C84.00 coverage policies: Medicare and commercial payers

74 active Medicare policies list C84.00, and 10 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 C84.00

LCD · NGS-J6-L39513

Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin and Non-Hodgkin Lymphoma with B-cell or T-cell Origin

J6 · Effective Aug 1, 2023

LCD · NGS-JK-L39513

Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin and Non-Hodgkin Lymphoma with B-cell or T-cell Origin

JK · Effective Aug 1, 2023

LCD · CGS-J15-L39434

Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

J15 · Effective Feb 19, 2023

LCD · NORIDIAN-JE-L39396

Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

JE · Effective Mar 5, 2023

LCD · NORIDIAN-JF-L39396

Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

JF · Effective Mar 5, 2023

LCD · PALMETTO-JJ-L39270

Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

JJ · Effective Sep 4, 2022

LCD · PALMETTO-JM-L39270

Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

JM · Effective Sep 4, 2022

LCD · WPS-J5-L39477

Commercial payer policies listing C84.00

10 policies from 3 payers

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

Aetna

Aetna policies listing C84.00, with the code’s status in each
Policy	Effective	Status of C84.00
Bortezomib ProductsPayerPolicy · AETNA-CPB-0675	Feb 2, 2024	Covered
Extracorporeal Photochemotherapy (Photopheresis)PayerPolicy · AETNA-CPB-0241	Mar 29, 2023	Covered
Laser Treatment for Psoriasis and Other Selected Skin ConditionsPayerPolicy · AETNA-CPB-0577	Aug 11, 2023	Covered
Pharmacogenetic and Pharmacodynamic TestingPayerPolicy · AETNA-CPB-0715	Feb 27, 2024	Covered
PlerixaforPayerPolicy · AETNA-CPB-0779	Jan 9, 2024	Covered
Tumor MarkersPayerPolicy · AETNA-CPB-0352	Mar 5, 2024	Covered

Policy	Effective	Status of C84.00
Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell TransplantationClinical Guideline · ANTHEM-CG-TRANS-03	Jul 1, 2026	Covered
Ultraviolet Light Therapy Delivery Devices for Home UseClinical Guideline · ANTHEM-CG-DME-41	Oct 1, 2026	Covered
Vitamin D TestingClinical Guideline · ANTHEM-CG-LAB-11	Oct 1, 2026	Covered