D33.4 coverage policies: Medicare and commercial payers

84 active Medicare policies list D33.4, and 6 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 D33.4

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-L33461

Implantable Infusion Pump

JJ · Effective Oct 1, 2015

LCD · PALMETTO-JM-L33461

Implantable Infusion Pump

JM · Effective Oct 1, 2015

LCD · NOVITAS-JH-L35003

Intraoperative Neurophysiological Testing

JH · Effective Oct 1, 2015

LCD · NOVITAS-JL-L35003

Intraoperative Neurophysiological Testing

JL · Effective Oct 1, 2015

LCD · WPS-J5-L34623

Intraoperative Neurophysiological Testing

J5 · Effective Oct 1, 2015

LCD · WPS-J8-L34623

Intraoperative Neurophysiological Testing

J8 · Effective Oct 1, 2015

LCD · NORIDIAN-JE-L34220

Lumbar MRI

JE · Effective Oct 1, 2015

LCD · NORIDIAN-JF-L34220

Lumbar MRI

JF · Effective Oct 1, 2015

Commercial payer policies listing D33.4

6 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 D33.4, with the code’s status in each
Policy	Effective	Status of D33.4
Back Pain - Invasive ProceduresPayerPolicy · AETNA-CPB-0016	Mar 13, 2024	Covered
Intraoperative Neurophysiological MonitoringPayerPolicy · AETNA-CPB-0697	Oct 26, 2023	Covered
Ziconotide (Prialt)PayerPolicy · AETNA-CPB-0712	Sep 21, 2023	Covered