C77.4 coverage policies: Medicare and commercial payers

97 active Medicare policies list C77.4, and 1 commercial payer policy lists 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 C77.4

LCD · NOVITAS-JH-L35396

Biomarkers for Oncology

JH · Effective Oct 1, 2015

LCD · NOVITAS-JL-L35396

Biomarkers for Oncology

JL · Effective Oct 1, 2015

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 · PALMETTO-JJ-L34415

CT of the Abdomen and Pelvis

JJ · Effective Oct 1, 2015

LCD · PALMETTO-JM-L34415

CT of the Abdomen and Pelvis

JM · Effective Oct 1, 2015

LCD · NGS-J6-L33394

Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

J6 · Effective Oct 1, 2015

LCD · NGS-JK-L33394

Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

Commercial payer policies listing C77.4

1 policy from 1 payer

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

Anthem

Anthem policies listing C77.4, with the code’s status in each
Policy	Effective	Status of C77.4
Prostate Specific Antigen TestingClinical Guideline · ANTHEM-CG-LAB-28	Apr 15, 2026	Covered