D57.09 coverage policies: Medicare and commercial payers

58 active Medicare policies list D57.09, 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 D57.09

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 · NORIDIAN-JE-L34315

Electrocardiograms

JE · Effective Oct 1, 2015

LCD · NORIDIAN-JF-L34315

Electrocardiograms

JF · Effective Oct 1, 2015

LCD · CGS-J15-L34037

Flow Cytometry

J15 · Effective Oct 1, 2015

LCD · PALMETTO-JJ-L34580

Intravenous Immunoglobulin (IVIG)

JJ · Effective Oct 1, 2015

LCD · PALMETTO-JM-L34580

Intravenous Immunoglobulin (IVIG)

JM · Effective Oct 1, 2015

LCD · NORIDIAN-JE-L34215

Lab: Flow Cytometry

JE · Effective Oct 1, 2015

Commercial payer policies listing D57.09

1 policy from 1 payer

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

UnitedHealthcare

UnitedHealthcare policies listing D57.09, with the code’s status in each
Policy	Effective	Status of D57.09
Adakveo (Crizanlizumab-Tmca)PayerPolicy · UHC-POL-adakveo-crizanlizumab-tmca	May 1, 2026	Covered