C75.4 coverage policies: Medicare and commercial payers

122 active Medicare policies list C75.4, and 3 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 C75.4

Showing 100 of 122

LCD · FIRST_COAST-L36767

Aortography and peripheral angiography

J9 · Effective Oct 31, 2016

LCD · PALMETTO-JJ-L33457

Cardiac Radionuclide Imaging

JJ · Effective Oct 1, 2015

LCD · PALMETTO-JM-L33457

Cardiac Radionuclide Imaging

JM · Effective Oct 1, 2015

LCD · PALMETTO-JJ-L33459

Computerized Axial Tomography (CT), Thorax

JJ · Effective Oct 1, 2015

LCD · PALMETTO-JM-L33459

Computerized Axial Tomography (CT), Thorax

JM · Effective Oct 1, 2015

LCD · NGS-J6-L40333

Erythropoiesis Stimulating Agents

LCD · NGS-J6-L40334

Erythropoiesis Stimulating Agents

J6 · Effective Jul 15, 2026

LCD · NGS-JK-L40333

Erythropoiesis Stimulating Agents

LCD · NGS-JK-L40334

Erythropoiesis Stimulating Agents

JK · Effective Jul 15, 2026

LCD · PALMETTO-JJ-L39237

Erythropoiesis Stimulating Agents

JJ · Effective Jul 24, 2022

Commercial payer policies listing C75.4

3 policies from 2 payers

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

Aetna

Aetna policies listing C75.4, with the code’s status in each
Policy	Effective	Status of C75.4
Intraoperative Radiation Therapy (IORT)PayerPolicy · AETNA-CPB-0721	Sep 22, 2023	Covered
Proton Beam, Neutron Beam, and Carbon Ion RadiotherapyPayerPolicy · AETNA-CPB-0270	Oct 3, 2023	Covered

Cigna

Cigna policies listing C75.4, with the code’s status in each
Policy	Effective	Status of C75.4
Duplex Scan of Extracranial ArteriesPayerPolicy · CIGNA-0542	Jul 15, 2026	Covered