source. Listing a code is not a coverage decision: read each policy’s source for the requirements that apply.

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Medicare policies listing B39.4

LCD · NOVITAS-JH-L34914

Assays for Vitamins and Metabolic Function

JH · Effective Oct 1, 2015

LCD · NOVITAS-JL-L34914

Assays for Vitamins and Metabolic Function

JL · Effective Oct 1, 2015

LCD · CGS-J15-L33959

Cardiac Catheterization and Coronary Angiography

J15 · Effective Oct 1, 2015

LCD · PALMETTO-JJ-L34417

CT of the Head

JJ · Effective Oct 1, 2015

LCD · PALMETTO-JM-L34417

CT of the Head

JM · Effective Oct 1, 2015

LCD · NORIDIAN-JE-L34315

Electrocardiograms

JE · Effective Oct 1, 2015

LCD · NORIDIAN-JF-L34315

Electrocardiograms

JF · Effective Oct 1, 2015

LCD · PALMETTO-JJ-L34426

Ophthalmic Angiography (Fluorescein and Indocyanine Green)

JJ · Effective Oct 1, 2015

LCD · PALMETTO-JM-L34426

Ophthalmic Angiography (Fluorescein and Indocyanine Green)

JM · Effective Oct 1, 2015

LCD · NGS-J6-L33567

Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

Commercial payer policies listing B39.4

9 policies from 4 payers

Summary of the payer’s published policy. Not a coverage determination — confirm with the payer before submitting.

Aetna

Aetna policies listing B39.4, with the code’s status in each
Policy	Effective	Status of B39.4
Color-Flow Doppler Echocardiography and Myocardial Strain ImagingPayerPolicy · AETNA-CPB-0008	Mar 14, 2023	Covered
Optic Nerve and Retinal Imaging MethodsPayerPolicy · AETNA-CPB-0344	May 17, 2023	Covered
Verteporfin (Visudyne) Photodynamic TherapyPayerPolicy · AETNA-CPB-0594	Jun 29, 2023	Covered

Ambetter

Ambetter policies listing B39.4, with the code’s status in each
Policy	Effective	Status of B39.4
Extended OphthalmoscopyPayerPolicy · AMBETTER-CP-VP-26	Not recorded	Covered
Fluorescein AngiographyPayerPolicy · AMBETTER-CP-VP-28

Policy	Effective	Status of B39.4
Fundus PhotographyClinical Guideline · ANTHEM-CG-MED-47	Apr 15, 2026	Covered
Gamma Glutamyl Transferase TestingClinical Guideline · ANTHEM-CG-LAB-29	Jul 1, 2026	Covered