D05.01 coverage policies: Medicare and commercial payers

89 active Medicare policies list D05.01, and 2 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 D05.01

LCD · FIRST_COAST-L36499

BRCA1 and BRCA2 Genetic Testing

J9 · Effective Apr 11, 2016

LCD · NOVITAS-JH-L36715

BRCA1 and BRCA2 Genetic Testing

JH · Effective Dec 1, 2016

LCD · NOVITAS-JL-L36715

BRCA1 and BRCA2 Genetic Testing

JL · Effective Dec 1, 2016

LCD · CGS-J15-L33950

Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography

J15 · Effective Oct 1, 2015

LCD · NGS-J6-L33585

Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography

J6 · Effective Oct 1, 2015

LCD · NGS-JK-L33585

Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography

JK · 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

Commercial payer policies listing D05.01

2 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 D05.01, with the code’s status in each
Policy	Effective	Status of D05.01
External Breast ProsthesisPayerPolicy · AETNA-CPB-0097	Dec 15, 2023	Covered

Cigna

Cigna policies listing D05.01, with the code’s status in each
Policy	Effective	Status of D05.01
Low-Level Laser and High-Power Laser TherapyPayerPolicy · CIGNA-CPG030	Mar 15, 2026	Covered